Constipation In Pregnancy Research Articles

Probiotics combination effectively improves constipation in pregnancy by modifying the gut microbiota composition.

Constipation during pregnancy can induce serious complications, including miscarriage and preterm labour, while the evidence of probiotics in improving constipation during pregnancy was little. In this study, 29 healthy pregnant women and 65 constipated pregnant women were enrolled to assess the effectiveness of probiotics on constipation during pregnancy. Our results showed that the probiotics were effective in improving the Constipation Severity Scale (CSS) and Bristol Stool Scale (BSS) scores, including increasing defecation frequency, decreasing defecation time, and improving fecal characteristics. 16S rRNA sequencing revealed that the probiotics effectively restored the diversity of intestinal microbiota. At the phylum level, Firmicutes (13.27% vs 57.20%) and Actinobacteria (3.77% vs 12.80%) were increased, while Bacteroidetes (77.82% vs 20.24%) was decreased. At the level of the genus, Faecalibacterium (2.03% vs 10.33%), Bifidobacterium (1.21% vs 8.56%), and Phascolarctobacterium (0.05% vs 2.88%), the beneficial bacteria were increased, while the Bacteroides (29.23% vs 12.28%) and Prevotella (24.32% vs 4.92%) were decreased. In conclusion, these results indicated that probiotics can effectively relieve the constipation symptoms by improving the diversity of intestinal microbiota, regulating the disturbance of microflorae, and restoring the balance of microflorae to exert a stronger moderating effect than diet and lifestyle modification. Our results provided clinical data and a theoretical basis for the exploitation of probiotics in treating constipation during pregnancy. Chinese Clinical Trial Registry: ChiCTR2100052069.

Imbalances in the gut microbiota and metabolome are associated with functional constipation in pregnancy

Functional constipation in pregnancy (FCP) is a common gastrointestinal disorder unique to pregnant women. The gut microbiota supports gastrointestinal function and maintains immune homeostasis, suggesting gut microbiota can become the target for FCP prevention and treatment. However, it remains unclear whether and how the gut microbiota and its correlated metabolites change for FCP. In this study, we aimed to explore the role of the gut microbiota in the pathogenesis of FCP and provide a reference for the selection of probiotics in further clinical trials. We comprehensively profiled the gut microbiota, Bifdobacterium and Bacteroides communities via high throughput sequencing, and faecal metabolome based on untarged metabolomics and targeted metabolomics of short-chain fatty acids (SCFAs) in 100 patients with FCP and 100 matched pregnant controls. We found that gut dysbiosis occurs in FCP patients, characterised by a reduced abundance of SCFAs-producing bacteria (e.g., Faecaliberium) and the enrichment of several opportunistic bacteria (e.g., Escherichia-Shigella), which were highly correlated with the clinical indicators of FCP. Furthermore, a reduced abundance of anti-inflammatory metabolites was seen, particularly arachidonic acid (AA) and butyric acid. We observed a complex co-occurrence between FCP-associated microorganisms and discriminative metabolites in an integrated network, with AA and Ruminococcaceae UCG-002 being identified as the main contributors. Collectively, imbalances in the gut microbiota and metabolome are associated with functional constipation in pregnancy. These findings provide a greater understanding of the pathogenesis and targets for probiotic interventions in FCP.

Polyethylene glycol compared to lactulose for constipation in pregnancy: A randomized controlled trial.

To compare polyethylene glycol 4000 versus lactulose in chronic constipation during pregnancy. Women at 28-32 weeks' gestation attending antenatal clinic for routine care were screened using the Rome IV chronic constipation criterion. Eligible women were approached and consented. Participants were randomized to oral polyethylene glycol (10 g/day) or lactulose (10 g/day) for 4 weeks. A bowel movement diary was kept and outcomes using the Patient Assessment of Constipation Symptoms questionnaire (PAC-SYM), Patient Assessment of Constipation Quality of Life questionnaire (PAC-QoL) and Bristol Stool Form Scale (BSFS), which were evaluated at the start and end of the four-week period. Relative risks (RR) were determined for the coprimary outcomes of complete spontaneous bowel movement (CSBM) and PAC-SYM mean score improvement (decrease in score of >1 from the baseline). A total of 4323 women underwent screening, of which 780 fulfilled the Rome IV criterion, and 360 consented to participate (180 randomized to PEG and lactulose, respectively). Data from 247 women who completed the study were analyzed. CSBM was achieved in 107/124 (86.3%) versus 102/123 (82.9%) (RR 1.04, 95% CI: 0.93-1.16, P = 0.464) for PEG and lactulose trial arms, respectively. PAC-SYM mean score improvement was 62/118 (52.5%) in the PEG arm versus 44/118 (37.3%) in the lactulose arm (RR 1.40, 95% CI: 1.05-1.88). Of secondary outcomes, a significant difference was found in favor of PEG, with respect to PAC-SYM abdominal symptoms subscale, normal stool versus loose stool consistency and side effects of vomiting and diarrhea. After controlling for parity, baseline PAC-SYM, PAC-QoL scores, characteristics different at baseline, only diarrhea and loose stools remained significant. Both PEG 4000 and lactulose are effective laxatives in pregnancy with similar performance after adjusted analysis. Diarrhea and loose stools are less frequently reported with PEG.

