How Pregnancy Affects Digestive Health

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, colorectal surgeon and president at Main Campus here at Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to have Dr. Erica Newlin on who's a staff physician in the Department of Obstetrics and Gynecology here at the Cleveland Clinic. And we're going to talk a little bit about how pregnancy affects digestive health. Dr. Newlin, thanks so much for joining us here on Butts & Guts.

Dr. Erica Newlin: Yeah, thanks so much for having me.

Dr. Scott Steele: So as you and our listeners know, I always like to start out with a little bit of background. Tell us where you're from, where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Erica Newlin: Sure. So I actually went to medical school in Orlando, Florida and then matched at the beautiful Cleveland Clinic for residency. So I did my OB-GYN residency here at the clinic and then decided to stay. Yeah, my husband and I live in Shaker Heights and we have loved being at the clinic. I'm an OB-GYN specialist and do general obstetrics, gynecology, also vulvar care at our Westlake office.

Dr. Scott Steele: That's fantastic. For those non-Clevelanders, to have an Eastsider actually work on the Westside is a little bit of an anomaly. So today, as I said, we're going to talk a little bit about the effects of pregnancy and what they can have on digestive health. So Dr. Newlin to start, how do pregnancy hormones like progesterone and relaxin specifically affect the digestive system?

Dr. Erica Newlin: So during pregnancy, you see elevated levels of progesterone and relaxin. So I always tell patients that whenever we were naming hormones, we weren't very creative with relaxin. Relaxin basically works to relax all of the smooth muscles including that in the GI tract. So we see a slowing of everything, slowing of the colon, the small intestine. So we see a lot of constipation, a lot of bloating. And then progesterone can contribute to that as well. So those hormones also relax the lower esophageal sphincter muscle, which is the muscle that controls the tube that goes from your throat to your stomach. So that's why you're seeing a lot of heartburn in pregnancy.

Dr. Scott Steele: So you talked a little bit about lots of heartburn in the pregnant woman, especially during the first trimester. So does this differ from regular heartburn or is it just kind of that physiological effect that leads to the same end result?

Dr. Erica Newlin: So certainly people who are already prone to heartburn see that much more so in pregnancy, but people who have never experienced heartburn before tend to see it more often in pregnancy. So even starting in the first trimester, you can start to be a little more sensitive to reflux and heartburn. And then as the uterus grows, as baby is inhabiting space, I pretty much tell my patients that you have feet where your stomach once was and everything's pushing up. So certainly people can experience heartburn that they never have before.

Dr. Scott Steele: Well, definitely that's an image I won't forget anytime soon. So I could ask you this next question, with any of the things that we talk about conditions, because we're always cognizant of the type of medications or what we put into our body for our pregnant moms out there. So what's the safest way for expectant moms to treat heartburn or acid reflux?

Dr. Erica Newlin: Often the first step is, as with a lot of conditions, is lifestyle modifications. So often eating smaller meals, avoiding eating late at night, avoiding trigger foods. And trigger foods are often spicy foods, caffeine, chocolate, things that are very greasy, any of your more kind of indulgent meals can also trigger heartburn. And then if that's still not cutting it, then over-the-counter antacids like Tums or Rolaids are generally considered safe in pregnancy. But I've had patients come to me sometimes and be like, "Yeah, I'm taking 10 Tums a day." It's like, "No, well, let's not do that." So things like famotidine are generally considered safe in pregnancy.

Dr. Erica Newlin: It's always difficult in pregnancy because we're never going to do what's called randomized control trials. So no one's going to, usually in pregnancy for medications, have a group that's not taking it versus a group that is. So most of what we're seeing in pregnancy are retrospective trials, meaning we're looking back seeing, "Okay, people who took Pepcid in pregnancy didn't tend to have a problem." So Pepcid or famotidine is considered to be safe. If people are still having problematic symptoms after that, then we can move on to what's called the proton pump inhibitors like Pantoprazole.

Dr. Scott Steele: Fantastic. And so how does that growing uterus physically impact digestion throughout each trimester? And then as a result of that, what digestive issues are the most common in each trimester?

Dr. Erica Newlin: So in the first trimester, the uterus usually isn't taking up very much space. So the issues we're seeing with digestion in the first trimester are usually due to those hormones that we referenced before. So the progesterone, the relaxin, in addition to there is a hormone very early in pregnancy called HCG. And the HCG level early in pregnancy is what's usually leading to what's referred to as morning sickness. So despite its name, morning sickness can be throughout the entire day. It's the nausea and vomiting that's generally associated with pregnancy.

