Constipation during pregnancy and the postpartum period is common, frequently overlooked, and requires careful, safe management tailored to physiologic changes, according to guidance presented at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology 2026, held in Paris.

Constipation affects a substantial proportion of women during pregnancy and in the postpartum period, yet it remains underrecognized despite its impact on quality of life. Véronique Vitton, MD, a gastroenterologist and hepatologist at Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France, reviewed the pathophysiology, clinical presentation, and management.

Constipation is the second most frequent digestive symptom during pregnancy, after nausea. It may develop de novo or worsen during pregnancy. “In all cases, it is a symptom with a fairly significant impact on quality of life during pregnancy, and that leads to stress,” Vitton explained.

The reported prevalence ranges from 10% to 40%, although data are limited. Vitton noted that constipation is often trivialized, neglected, and sometimes considered a secondary sexual characteristic in women. Multiparous women are more affected.

Prevalence 

A study including more than 1000 women reported constipation in 40% of pregnant women, 52% of postpartum women, and 21% of age-matched women who were not pregnant and had not given birth in the previous year. The rates did not differ by trimester. Constipation occurred more often after vaginal delivery than after caesarean delivery, due to perineal injury. 

Underlying Causes 

Multiple mechanisms contribute to constipation and vary by trimester. Reduced physical activity, dietary changes, and iron supplementation can promote constipation. The use of antiemetics during early pregnancy may lead to dehydration. Changes in the microbiota have been described, although evidence remains limited. Mechanical compression of the sigmoid colon may occur later in pregnancy.

Hormonal factors also play a significant role in this process. Increased progesterone levels exert a myorelaxant effect, which reduces intestinal motility. Elevated levels of the hormone relaxin, combined with reduced peristalsis (slowed gut motility) and increased absorption of water and electrolytes, are primary factors causing stool dehydration and, consequently, constipation.

Proctologic complications, including anal fissures and hemorrhoids, may result from constipation and can worsen, particularly when pain interferes with evacuation.

Clinical Approach 

The clinical presentation is nonspecific and may include abdominal pain. Systematic assessment using the Bristol Stool Scale is essential. “Stool quality is the basis of constipation treatment. Without this evaluation, the correct treatment choice is missed,” Vitton said.

A comprehensive pelvic floor evaluation must include assessment of dyschezia (painful or difficult defecation) and perineal integrity. Avoiding excessive straining before, during, and after delivery is critical because constipation is a risk factor for anal incontinence.

Assessment should also include screening for anorectal symptoms, hemorrhoids, and fissures. Secondary causes must be considered. Gestational diabetes may contribute in addition to hormonal and mechanical factors.

Although rare, colorectal cancer can occur during pregnancy. “Even though there are few data, cases do exist, with a reported mean age of about 31 years,” Vitton noted. Prevalence is approximately 0.08%. Diagnosis is often delayed because symptoms are attributed to pregnancy. Any suspicion of organic disease should prompt further evaluation.

Management Strategies 

Management largely mirrors that in women who are not pregnant but requires specific precautions. Lifestyle measures remain first-line management. Adequate hydration, increased fiber intake, and proper physical activity are recommended. Excessive fluid intake is unnecessary; moderate intake is sufficient. Magnesium-containing water can increase stool frequency.

Lifestyle measures are often sufficient to improve symptoms.

Preferred Treatments 

When pharmacologic treatment is required, clinicians should consult the Reference Center for Teratogenic Agents, a French evidence-based database that provides detailed guidance on medication safety during pregnancy and lactation. Bulk-forming agents such as sterculia, ispaghula, psyllium, and guar gum are preferred, along with osmotic laxatives. However, these agents lack systemic absorption and have established safety profiles during pregnancy. Bulk-forming agents are prioritized over osmotic laxatives.

Lubricant laxatives, such as paraffin oil, may be used but are less commonly recommended. If a stimulant laxative is necessary, senna is preferred despite its reputation. No adverse data has been reported for other stimulant laxatives, such as bisacodyl or rhubarb.

During breastfeeding, the choice of laxatives is similar, with osmotic laxatives and bulk-forming agents preferred. “Some authors prefer lactulose, whereas others recommend avoiding saline osmotic laxatives, which, in women who are vomiting, may increase fluid and electrolyte disturbances,” Vitton explained. “Senna can be used with caution. Bisacodyl, despite its reputation, has minimal systemic absorption and can be administered when necessary.”

Although bulk-forming agents are often considered the preferred choice in pregnant women based on consistent data, suppositories may also be used at any stage of pregnancy. Avoiding straining is essential for preserving the pelvic floor integrity.

There are no formal contraindications to micro-enemas or enemas of different volumes. However, initiating transanal irrigation is not recommended for pregnant women. Treatment that has already been initiated may be continued on a case-by-case basis with caution, including the use of water enemas and appropriate monitoring.

Clinicians should avoid prescribing probiotics during pregnancy. Vitton said: “Clinicians generally avoid prescribing probiotics during pregnancy. Some are reluctant to administer billions of live organisms to a pregnant woman without proven benefit [and] no robust effect has been demonstrated for constipation.”

Peripherally acting mu-opioid receptor antagonists are used to treat opioid-induced constipation in pregnancy. Evidence shows that these agents may be used in pregnant women when necessary. Several studies have reported their use without major safety concerns.

This story was translated from Medscape’s French edition.