Knowledge, attitude and practice regarding constipation in pregnancy among pregnant women in Shanghai: a cross-sectional study.

This study aims to investigate the Knowledge, Attitude, and Practice (KAP) pertaining to constipation during pregnancy among pregnant women in Shanghai. Demographic data and KAP scores were collected using a questionnaire. Differences across groups were analyzed using either Wilcoxon-Mann-Whitney tests or Kruskal-Wallis analysis of variance. Spearman's correlation analysis was utilized to evaluate the relationships between KAP scores. Multivariable logistic regression analyses were conducted to identify factors that influence KAP scores. Encompassing 241 individuals (46.6%) aged between 30 and 34 years, with 349 participants (67.5%) being nulliparous. The median scores for knowledge (possible range: 0-26), attitude (possible range: 7-35), and practice (possible range: 14-70) were 22 (18, 24), 26 (23, 29), and 51 (46, 56), respectively. Multivariate analysis indicated that being a medical professional (OR = 2.222, p = 0.043) and receiving education on constipation during pregnancy (OR = 0.432, p < 0.001) were significantly associated with higher knowledge scores. Factors significantly associated with practice included being aged 30-34 years (OR = 2.745, p < 0.001), aged 35 years and above (OR = 2.514, p < 0.001), working in education (OR = 2.310, p = 0.012), and not experiencing constipation before pregnancy (OR = 1.894, p = 0.001). Pregnant women demonstrated satisfactory knowledge, positive attitudes, and proactive practices concerning constipation during pregnancy. To further augment clinical practice, healthcare providers should tailor educational interventions and guidance specifically for pregnant women who are not medical professionals and those who have not received education and guidance related to constipation during pregnancy.

Evaluation and treatment of constipation in pregnancy:Examination using the Japanese version of the constipation evaluation scale.

No study has examined the effects of new constipation treatment drugs released in recent years in pregnant women. This prospective cohort study aimed to examine and compare the perinatal prognosis, efficacy rate, and safety of drugs frequently used to treat constipation. The study included 211 perinatally managed individuals who answered a self-administered questionnaire during the second trimester and after delivery. The Japanese version of the constipation evaluation scale (Constipation Assessment Scale [CAS] long-term [LT] version) was used for the subjective evaluation of defecation status. Participants aware of constipation had significantly higher CAS scores than those who were unaware. Some participants with a CAS score of 5 points (treatment range) had no subjective symptoms of constipation, whereas some participants with a CAS score of ≤ 5 points were aware of constipation. Regarding the time of onset, 60% of those who had constipation before pregnancy had a high rate of constipation during pregnancy and after delivery. No significant difference was noted in conventional magnesium oxide and polyethylene glycol, a relatively new daily treatment drug, in perinatal prognosis or side effects. Polyethylene glycol preparations alleviate constipation without inducing diarrhea, making them an appropriate therapeutic option for pregnant women.