Dr. Erica Newlin: And then as you move into the second trimester, the uterus is growing a little more, starting to take up a little more space. Usually the HCG levels having gone down, the nausea and vomiting have decreased. I can never make promises. I often tell patients that the nausea and vomiting can continue through pregnancy, but the majority of people are seeing relief of their nausea and vomiting from the first trimester in that second trimester. But you're starting to see a little more of the constipation, a little more of the bloating. And then by the third trimester baby is taking up a lot of space, so can certainly have a lot more of that heartburn, a lot more of that acid reflux in addition to that constipation symptom.

Dr. Scott Steele: So how do pregnancy-related digestive changes affect the nutrient absorption? And should women take maybe special or specific probiotics or postbiotics to support their digestive health during pregnancy? You may pick up an article or see an ad or something about this and does it really work, is there good science behind it?

Dr. Erica Newlin: Yeah, really an area of developing research. So as I mentioned, as far as nutrient absorption, we discussed that things are a little slower during pregnancy. So there's some evidence for a greater capacity for glucose uptake, but really not seeing much change as far as uptake of other nutrients. There are also hormones like human placental lactogen and that makes us less sensitive to insulin. So that can lead to higher blood sugar levels. So that change in insulin sensitivity is why some pregnant people get diabetes in pregnancy, which then resolves after delivery.

Dr. Erica Newlin: Probiotics in pregnancy is a hot topic. There is a lot of research suggesting that while it's not harmful, the benefit is debatable. So some studies have shown it may help with everything from depression to gestational diabetes, but then when they do big reviews of these trials, nothing is definite. It's been tough to replicate a lot of these studies. So more so than spending a lot of money on supplements, I would say it's better to make sure you're eating a balanced diet. You can include some probiotics like yogurt, some of probiotic foods like sauerkraut or kefir. You want to make sure that it's pasteurized and a lot of that pasteurization may decrease the probiotic effect.

Dr. Erica Newlin: So really looking at yogurt as one of the primary ones. There is some evidence that a less inflammatory diet, so decreasing your refined sugars, red meat, foods that are high of saturated fats may be more benefit to digestive health than those supplements because it tends to promote good bacteria growth.

Dr. Scott Steele: So in sum, you would say that maybe a little bit of some anecdotal, a little bit of that out there, but not certainly something that every pregnant woman should take.

Dr. Erica Newlin: Yeah. I have a lot of patients who come to me interested in it, and like I mentioned, there's unlikely to be harm, but it's one of those things where there are a lot of targeted ads, a lot of promotion for these things, and it's probably not worth the money.

Dr. Scott Steele: So kind of moving into my neck of the woods a little bit.

Dr. Erica Newlin: Sure.

Dr. Scott Steele: If you will, what's the relationship between pregnancy, constipation and hemorrhoids, and what preventative measures work the best?

Dr. Erica Newlin: So like we talked about, the digestion tends to slow down. And as you think about digestion slowing in the colon, you get more water absorption in the colon, which then leads to more constipation in pregnancy. So with constipation and with straining to poop comes hemorrhoids. And the main preventive measures that people can take are consuming a high fiber diet, with that, drinking a ton of water, engaging regular exercise, and then doing what you can to not strain with bowel movements, because the more that you're straining, the more you're going to provoke those hemorrhoids.

Dr. Scott Steele: Yeah, no question this can be an issue. And oftentimes, we may get consulted as colorectal surgeons for that thrombosed hemorrhoid, and it's acute one, and they can even be circumferential and really, really morbid. We try our best to manage those conservatively. And then long-term, see, because in many cases they'll be able to go away in the long-term. So can you talk a little bit more about the connection between morning sickness and digestive health during and after the first trimester?

Dr. Erica Newlin: Sure. So like I mentioned, the name morning sickness is the name that we've given to nausea and vomiting in pregnancy. It can happen throughout the day, certainly isn't confined to the morning, but can be triggered by a period of time not eating. So that's why some people find that it's worse in the morning. It's caused by that hormone HCG which is highest in the early part of pregnancy. So we're seeing most of the symptoms before 10 weeks. Usually the symptoms are starting to decrease after 10 weeks. And then for most women, it can be handled with conservative measures. So eating regular meals, trying to avoid triggers. But some people do need medications to help with the morning sickness.

Dr. Scott Steele: So what is the pregnancy microbiome and how does it affect the overall gut microbiome?

Dr. Erica Newlin: So the microbiome is just consists of the bacteria that lives on or in us, from the bacteria on our skin to our vagina to our gut, kind of everywhere. So changes in pregnancy like slow digestion, the increase in progesterone, just pregnancy itself is a "inflammatory process". So we see a higher white blood cell count, more of those inflammatory aspects in the blood, that can affect the bacteria that live everywhere on us, particularly in the vagina. And the vagina is very close to our butt. So we do see some changes in the pregnancy microbiome and in the small intestine and the colon just due to those changes in digestion.

