Imagine being pregnant and unable to have a bowel movement for over a month. This happened to Ivana Gogh* from Pittsburgh, Pa.
Needless to say, she was very uncomfortable. Her stomach hurt a lot and she felt bloated. Her belly was distended, and it wasn’t from the pregnancy – because at 8 weeks she was too early to be showing as much as she was. Gogh was extremely fatigued and barely had enough energy to take care of herself, much less her toddler. Many days it was a struggle to even shower.
Constipation is having a bowel movement less than three times per week.
Unfortunately, Gogh’s predicament – while extreme in its length – is common for pregnant women.
More than 50 percent of all pregnant women suffer some degree of constipation, says Dr. Ken Troffater, director of Maternal-Fetal Medicine and professor of Clinical Obstetrics in the Department of Obstetrics and Gynecology at the University of South Carolina. “It is probably only second to headaches among common pregnancy complaints. Think of it as ‘nature’s way’ of getting the mother to absorb the most food and fluid from her diet she possibly can to help maintain the pregnancy.”
The Three Ws: What, When and Why
The standard definition of constipation is having a bowel movement less than three times per week, but in Dr. Trofatter’s experience, even this can’t be defined as constipation unless it’s accompanied by hard, dry stool that requires straining to eliminate.
This discomfort can start early in the first trimester, but usually becomes more of a problem from 20 weeks on, Dr. Troffater says. He says that some people are unusually prone to constipation because of poor fluid or fiber intake in their diets, so it can be a chronic problem throughout the pregnancy.
What causes this lovely side effect of pregnancy, anyway? A primary cause is the hormone progesterone, which is made in large amounts by the placenta by the end of the first trimester.
“One of the major effects of progesterone is to cause relaxation of ‘smooth muscles,'” Dr. Trofatter says. “Progesterone decreases the strength and frequency of bowel contractions. The slower the motility of the bowel, the greater the opportunity for absorption of fluids and foods. Unfortunately, by the end, if the remaining waste becomes very dehydrated, the stool becomes compact and hard, making it more uncomfortable to pass, sometimes getting to the point where a woman will not have a bowel movement for five or more days. This is constipation and it can be very uncomfortable.” He says other causes are iron and calcium supplements, poor fluid and fiber intake and too little exercise during pregnancy.
There is also an anatomical effect, says Dr. Madhuri Bewtra, an OB/GYN in private practice in Bergen County, N.J. The uterus enlarges, the fetal head is in the pelvis and the pelvic floor relaxes as the pregnancy progresses, causing the lower intestine and rectum to become compressed.
Prevention and Treatment
Gogh started experiencing constipation when she was about 8 weeks along. After a week, she swallowed her embarrassment and contacted her OB/GYN. The nurse recommended a regimen of increased water (at least six to eight glasses per day), more fruits and fiber-rich foods in her diet, apricot nectar, a fiber supplement and then if none of these things worked within a few days, a stool softener.
Gogh was told that her prenatal vitamin could be contributing to the problem since it had a lot of iron in it, so she was given the OK to stop taking it for the first trimester and substitute a children’s vitamin. Once she entered the second trimester, the nurse told her to return to the prenatal vitamin as she would need the increased iron.
Indeed, this advice is echoed by Dr. Trofatter, who says 15 grams or more per day of fiber is recommended. He adds that exercise is also good, unless on bed rest, as it helps improve bowel motility.
Dr. Bewtra suggests practicing Kegel exercises to strengthen the pelvic floor. “Regular bowel movements are important,” she says. “Women should not hold in their stool when they have the urge to go. Routine is helpful. Women should try to defecate at the same time every day after a meal.”
Bulk laxatives can help treat constipation but avoid irritant laxatives, mineral oils, and irritating enemas since these might cause the uterus to contract prematurely, Dr. Trofatter says.
The National Institutes of Health (NIH) defines RLS as a neurological disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging or like insects crawling inside the legs.
RLS sensations are often described by people as burning, creeping, tugging or like insects crawling inside the legs.
Dr. Philip Becker, medical director of the Sleep Medicine Institute at the Presbyterian Hospital of Dallas and a clinical professor in the department of psychiatry at Southwestern Medical Center at Dallas, says RLS is estimated to affect approximately 17 percent of pregnant women based on four criteria. Dr. Becker uses the acronym URGE to define these criteria:
- Urge to move.
- Rest worsens symptoms.
- Getting up relieves symptoms.
- Evening worsening of symptoms.
Although it disrupts sleep, Dr. Becker says RLS is not a sleep disorder. Rather, it is a movement disorder tied to the circadian cycle. It usually comes on between 4 p.m. and 4 a.m. and reaches its peak around bedtime. There are other factors, particularly in pregnancy, which may worsen the incidence of RLS.
“There’s an anticipatory factor to this syndrome,” says Dr. Becker. “You start looking for it and that intensifies it. Then you get emotionally involved and frustrated. At that point arousal is so high it’s hard to settle and hard to relax. Then, if you do, the sensation intensifies and the movement comes out. In addition, the pregnant mother may be feeling a great deal of concern over how the lack of sleep is affecting her fetus, and that anxiety can worsen the incidence as well.”
Dr. Becker is quick to note there is no evidence that lack of sleep does hurt the fetus and that pregnant women often have sleep disruptions from other causes besides RLS. However, RLS can still make a joyful time pretty miserable.
Researchers have not been able to determine what causes RLS, but research is ongoing into causes ranging from genetics to mineral imbalances. It’s the latter that is often suspected in pregnancy.
Georgianna Bell, executive director of the Restless Legs Syndrome Foundation, says some of the ongoing research is focusing on the role of iron in the brain. “Sometimes people will experience a form of secondary RLS and one of the causes can be very low iron in the blood,” says Bell. “The symptoms are then resolved by taking iron supplements. There is also ongoing research studying the administration of iron intravenously. There does seem to be a connection; why it is more prevalent in pregnancy we just don’t know.”
Dr. Becker agrees, noting that the first step in treatment of RLS is to make sure iron, ferritin and folate levels are normal. If any of those appear low, they should be supplemented. He also suggests the following:
Limit caffeine to early morning and preferably only one cup of coffee.
Drink plenty of water.
Try to fatigue the legs as little as possible. If you have a job where you’re on your feet a lot, try to arrange to put your legs up more often.
Counter stimuli: This can include support stockings, stretching exercises before bed, putting something at the foot of the bed that you can push against and having your partner give you a massage.
Water therapy. Stand in the shower and let the water hit you in the lower back and run down your legs. Some people prefer warm or hot water, some cold or cool. Some people report that starting with hotter water and gradually moving it to cool also works to relieve the sensations. A warm bath is also a good idea and provides other positive benefits such as relaxation and distraction.
Distraction. Try this when RLS occurs in resting situations that do not involve trying to sleep. Use whatever interests you: crossword puzzles, computer games or any hobby or activity that will engage your attention.
For most people one of the above suggestions will work. For the one in 10 that Dr. Becker estimates won’t find relief in these simple measures, it may be necessary to evaluate the risk/benefits of drug therapy. Because RLS generally is at its worst in the third trimester, many of the drugs used to treat it in non-pregnant persons will be safe to use during pregnancy. However, this is a decision to be made by the woman and her obstetrician.
The good news, according to Dr. Becker, is that RLS usually resolves itself once the baby is delivered. Then, he jokes, the real sleep disruptions begin.