Perianal Complications in Puerperium and Associated Risk Factors

Abstract Introduction Puerperium is defined as the period of about 6 weeks after childbirth during which the mother's reproductive organs return to their original nonpregnant condition. Perianal problems, including constipation, hemorrhoids, and fissure, are among the most common digestive complications among women in puerperium, observed in about 30 to 50 percent of women. Considering this great prevalence and the paucity of similar research in this aspect in an Indian population, the present study was done to assess the prevalence of perianal problems seen in puerperium and the risk factors associated with it. Methods This was a prospective observational cohort study done over the span of 3 years on 902 puerperal women. A self-structured questionnaire covered detailed history and per-rectal and proctoscopy examination. Patients were followed up telephonically for regression of perianal problems post management. Results The total prevalence of all the perianal problems in puerperium encountered in the present study, out of 902 subjects, was 36.3% (327 subjects). The perianal problems encountered were fissure in 185 patients (20.5%) followed by hemorrhoids in 110 patients (12.2%), perianal episiotomy infections in 25 patients (2.8%), and perineal tears in 7 patients (0.8%). On comparative analysis, positive family history, macrosomia, past history of perianal diseases, and second stage of labour &gt; 50 minutes showed a higher prevalence in the perianal disease group as compared with the healthy group. Out of these, positive family history of perianal diseases (p = 0.015) and past history of perianal diseases (p = 0.016) were statistically significant. The percentage of multipara with hemorrhoids was more when compared to primipara (p = 0.01), patients who had a past history of any perianal disease have a higher chance of hemorrhoids during puerperium (p = 0.00). Patients with constipation in pregnancy have higher chance of hemorrhoids in pregnancy (p = 0.00). Patients who had a past history of any perianal disease had higher chance of fissure during puerperium (p = 0.00). A total of 27.74% of the study subjects with macrosomic babies had fissure in their puerperal period which on comparison with patients with non macrosomic babies was only 19.22%, which was statistically significant (p = 0.02). Conclusion Constipation, hemorrhoids, and anal fissures are the most common perianal problems in postpartum period causing significant reduction in the quality of life of those afflicted with them.

Genjer Extract As An Alternative Preventing Constipation In Pregnancy

Background : Constipation is a problem that is always disturbing in pregnant women, in general trimester pregnant women 3. Constipation is a difficult condition or unable to defecate, hard stool, a sense of defecation is not complete (there is a sense of wanting to defecate but unable to remove it) accompanied by complaints of the stomach feeling full and bloating. If this problem is left alone it will have an impact on the process of childbirth and childbirth. Objectives : The purpose of this study can be seen the effect of giving genjer extract as an alternative to prevent constipation during pregnancy at PMB Rusmiati Karang Tengah Tarumajaya Research Methods : This research design uses the quasi-experimental study method with pretest-posttest with control group design with a total of 32 respondents. The technique used in this study is a saturated sample. Results : The results of the study were found that after consuming the genjer extract of pregnant women who experience constipation into non-constipation it is shown in the occurrence of chapters for 2 weeks in pregnant women to normal. Conclusion : There is an effectiveness of the effect of providing genjer extract consumption as an alternative to prevent constipation during pregnancy.

Hubungan Aktifitas Fisik Ibu Hamil Dengan Konstipasi Masa Kehamilan

Constipation occurs in about 11-13% of pregnancies by symptoms of difficulty on defecating, lower abdominal pain and frequency of passing stools of 3 times a week, causing discomfort and anxiety for pregnant women. The study was to determine the relationship between physical activity and constipation.The research method is correlation analytic cross sectional approach. Data retrieval is from June to December 2020 at Praktik Mandiri (midwifery services) at Jatikalang Kec. Prambon, Sidoarjo. Population: All 3rd trimester pregnant women totaled 37 people in 2020, or it is called total population sample. Collecting data is by direct questionnaire on statements of light physical activity, moderate physical activity and heavy physical activity. Data analysis uses simple correlation test statistics.Research results indicate that pregnant women who experience constipation do more light activities are 13 people (100%, moderate physical activity are of 13 people (92.9%) than those who are not constipated on heavy physical activity as many as 10 people (100%), moderate physical activity being 1 person (7.1%).The results of the statistical test of the correlation between physical activity and constipation in pregnant women have positive value of 0.821, indicating very strong correlation between physical activity and constipation, significant (2-tailed) 0.00 &lt; 0.01, the higher the physical activity of pregnant women, the higher the occurrence of constipation.Conclusions from this study; There is a strong relationship between physical activity and constipation in pregnant women, namely light physical activity and moderate physical activity less than 30 minutes at risk of constipation. Suggestions for preventing constipation can be done by doing physical activity more than 30 minutes a day, consuming high-fiber nutritional diet and drinking enough mineral water to prevent constipation in pregnancy.

