Clinical Pharmacy

2018/2019

Constipation and Heartburn in Pregnancy

Names & ID:

Fatima Abdulrazzaq Thabit 201510382

Zahraa Rabia 201511082

Section: 22

* Fatima Abdulrazzak had done the first part about Constipation and Zahraa Rabia Has completed the heartburn part.
((Constipation))
Constipation is a common and debilitating problem among pregnant women worldwide. It has been estimated that 11% to
38% of pregnant women experienced constipation, particularly 15% in North America and 38% in UK.(1,2)

Pathophysiology: Inappropriate diet that lacks fibers and fluids can cause constipation. Changes in the levels of hormones,
particularly increased progesterone levels (which inhibits a peptide hormone called Motilin that is smooth muscle
stimulator) during pregnancy, are responsible for reduced intestinal smooth muscle motility .Compression of the enlarging
uterus on the bowel (Mechanical effects), and the increased absorption of water in the colon due to the activation of renin
angiotensin system. In addition, many pregnant women take supplements which are high in iron. All these contribute to
reducing bowel movement and hardening of the stool.(1)

Symptoms: Women usually report symptoms such as evacuating infrequently, passing dry hard stools associated with pain
and straining. Incomplete evacuation also is a sign of constipation.(1)

Diagnosis: The Rome III criteria are the most commonly used in the diagnosis for constipation. Most obvious diagnostic
criteria: Must include two or more of the following:
a. Straining during at least 25% of defecations.
b. Lumpy or hard stools in at least 25% of defecations.
c. Sensation of incomplete evacuation/ anorectal obstruction for at least 25% of defecations.
d. Fewer than three defecations per week.(3)
- Hemoglobin blood test should be done. If it falls within an acceptable range (12-16 g/dl), it could be suggested to
switch to a prenatal vitamin with a lower amount of iron.(1)
- Although MRI imaging is proved to be safe in pregnancy, if it is non-urgent and the case not sever then it’s preferred
not to do it. While X-ray is absolutely avoided.(4)

Non-pharmacological management: It is advised to increase fluid and fiber intake (fruits, vegetables, beans, grains,
cereals …), a moderate amount of daily exercise even walking for 20-30 minutes, and defecation after meals when
colonic activity is the highest. Meal supplementation with 4 to 6 tablespoons of bran showed effective results. Despite
this, a study of weighted fibers food (18-20 g each day) where done on a group of women with constipation vs. women
without constipation during pregnancy, it was found that both groups consume the same amount of fibers which indicates
that inappropriate diets do not appear to be the primary cause of constipation during pregnancy. It was recommended
later that 27-28 g each day could be an effective amount to treat constipation but not necessarily.(1,5)
Probiotics are being suggested more often in pregnant patients and found to be effective.(3)

Pharmacological management: If relief wasn’t achieved from lifestyle changes which is the first line therapy, second
line therapy should be started.(Table1) shows the types of laxatives which are ordered according to their uses
preference.(5,6,7,8)

Drug CategoryDose Outcomes

Bulk forming laxatives 1 tsp(2.5g) mixed in 8 oz water up to t.i.d. All: -safe for long-term use
Psyllium/ Ispaghula husk B 2 tablets (625mg) qday to q6hr. (not abosorbed).
Polycarbohphil - 2 caplets (500mg) up to 6 times/day
Methylcellulose - -slow onset and delayed action.

Osmotic Laxatives 15-30 mL (10-20 g) PO qday. 64% of prescribed laxatives by 2009.

Lactulose B 30-150 mL (70% solution) qday. Both: CI with diabetes.
Sorbitol C 17g packet oral powder in 240mL of beverage It appears safe for long-term use.
Polyethylene glycol C qday; not to be used for >1-2 weeks. Prescription rose to 32% in 2009
 Stool Softeners
Sodium/Calcium Docusate C 1 tablet (50mg) qday. Should always Safe; 1/473 reported of chronic use associated -
Considered at lowest dose. with symptomatic neonate hypomagnesemia.