Dr. Erica Newlin: But like we talked about before, there hasn't been good evidence to show that any sort of probiotics or prebiotics might be helpful. It is an area of study, particularly as far as the vaginal microbiome. Implications in things like preterm labor, but again, like I talked about, really focusing on eating well, exercising, some evidence towards a less inflammatory diet. Those are things that I think people could focus on that might be easy changes to make in their lifestyle.

Dr. Scott Steele: That's fantastic. And it seems like something that we can kind of all do. So how about exercise, specific exercise or exercise in general support digestive health?

Dr. Erica Newlin: Yeah, so exercise in general is something that I always recommend in pregnancy. I think sometimes you have to overcome that hurdle because it's always someone's mom or mother-in-law who's like, "Oh, no, no, you can't exercise in pregnancy. You shouldn't lift anything." And certainly if someone is already leading an active lifestyle, they can continue to do cardiovascular exercise and can continue to do some lifting within reason. And then there has been some evidence that exercise in general may increase your likelihood of having a vaginal delivery.

Dr. Erica Newlin: Exercise and regular movement can decrease that risk of constipation, it keeps everything moving, helps you feeling good. Any activity is beneficial. Certainly I tell people who aren't usually exercising that it's not the time to start training for an Ironman, but things like walking, swimming, prenatal yoga are really awesome places to start.

Dr. Scott Steele: So what digestive issues commonly persist after delivery? Hemorrhoids could be one of them for sure, but how long might they take to resolve?

Dr. Erica Newlin: So it can really range. So in the immediate postpartum period, people often still have a bit of constipation. People often talk to each other about that first poop after their C-section or that first poop after delivery. And making sure that you're drinking a ton of water and walking around immediately after delivery and after your C-section can really help with that initial constipation. People who have had a C-section, sometimes it takes a little bit of time for their bowels to "wake up" after surgery, similar to other abdominal surgeries. Also with vaginal deliveries, if there is any sort of tearing or prolonged pushing, then sometimes we can see changes in the pelvic floor that can lead to incontinence, so leaking of poop. And that may be something that people will see something like pelvic floor physical therapy for to help strengthen those muscles, help get back to where they were.

Dr. Erica Newlin: Most constipation issues after delivery resolve pretty quickly. It's usually more of the long-term pelvic floor issues that we see lasting further out. Hemorrhoids certainly tend to improve in the first four weeks or so after delivery, but some people do find that things just aren't the same as they were as before they got pregnant. So that's one of the reasons to really try to maintain a high fiber diet, try to drink a lot of water, try to really avoid... Some changes in our body after pregnancy are not preventable, but certainly trying as much as you can to avoid straining with pooping can decrease your risk for long-term issues.

Dr. Scott Steele: That's fantastic. And so for all of those listeners out there that may have some chronic conditions, especially associated with constipation, I encourage you to listen to other episodes on the pelvic floor that you can get a lot more detailed information on that. And so now it's time for our quick hitters, a chance to get to know Dr. Newlin a little bit better. So first of all, what was your first car?

Dr. Erica Newlin: I had a gray Nissan Maxima. I forget what year it was. I think it would age me to say, I think it might've been like 2002 Nissan Maxima.

Dr. Scott Steele: Fantastic. So some of us are much older than you. So what is your favorite meal?

Dr. Erica Newlin: I'll have pizza anytime and anywhere.

Dr. Scott Steele: Fantastic. Is there a favorite trip you might've taken or looking forward to take?

Dr. Erica Newlin: We just got back from Disney World with my 5-year-old a couple months ago. It was really fun to see him go to Star Wars World.

Dr. Scott Steele: Fantastic. And then finally, do you have a hidden talent or maybe one that not as many people know about?

Dr. Erica Newlin: I have a black belt in Japanese Shotokan karate.

Dr. Scott Steele: Wow. I don't even know what that is, but it sounds scary. So give us a final take-home message to our listeners regarding how pregnancy affects digestive health.

Dr. Erica Newlin: The main underline is try to eat well, try to stay with exercising, and certainly if you have any issues with constipation, leaking stool, anything that you're worried about, don't be afraid to bring it up to your OB while you're pregnant because we've heard it all, we've seen it all, and it's something that we're used to talking to. So certainly don't feel like you have to suffer.

Dr. Scott Steele: That's fantastic advice and no question. And so to learn a little bit more about these disorders or to connect with Dr. Newlin or another OB-GYN provider here at the Cleveland Clinic, please call Obstetrics and Gynecology Institute at 216.444.6601. That's 216.444.6601. You can also visit our website at clevelandclinic.org/womenshealth. That's clevelandclinic.org/W-O-M-E-N-S-H-E-A-L-T-H. Dr. Newlin, thanks so much for joining us on Butts & Guts.

Dr. Erica Newlin: Yeah, thank you. And if anyone is interested in learning more about pregnancy or OB-GYN issues, we have a podcast with our OB-GYN Institute called Ob/Gyn Time. So you can find that anywhere you listen to your podcast.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.