From ACOG - Philadelphia, Pennsylvania - May, 1999
Roberta Speyer: "This is Roberta Speyer, reporting from the 37th annual clinical meeting here in Philadelphia at the ACOG. I'm talking to Dr. Mary Powderly from New Jersey. We're going to discuss the topic that maybe it's not always easy for the pregnant women to discuss with their physician - constipation. That's a problem?"
Dr. Powderly: "I think that it is a topic that many women don't bring up but I bring it up as part of a history in every physical exam on pregnant, as well as nonpregnant women, because I think it's a part of total care. I think that it's also part of nutrition and part of something to ask about the same way you would ask about diet and the same way you would ask about some of their other health concerns."
Roberta Speyer: "What is your view point? Are you focused more on prevention or correction? What can happen to a woman when she's pregnant? What physiologically changes that makes this a time when this becomes a greater issue?"
Dr. Powderly: "It's a high estrogen state, no pregnant woman that I know drinks enough water, and it's a time when a woman is concerned about her diet, is concerned about weight gain, and is certainly concerned about not straining the bowel movements. It's a time when hemorrhoids become most prominent from the extra weight of the pregnancy."
Roberta Speyer: "Is that what causes the hemorrhoids - the straining?"
Dr. Powderly: "Hemorrhoids are the veins of the anus, and anything that would increase pressure in those veins is going to increase hemorrhoidal activity. The weight of the pregnancy is one, the straining with bowel movements is another thing that increases intra-abdominal pressure, and therefore, makes hemorrhoids already present much more symptomatic."
Roberta Speyer: "Once you've had hemorrhoids, do you always have them?"
Dr. Powderly: "Yes. Once you've had hemorrhoids, you always will - it's the stretching of the vein. The issue is can you keep them asymptomatic so that women are not in pain, and they don't have to be surgically corrected, which is certainly the ultimate answer for them but an uncomfortable procedure that you would like to avoid if you can."
Roberta Speyer: "What do you do with your patients? How do you address this to keep them from getting hemorrhoids and to keep women that have had them from having them flare up during the pregnancy? What do you recommend?"
Dr. Powderly: "I recommend that all women pay strict attention to their diet. I recommend at least two quarts of water a day."
Roberta Speyer: "What diet should they be paying attention to? What does that mean?"
Dr. Powderly: "Paying attention to their exact intake. I actually have my pregnant women keep a diary of what they eat for me to be able to assess how much fiber they had and to keep in touch with the amount of water that they're drinking. And I recommend fiber supplements to all women because no matter what, in a highly civilized diet, we just don't have enough tree bark, and that is the most - in my opinion - and best prevention you can do as far as…"
Roberta Speyer: "What about laxatives and stool softeners? No?"
Dr. Powderly: "Stool softeners are ok in pregnancy but they really don't do the trick completely - but I don't want women taking stimulants when they're pregnant. Yes, it's true if you haven't gone in three or four days it may be time for that but if you have fiber in your diet as a prevention, as something to increase the water intake in the colon, then you don't have to fool around with things that are stimulating the colon, which of course are the medications that have that effect. If you get used to that, your colon needs something to be stimulated each time you go."
Roberta Speyer: "So that's a dangerous road to go down. So what do you use? How do you get that much fiber? What do you recommend besides, like you said, eating a tree?"
Dr. Powderly: "Trees are good. I think that psyllium is truly the way to go. Psyllium has the great advantage of being a stool softener, as well as a fiber-bulking agent. It helps to increase the amount of water brought back into the colon, it's easy, it's daily, and it's natural. It's a supplement the same way a prenatal vitamin is a supplement and prenatal vitamins contains iron, which is constipating. So consequently, if a woman is anemic and wants a little extra iron, the whole idea is that by adding something ahead of time you don't have the problem, you don't have the constipation, therefore, hopefully not having the hemorrhoidal flair up, and you have a more comfortable pregnancy."
Roberta Speyer: "What is psyllium?"
Dr. Powderly: "Psyllium is a seed. It is actually the basic ingredient in Konsyl, the basic ingredient in Metamucil as well, and it is a plant. It's a natural fiber enhancer, and it is very absorbable as far as taking water back in."
Roberta Speyer: "We personally, we - as the queen of England here - have had five children and have had problems with hemorrhoids and have used Konsyl very effectively. Why do you usually - you said that's the one that you use."
Dr. Powderly: "In particular. I was introduced to it by a dear friend who I was in internship with who went on to do colo-rectal surgery, who has every single patient in her practice on Konsyl. I started out with it for hemorrhoid prevention and worked it in and realized that in pregnancy it is completely safe. It is a natural product, it's also completely safe, and it stays completely within the GI tract. It's not absorbable, so consequently, you don't have to worry about any women coming and saying, "Is this safe to take in pregnancy?" It certainly is, and it's not a stimulant, so therefore - it's not habit forming."
Roberta Speyer: "What about sugars and things like that? Is that something pregnant women should be aware of if they use a product that has the psyllium in it - that they should be trying to make sure they're on other additives? Is that an issue because some people tend to have diabetes or other things in pregnancy? Should they be looking at the labels and avoiding added sugars and things like that?"
Dr. Powderly: "Oh, sure that makes a big difference as well, and of course the pregnant state gives you a slight disposition to become a true diabetic, which is why we test everyone at 28 weeks for sugar. However, adding sugar in anybody's diet is not a good idea and certainly a pregnant woman who is counting calories. You don't want to be adding a supplement that is also adding sugar to your system, not to mention tooth decay and a number of other things that sugar is not good for. The idea is to be able to give something that is going to be literally a food supplement taken regularly just like a prenatal vitamin - not waiting until there is a problem and not having it disturbing any other aspect of their life or diet or calories or general calories, etc, etc."
Roberta Speyer: "So its important if this is going to be effective to just start the regimen early enough before there is a problem. I want to recap and make sure I'm getting the high points - start early and then do it continuously. "
Dr. Powderly: "That's right. As a matter of fact, if a woman is coming to me and talking about getting pregnant, I start prenatal vitamins and Konsyl prior. I'd love to get women three months before they conceive, but that doesn't always happen. But as part of a prenatal regimen I like to get the vitamins in for the folic acid and to make sure they are not having a constipation problem ahead of time before you run into problems with constipation. The other thing is in women who have bleeding, any kind of pre-term bleeding, of course straining on the toilet is going to increase that because it increases intra-abdominal pressure, so it's a safety factor - prophylaxis against some other problems with pregnancy as well, not to mention pre-term contractions."
Roberta Speyer: "So really it's just fundamental, it's something everyone can work into their practice making their patients aware of, that this is something if it's handled up front, as part of the regular treatment that care that's going on."
Dr. Powderly: "Prophylaxis care, yes it can be given for that reason as well."
Roberta Speyer: "So for a woman who's doctor maybe hasn't mentioned this to her, are these products still available on the open market?"
Dr. Powderly: "It's over the counter, it's not even something you need a prescription for, so that if you don't have someone who spends that much time with you, it's easy enough to pick up. I think it should be pretty much a part of everyone's diet."
Roberta Speyer: "Thank you so much for taking the time out of your busy schedule to talk to us about this."