Stimulant laxatives
Bisacodyl B 5 mg tablet qday. Fastest onset of action
Senna C Least dose 8.6 mg or 15 mg qday No risk of malformations but better to be avoi-
Not for use >1 week ded as they may stimulate uterine contractions
Around 3% each prescribed in 2009.
Table 1. (5,6,7,8)
Counseling points: - Reassurance that constipation is due to a natural process and it is temporary.
- It is recommended to use laxatives especially osmotics and stimulants for short-term (not more than 2 weeks) to avoid
dehydration, electrolyte imbalance and even lazy bowel.
- Avoiding mineral and castor oil as the former interferes with fat soluble vitamins absorption and the latter induce labor.
- The medication should be stopped gradually to avoid recurrence.
- Side effects such as flatulence, gas and bloating is expected.
- Glycerin suppositories (4g) can be used if oral medications are not tolerated due to nausea and the right way of inserting
should be applied (laying on the side with knees bend and remain steady for couple of minutes after insertion).(5,6,7)

((heartburn))

heartburn is a common clinical problem in pregnant women. It is reported to occur in 30 to 50% of all pregnant women,
in most cases, symptoms occur for the first time during the pregnancy and subside soon after delivery.(9)

607 women at various stages of pregnancy were recruited at antenatal clinic. The result found that he prevalence of
heartburn increased with gestational age (22% in the first, 39% in the second, and 72% in the third trimester, as did
severity of heartburn, Symptoms of heartburn rapidly increased towards the end of the second trimester, Logistic
regression analysis showed increased risk of suffering heartburn with increasing gestational age, and inversely with
maternal age, but not with body mass index before pregnancy, race, or weight gain in pregnancy.(9)

Pathophysiology: Since in pregnancy hormone levels are always flatulating especially progesterone that when it’s
increased it will cause relaxation of the esophageal sphincter, this allows partially digested food and stomach acids to
reflux, into the esophagus. Especially in the first trimester (first 12 weeks), then it will disappear in the second trimester,
but will come back in third trimester because of the physical stress of the fetus head down and the feet pushing the
stomach, that will open the esophageal sphincter and the acid will go up which is called mechanical pressure.(9) In
addition, progesterone also slows the digestive process. This keeps food in the stomach longer. Some studies have
suggested that abnormal gastric emptying or delayed small bowel transit might contribute to heartburn in pregnancy.
Heartburn may also be caused by medications taken during pregnancy, such as antiemetics.(14)

Symptoms: Common sign and symptoms of the heartburn reported by pregnant women includes: burning sensation in the
chest just behind the sternum, that occurs after eating and lasts a few minutes to several hours, Chest pain, especially after
bending over, lying down, or eating, tasting fluid acid at the back of the throat, belching, regurgitation.(11)

Diagnosis: The initial diagnosis of GERD in pregnancy can reliably be made based on symptoms alone, Esophageal
manometry and pH studies are rarely necessary during pregnancy but can be performed safely. Upper gastrointestinal
(GI) endoscopy is the procedure of choice to evaluate intractable reflux symptoms or complications. This procedure can
be safely performed without harm to the mother or fetus by carefully monitoring blood pressure and oxygen and
judicious use of conscious sedation and fetal monitoring. (11)
Non-pharmacological management: lifestyle and dietary modifications, that includes pregnant woman avoiding
and reducing intake of reflux-inducing foods (such as) greasy and spicy foods, tomatoes, highly acidic citrus
products, and carbonated drinks, pregnant woman should reduce the size and frequency of meals, those are
considered the first-line treatment for heartburn in pregnant women, also pregnant woman should reduce their
caffeine intake, also raising the head of the bed for pregnant woman is always preferable, pregnant women should
avoid laying down within 3 hours after eating, also chewing gum stimulates the salivary glands and can help
neutralize acid.(10)
Pharmacological management:
If the heartburn won’t go away after the lifestyle modification we start the drugs treatment: we have 3 categories,
antacids, H2 blockers, and PPI. Table (11,12,13)

