Updated November 12, 2021
At least once per day, I get a cry for help from Hyperemesis Gravidarum (HG) sufferers about how to relieve constipation during pregnancy, often due to a side effect from taking ondansetron (Zofran). Being in an almost constant state of dehydration as a result of HG will itself lead to constipation. Add Zofran to that, and the last step of our digestive system will just stop working. According to the Mayo Clinic, chronic constipation is, “infrequent bowel movements or difficult passage of stools that persists for several weeks or longer. Constipation is generally described as having fewer than three bowel movements a week.” Three bowel movements per week” you ask??? To a healthy, non-pregnant woman that may seem just terrible, but to an HG mom on Zofran, that would be a dream!
Constipation during pregnancy was a taboo topic when I was pregnant with HG, with the importance downplayed. I do not remember any doctors asking me about it. Today, HG moms are asking others online for advice. Since there are no set or even suggested guidelines nor any FDA approved medications specific for treating this medication-induced constipation, as there are for other disease states including Crohn’s Disease, Irritable Bowel Syndrome (IBS) and opioid medication-induced constipation, here are my suggestions combining what I learned when earning my Doctorate of Pharmacy degree (PharmD) along with advice from the HER Foundation and feedback I received from other HG survivors. Each of my Top 10 are single ingredients, so check out the bonus section of mom-approved combination products.
How to choose a product:
- Determine what is most important to you: cost ($0.99 to $40.00), formulation (oral, rectal…), time to have an effect (seconds to days), quality of the product (gluten-free, dyes, flavors, fillers, non-GMO, vegan, vegetarian), etc…
- Some products labeled gluten-free actually have gluten in them, because they still meet the FDA definition which allows for up to 20 parts per million.
- Look at the source of the flavors and dyes to ensure safety during pregnancy
- Constipation treatment options are limited when you can’t swallow, eliminating many options. Since my suggestions are for information only and not in any particular order, start with whichever one you can tolerate. If that doesn’t work, then try another option.
- Many women save the enema as a last resort, and then report it’s the only effective treatment. Additionally, look for products that are free of dyes and other fillers, if that is important to you.
- Diarrhea can cause electrolyte imbalances that are already an issue with HG, so always use the least amount you need to have an effect.
- Manufactures often change their names and formulas, so look at the active ingredient or generic names opposed to the brand names.
- These suggestions are for women without other disease states. If you have another disease state including diabetes, seizures or blood clots or have kidney, liver, or gastro-intestinal (GI) issues or take medications with possible interactions, check with the manufacturer to determine if their product is safe for you.
***Important: If you are not finding relief from these over-the-counter products, ask for a consult or appointment with a gastroenterologist doctor or gastrointestinal specialist. These doctors can safely prescribe and monitor more aggressive treatment protocols.
***Always check with your medical doctor before starting any medication. The following list is for information only.
*Product links are for convenience and for those who like to see pictures to remember. When you make a purchase through links on this page, I may earn a commission.
#1. Docusate (Colace)
How it works: Draws water and fat into the stools to soften them which make passing them easier. The oral forms take 1-2 days to have an effect, while the rectal works in 2-15 minutes. Comes as docusate sodium, docusate calcium and docusate potassium. The sodium form is most common.
Dose: Docusate sodium: 50 to 360mg, either in one dose or divided dose.
Sold as many different brand names including: Colace, DDS, Phillips Liqui Gels, Correctol and DocQlace
Pros: Non-addictive, many formulations: tablets, capsules, liquid and a rectal enema formulation
Cons: It has to stay down to have an effect
***Products that have a combination of docusate with sennasides should be used sparingly. Sennasides are laxatives and may cause dependency.
Magnesium! (#2, 3 and 4)
Magnesium comes in many formulations and brand names. Try these, just not at the same time. Be very careful not to use more than the manufacturer’s directions, as too much can be dangerous. Note: Do not choose magnesium oxide because it does not absorb as well as magnesium citrate or magnesium hydroxide.
#2: Magnesium citrate and #3: Magnesium hydroxide, known as Milk of Magnesia.
*These are said to taste better if chilled.
How they work: These are also osmotic. They bring water into the colon and cause the muscles to make wave-like movements which assist in pushing the stools through the tract.
Mg citrate dose: Take 195 to 300 mL at one time or drink it in divided doses.
Mg hydroxide dose: Depends on concentration. Read the product label.
Pros: Takes 30 minutes to 6 hours to work, OTC and very cheap.In fact, many stores cell Magnesium citrate for $0.99 per bottle.
Cons: Like the other oral options, if it won’t stay down, it won’t work.
One magnesium product hailed by HG sufferers is Natural Calm Gummies. This product has 325mg magnesium per serving of Mg citrate and comes in different flavors. It’s sold as a product to help calm nerves to support sleep, but that diarrhea is a side effect.
#4. Magnesium Sulfate, known as Epsom Bath Salts ***Warning: Never ingest Epsom salts!!!
How it works: Soaking in a bath full of Magnesium salts allows the Magnesium to soak into the body through the skin while you relax.
Pros: Over-the-counter, cheap, additional benefits including relaxing legs cramps. Many brands come with essential oils including lavender, eucalyptus and rosemary.
Cons: No studies to show how long it takes to help with constipation. Be careful not to overheat in the bathtub, as temperatures over 101 degrees can be dangerous in pregnancy.
Bonus: Magnesium salts are known to support the nervous system to help as well as relax muscle contractions, which could possibly benefit women with anxiety or restless legs. They are also recommended to help relieve migraine headaches.
#5. Glycerin suppository
How it works: Glycerin suppositories are a solid dosage form that gets inserted into the rectum where it dissolves. This draws fluid into the colon, therefore creating pressure which stimulates movement.