Functional constipation during and after pregnancy

Functional constipation is a common problem in pregnancy and postpartum period and is now considered not just a medical problem but also a factor influencing the quality of life. The frequency of defecation differs in people. Recent years specialists prefer personalized evaluation of the frequency of defecation for exact diagnostics of the condition, but not the classic definition. Functional constipation in pregnancy is caused by functional and anatomy changes of gastrointestinal tract and also by hormonal changes in pregnancy. Early diagnosis and correction of this pathology is one of the main objectives when managing normal pregnancy. This review covers current information on the theme, contains recommendations about the lifestyle during pregnancy and postpartum period and treatment options. Some foreign and Russian authors note the effectiveness of sodium picosulfate which accelerates the passage of the feces in a short time. It can be used during II and III trimesters of pregnancy as well as in the postpartum period and breastfeeding. Thus, complex correction of factors causing functional constipation decreases the risk of colon diseases as well as of all gastrointestinal tract in pregnant women and in the puerperium.

AKT answer relating to constipation in pregnancy

AKT answer relating to constipation in pregnancy

AKT question relating to constipation in pregnancy

AKT question relating to constipation in pregnancy

Constipation in pregnancy. Approaches to the treatment

Constipation is one of the most common problems. About half of pregnant women experience stool retention, which occurs due to maternal physiological changes in pregnancy: the action of progesterone, uterine growth and other causes, can cause complications of pregnancy, childbirth and the postpartum period and requires treatment. However, this condition is not discussed enough among obstetrician-gynecologists. In the authors’ opinion, the importance of the problem is underestimated. The clinical data provided in the text of the article show that intestinal biocenosis disorder due to chronic colostasis in pregnant women can become a predisposing factor for bacterial vaginosis. In addition, constipation in pregnancy is one of the risk factors that may increase the rate of preterm birth, premature rupture of membranes, birth of small-for-date babies and other complications. For these reasons, the problem demands close attention of the medical community. The article provides basic information about the causes, endocrine, metabolic and other prerequisites for constipation, the features of their manifestations during pregnancy, possible complications, modern pharmacological and non-pharmacological treatments and lifestyle correction capabilities. The authors provided a list of essential drugs to treat constipation, described indications and contraindications for use of such drugs during pregnancy and listed side effects. Sodium picosulfate may be used in the second and third trimesters, which restores the passage of stools in the intestine in a short time and is not contraindicated in a pregnancy. Consideration has been given to the usage of the drug in the practice of obstetrician-gynecologists.

Functional Constipation in Pregnancy; Need to Furnish Some More Emphasis

Objectives: This study was conducted to determine the occurrence of functional constipation in ob- stetric population in our context and to explore the extent to which pregnant females were aware of the problem and their usual practices to deal with it.&#x0D; Methodology: This was a cross sectional study conducted on 332 pregnant females, from June 2017 to June 2018 in gynaecology unit 3, Karachi Medical and Dental College (using a convenient sam- pling technique after taking ethical approval). All the pregnant females visiting antenatal out-patient department from age 17 - 46 years were included in the study. The validated Rome III criteria were used to diagnose functional constipation. Information regarding awareness of constipation and de- mographic data, with the measure used for relief of constipation identified.The data analysis was per- formed by SPSS version 20. Qualitative data was presented as frequency and percentage. Bar graph was also used for presentation of the qualitative data.&#x0D; Results: Out of the total of 332 pregnant females, functional constipation was observed in 207 (62.3%) females according to the Rome III Criteria. Evaluating the awareness of constipation and its associated problems during pregnancy our study showed that 61.1% pregnant females responded positively when reporting to doctor about constipation. While encountering functional constipation the most commonly used remedial measure was Ispaghol (Husk) observed in 74 (35.7%) pregnant fe- males. The observations of our study revealed that 89 (43.0%) pregnant women having functional constipation were well aware about constipation and its consequences in pregnancy.&#x0D; Conclusion: It is concluded that functional constipation occurs commonly in pregnancy in our context. Moreover, these females were mostly well aware of constipation and its worst outcomes during pregnancy.

