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Hello, I am 36 weeks pregnant and have had difficulty passing stools. I've been to the my doctor at the hospital where I'm receiving prenatal care and he says that constipation is common in pregnancy, and prescribed a magnesium based laxative.
However I'm worried that this is a fecal impaction - I ate some pumpkin seeds at the weekend, and a few hours later is when the trouble began. I passed some bright red AND dark red blood from the rectal area but couldn't pass any stools except a couple of very small ones. I had the feeling that I had to pass more but I couldn't even after
straining for a long time.
Now for three days I haven't had a proper bowel.
How likely is this to be a fecal impaction? I have read cases about seeds causing blockages. If it is at all likely, should I be searching out a specialist doctor rather than going to my ob/gyn? (I'm based in South Korea). Thanks for your help.

Category: OBGYN

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Category: Infertility Specialist
Dr. Aarti Vazirani is online now

Expert:  Dr. Aarti Vazirani replied 4 Days.

Hello. Thank you for posting your query at DoctorSpring.com
Constipation is actually quite common in pregnancy, and fecal impaction is not.
Fecal impaction is preceded by a history of chronic constipation, which is absent in your case.
Fecal impaction is common in morbid patients, not in healthy young women.
I would say you are not likely to have fecal impaction.
How long have you taken the laxative, and have you been passing small amounts of stool, or not at all?
Have you been having pain, because fecal impaction is painful too.
Painless bleeding from the rectal area is more indicative of a haemorrhoid, which are more common in pregnancy.
I would ask you to consult a specialist- a general or a colo-rectal surgeon, if your OB - GYN is not conclusively able to rule out fecal impaction on a per rectal exam.
All the best
Please feel free to discuss further.

Patient replied :

Thanks for your reply. I wanted to wait a few days to give you an update and then ask further advice.
I understand that fecal impaction is uncommon in younger patients where the cause is chronic,untreated constipation. This would clearly be unlikely in my case since I have never suffered with constipation before last Saturday, even throughout the entire course of my three pregnancies. However I have also read several studies (eg here, here and here) online about the potential of certain types of seed to form a lump (or bezoar) in the rectum, stomach or large intestine. It is this that concerns me since the day before eating the pumpkin seeds I had absolutely no symptoms of constipation, and within a few hours of eating them I was almost totally unable to have a bowel movement, and passing blood (I've never had haemorrhoids before either).
Also I am not really responding to the laxatives or suppositories as I am straining to produce even a small amount of stool. I have been taking the laxatives for six days now, and I have also used one bisacodyl suppository. I still feel that there is a large blockage that I cannot pass, however much I strain. I am able to pass gas and I have had on average one or two small bowl movements per day, but they are very much reduced in size and quantity compared to normal. Other symptoms: bleeding from the rectum after trying to pass stools, some muscular aching especially in the arms and shoulders, some itching on my arms and legs, minor headaches which seem to come and go. No pain or abdominal discomfort except when I am trying to pass a stool.
My obgyn has only prescribed laxatives and suppositories so far. He has not carried out a digital rectal examination or performed any kind of scan (I would have to go to see a specialist at another hospital for this). He says he could perform an enema, but warned me that this carried significant risk of inducing labor ( which I find unacceptable because I am only 37 weeks and wish to carry the baby to term unless it really is an emergency).
I have about three weeks left of the pregnancy if I go into labor close to my due date (as I did with my previous two pregnancies) .Should I just wait it out, using home remedies such as prune juice, a high fibre diet, and over the counter drugs such as Colace, and then have tests done after the baby is born? Or should I go to a larger hospital straightaway for further testing? I discussed this with my obgyn, who said that there would be very little they could do at a larger hospital- I can't have an Xray or CT scan since I'm pregnant, and even tests such as as a sigmoidoscopy typically require an enema to be carried out beforehand. I'm concerned however that the waste building up in my body even from a partial impaction could lead to serious consequences.
I'd like to know your opinion on this. If I went to a larger hospital, would there actually be anything that they can do (given that I don't want to risk inducing labor at 37 weeks by having an enema).Are there any scans or tests that can be used safely in pregnancy to check whether there is a fecal impaction?I'd also like to know how serious you think my situation is, based on the description I have provided.Could I be in danger of developing a complication such as sepsis or peritonitis due to fecal build up, despite the fact that I am passing small amounts of stool every day. In that case maybe the benefits of having a CT scan, X ray or enema outweigh the risks.
Thanks very much for your advice.

Expert:  Dr. Aarti Vazirani replied 3 Days.

Thank you for the detailed and insightful and well - read follow up.
It is rare to interact with patients who are so intelligent, interactive and vigilant.
Seeds are associated with fecal impaction, but in cultures where they are routinely consumed or in patients who have eaten quite a bit of them, exceeding what is normal intake.
I am sure you did not binge out on the pumpkin seeds.
To me, the association between your constipation and the pumpkin seeds seems incidental, though I can very well understand your concern regarding it.
You are also passing small amounts of stool, which would not happen in a fecal impaction.
Straining at stools, the bleeding and the reduced volume of stools points to constipation per se, and I still do not think you are having fecal impaction.
Diagnostic and therapeautic options involve enemas, which I would strongly recommend against at 37 weeks.
However, I fail to understand why a simple digital exam is not carried out, by a Specialist, it would clinch the diagnosis almost.
A CT could be done to support it , and at 37 weeks, is perfectly safe.
Also, I would say that do not go for enemas or other drastic measures, just seek a Specialist opinion, a per rectal exam is the next logical, safe step.
Carry on with the home remedies also.
You do not have any fever, pain , distension, bloating - I think you absolutely need to stop worrying about septicemia due to fecal build up as you are evacuating small amount of stools.
Again, from your history and clinical details, fecal impaction seems to be far fetched, but the constipation is severe, and necessitates a Specialist opinion and digital rectal exam, at the very least.
All the best
Will look forward to hearing from you again.
Hope this helped.

Dr. Aarti Vazirani
Category: Infertility Specialist
Residency: Obstetrics & Gynecolog, BJMC,Civil hospital, Ahmedabad, 2008
Post Graduate: MS (Obstetrics & Gynecology), B.J. Medical College, Ahmedabad, 2008
Medical School: MBBS, B.J. Medical College, Ahmedabad, 2004
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