Drug Category Dose Outcomes

Antacid drugs like:
Aluminum hydroxide/
magnesium hydroxide
(maalox)
aluminum
hydroxide/magnesium
carbonate (Gaviscon)
calcium carbonate/
magnesium hydroxide
(Rolaids)
calcium carbonate (rennie)
H2RA drugs:
cimetidine
ranitidine (zantac)
PPI drugs:
Omeprazole
Lansoprazole
10-20 mL orally between meals & qHS -Safe during pregnancy
C because of minimal
absorption
-It will neutralize the acids
that went up into the
esophagus
Chewable tablets: extra strength
C Chew 2-4 tablets PO q6hr when necessary; not -form a protective layer
to exceed 16 tablets/day -57% woman reporting
symptom relief within 10 min
using Gaviscon
C Suspension: 10-20 mL PO prn
B
calcium or magnesium are
(Tablets 500 mg): Chew 2-4 tablets; not to considered to be low risk
exceed 15 tabs/24 hr during pregnancy, however
avoid excessive use
-Cimetidine and ranitidine
have had considerable use in
B pregnancy over the last 30
B Oral tablets normal dose 150mg 2 times a day, years with an excellent safety
profile.
30 to 60 minutes before food to prevent acid
- ranitidine is the only H2RA
release stimulated by food whose efficacy during
pregnancy has been
established, studies in a
double-blind, placebo-
controlled, triple-crossover
Larson et al have shown that
it’s not harmful to the fetus
A case series have found no
C 20 mg PO qDay for 4 weeks infant congenital
B 15 mg PO qDay for 14 days malformations in mothers
taking 20–60 mg
omeprazole/day, even in
the first trimester of
pregnancy

Counseling points:

- Pregnant woman should avoid magnesium during the last trimester of pregnancy also maalox, because of the
aluminum hydroxide it might lead to constipation. (10)
- Unlike the non-pregnant heartburn patient, PPIs should only be used during pregnancy in women with well-
defined complicated GERD, not responding to lifestyle changes, antacids and H2RA (9)
-Rennie the drug of choice in pregnancy, since it consists of calcium carbonate and calcium is needed for the baby
(11)
The references:

1- Broussard B. Constipation During Pregnancy. Int J Childbirth Educ 1996; 11(1): 40-42.
2- Higgins P, Johanson J. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 2004;
99(4): 750-759.

3- Verghese T, Futaba K, Latthe P. Constipation in pregnancy. The Obstetrician & Gynaecologist 2015; 17(1): 111-115.

4- Applied Radiology. MRI in pregnancy: Gastrointestinal and genitourinary pathology, 2016-2017. Available at:
https://appliedradiology.com/articles/mri-in-pregnancy-gastrointestinal-and-genitourinary-pathology. Accessed November
11, 2018.

5- Longo S, Moore R, Canzoneri B, Robichaux A. Gastrointestinal Conditions during Pregnancy. Clin Colon Rectal Surg
2010; 23(2): 80-89.

6- Medscape. Laxatives, Stool Softeners, and Prokinetic Agents, 2015-2016. Available at:
https://emedicine.medscape.com/article/2172208-overview. Accessed November 11, 2018.

7- Trottier M, Erebara A, Bozzo P. Treating constipation during pregnancy. Can Fam Physician 2012; 58(8): 836-838.

8- Shafe A, Lee S, Dalrymple J, Whorwell P. Laxative Usage in patients with GP-diagnosed Constipation in the UK within
the general population and in pregnancy: an epidemiological study using the General Practice Research Database
(GPRD). Therap Adv Gastroenterol 2011; 4(6): 343-363.

9- Marrero JM, Goggin PM, De Caestecker JS, Pearce JM, Maxwell JD. Determinants of pregnancy heartburn.
BJOG An International Journal of Obstetrics & Gynaecology 1992; 99(9): 731-734.

10- PMC. heartburn in pregnancy, 2009-2010. Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217736/. Accessed November 14, 2018.

11- Richter J.E. Review article: the management of heartburn in pregnancy. Temple University School of Medicine.
PA, USA. 2005.

12- Medscape. aluminum hydroxide/magnesium hydroxide, 2016-2017. Available at:

https://reference.medscape.com/drug/riopan-comagaldrox-aluminum-hydroxide-magnesium-hydroxide-341992.
Accessed November 14, 2018.

13- Medscape. Ranitidine, 2015-2016. Available at: https://reference.medscape.com/drug/zantac-ranitidine-

342003#10. Accessed November 14, 2018.

14- de Paula Castro L. Reflux esophagitis as the cause of heartburn in pregnancy. AJOG 1967; 98(1): 1-10