Pros: No chance of throwing it up. Non-addictive. Safe. OTC. Cheap. Fast acting – should work within 15 minutes.
Cons: Some women may not feel comfortable using suppositories.
#6. Sugar free candy because the xylitol causes diarrhea
How it works: Xylitol is a sugar alcohol found in fruits, vegetables, trees and grains. It is used as a sugar substitute in gum and candies for diabetics, because it doesn’t raise glucose levels. It can cause bloating, gas and diarrhea because “the sugar alcohols pull water into the intestine or get fermented by the gut bacteria.”
Notes: Sugar alcohols are not the same as the alcohol in drinks and considered safe for those with alcohol addictions). It is toxic to dogs and dangerous for people with colon issues including Crohns and irritable bowel syndrome (IBS).
Pros: OTC, inexpensive, comes in a variety of forms and flavors
Cons: May take time to build up tolerance to the gas and bloating, there is no determined dose to start
Bonus: It is good for our teeth because it reduces the bad bacteria that feed on sugar in our mouth.
Fiber* comes as soluble and insoluble and is available in many formulations. While it would be best to add fiber through our diet, we know that’s not possible with HG. To help with constipation, there has to be fluid along with the increased fiber, so only try this is you are NOT dehyrated! If you are dehydrated and add fiber products, you might end up with sever stomach cramping.
HG moms recommend fiber gummies, as they seem easier to keep down. If you find that fiber gummies are causing gas and bloating without relief, it may be due to being dehydrated. Regardless which product you choose, try to choose a product that is free of unnecessary ingredients including dairy, soy, sugar. Look for non-GMO, vegetarian or vegan, artificial colors, artificial flavors or gluten-free if these are a concern. Also, look at the source of the fiber, to ensure it is safe during pregnancy.
*talk with your doctor if you a history of intestinal disease states or diabetes before adding fiber
How they work: the fiber bulks the stools which increases its fluid content, making it easier to pass.
Pros: OTC, affordable
Cons: Will only work in hydrated, as being dehydrated with extra fiber may cause painful cramping,May take 1-3 days to have an effect
Bonus: Many fiber products have prebiotics which aid in digestion
#8. Prunes and prune juice
One of the oldest methods to relieve constipation, prunes are on the HG mom recommenced list too.
How they work: Prunes are full of insoluble fiber and also naturally have sorbitol, which acts in the same way as xylitol. Together, these add bulk and fluids to the stools so they pass easier.
Pros: inexpensive, readily available
Cons: Some people do not like the taste of prunes, they must stay down to work
Bonus: They are full of magnesium and potassium
How it works: Liquid, often saline or mineral oil, is pushed through the rectum into the intestine. This softens the stools and adds pressure, allowing them to easily come out. This should happen within 5 minutes.
Enemas come in various forms, from kits to single use bottles. Read the instructions that come with the one you purchased.
Pros: OTC, inexpensive, fast acting.
Cons: May be uncomfortable, limit use as the body may become dependent.
How it works: Miralax is called an “osmotic laxative”. This means it brings water into the colon, which causes the stools to be softer allowing them to pass more often and more easily.
Dose: The container usually comes with a cap that has a line inside it. This measurement is 17 grams, which is the standard dose. If you can tolerate even 4-5 ounces of a juice, soda or Gatorade then start with 1-2 capfuls of polyethylene glycol daily mixed into your liquid. Adjust the portion size based on your stools. For example, add more powder if your constipation continues or your stools stay hard and then add less powder if they become too loose.
- Odorless and tasteless
- Does not cause dependency
- It is over-the-counter (OTC) but also may be covered by insurance with a prescription
- Takes 1-3 days to have an effect
- This comes as a powder that gets mixed into a liquid which you have to drink. Since very few liquids stay down with HG, it could be a challenge to take this consistently enough to continue working
- Some potential lawsuits are stating that the active ingredient polyethylene glycol 3350 (PEG 3350) can cause neuropsychiatric problems from long term use, but there is not yet clinical evidence to support this. To be safe, use the least amount you need for an effect and do not use for years
What to use sparingly for constipation when pregnant:
Senna (Senakot) and bisacodyl (Correctol, dulcolax) are stimulant laxatives. Studies have shown that “agents other than senna and bisacodyl are recommended for the treatment of constipation in pregnant women.” (Body 2016, Gomes 2018) I would bet the authors of this study did not have HG! For those who have tried the options above, it is safe the use stimulants a few times a week. The downside with stimulants is that the body can become dependent on them, so use them when you need then taper off as soon as possible. Long term use can create dependency.
Note: Do not take senna with Miralax, as Senna can increase the adverse/toxic effect of polyethylene glycol electrolyte solution (uptodate)
For those not finding relief with the above options, please consult your doctor and/or a gastrointestinal special about additional options and to determine an alternate cause of your constipation. These include:
- Lactulose (Generlac)
- Carafate (Sulcrafate)
- Pancreatic Enzymes: for those with pancreatic insufficiency: Pancreaze/Creon and Zenpep
Since treating the side effects of a medication is never ideal, I have to address the better option, which is preventing the constipation from happening in the first place. Being pregnant without HG tends to cause constipation, and then adding Zofran has been shown to stop digestion in its tracks. The best option for healthy digestion, if it will stay down, is to take a daily probiotic. Probiotics come in a variety of strains, so look for one within your budget, without unnecessary ingredients or additives and that target bacteria in the stomach. Other options include yogurt and kombucha.
Combination Products approved by Pregnant Moms
If your constipation continues postpartum, be sure to discuss this with your provider, as additional options may be available depending if you are breastfeeding or not.
If you find a method or product to keep your gut healthy while taking Zofran, please send your success stories to firstname.lastname@example.org so we can help ease the pain of those suffering now.
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