The Prevalence and Risk Factors of Constipation in Pregnancy

&#x0D; &#x0D; Objective: To estimate the prevalence of constipation inpregnancy and correlation between gestational age, dietaryfiber intake, water comsumption, and physical activity.&#x0D; &#x0D; Methods: This study used cross-sectional design with samples of174 healthy pregnant women undergoing antenatal care atObstetrics and Gynecology Outpatient Clinic RSCM during August -October 2016. Data were collected using questionnaire. Diagnosisof constipation was based on ROME III criteria, dietary fiber ismeasured using Food Frequency Questionnaire (FFQ), and physicalactivity was measured using International Physical Activity Questionnaire(IPAQ). Chi-square and Fisher’s exact test were conducted toevaluate the association between variables.&#x0D; &#x0D; Results: The prevalence of constipation in pregnant womenobserved in this study was 13.2% (95% CI 8.3-18.1). The mostfrequent complaints included straining, incomplete evacuation,and anorectal obstruction. Dietary fiber intake was low in 81.03%subject. with average dietary fiber intake of 18.97 gram/day.There was no significant association between constipation andgestational age (OR 4.36, 95%CI 0.51-37.48 for second trimesterand OR 2.04, 95%CI 0.25-16.7 for third trimester), dietaryfiber intake (OR 0.82, 95%CI 0.28-2.39), water consumption(OR 1.38, 95%CI 0.56-3.41), and physical activity (OR 1.167,95%CI 0.28-4.87).&#x0D; &#x0D; Conclusion: Prevalence of constipation in pregnant women is13.2%. There is no significant correlation between gestational age,dietary fiber intake, water consumption, and physical activity.&#x0D; &#x0D; Keywords: constipation, pregnant woman, ROME III

Constipation in pregnancy: causes and remedies

Constipation is a common gastrointestinal complaint in pregnancy that occurs in about 11-40% of the women. It is described by symptoms like pain, distress, straining, hard lumpy stools and a sense of incomplete bowel evacuation. Diet rich in fiber and increased fluid intake is recommended to improve defecation. The use of laxatives and probiotics is also reported to alleviate constipation, though the safety and efficacy of laxatives and probiotics on the mother and fetus need to be established. This review article provides an insight on different factors leading to constipation in pregnancy and evaluation of different remedies used for the treatment of constipation in pregnancy.

The effect of glucomannan on pregnancy constipation.

Introduction:Constipation is a common complication among pregnant women; it refers to hard and infrequent bowel movements where the stools defected from body becomes hard and dry, as well. various medical interventions are nowadays implemented to treat constipation, Some of which are either banned or not willingly implemented by pregnant women; thus, doctors try to avoid such methods. Glucomannan, a combination of a few simple sugars, is an effective substance for treating constipation. According to the results of studies conducted in this area, glucomannan has been greatly welcomed and approved by pregnant women. Thus, the present study was conducted to investigate the effect of glucomannan on pregnancy constipation and to compare it with other common treatment methods.Materials and Methods:This study is a clinical trial in which 64 pregnant women with constipation were investigated in the two groups of intervention and control (32 participants in each group). All participants were in their third trimester of pregnancy. The intervention group was treated with glucomannan, while the control group was treated with magnesium hydroxide. After 1 month, the participants were investigated and the questionnaires were responded to. The collected data were analyzed using the SPSS software and Chi-square tests.Results:The post-treatment frequency of bowel repulses increased in both the groups. However, the increase was different in the two groups. About 75% of the participants in the glucomannan group reported having at least 6 times of bowel movements. Moreover, 25% of the participants in the glucomannan group reported having >6 times of bowel movements. Using a Chi-square test, it was found that there is a significant difference between pre- and post-treatment frequency of bowel movements per week (P = 0.002). Moreover, there was a significant difference between the post-intervention frequency of bowel movements in the two groups (P = 0.001).Discussion:In the present study, it was attempted to investigate the effect of glucomannan on pregnancy constipation. The findings indicated that glucomannan is likely to improve constipation symptoms in pregnancy and reduce pregnant women's complaints to a significant level through increasing the frequency of bowel movements and affecting the stool consistency.Conclusion:Along with other treatment methods, glucomannan is recommended as a healthy medicinal plant for treating pregnancy constipation.

What interventions are most effective for treating constipation in pregnancy or immediately postpartum?

What interventions are most effective for treating constipation in pregnancy or immediately postpartum?

Pharmacists counselling of pregnant women: Web-based, comparative study between Serbia and Norway

ObjectivesTo describe, compare and evaluate whether pharmacists in two European countries, Serbia and Norway, give appropriate counselling for common ailments in pregnancy. DesignA cross sectional, web-based study. Participants and Settings: A study was conducted among Serbian and Norwegian pharmacists during two four-month study periods in 2012 respectively 2014. Participants were recruited through postal and electronic invitation facilitated by several pharmacy chains. Participation in the study was anonymous and voluntary. Measurement instrumentPharmacists were presented with the questionnaire that included five scenarios (back pain, heavy legs, nausea, cold and constipation in pregnancy) and were asked to give their advice about use of medicines, supplements (e.g. herbal products, vitamins, minerals), non-pharmacological treatment and referral to physician in each condition. FindingsIn total, 276 pharmacists, 119 in Serbia and 157 in Norway, accepted to participate in the study. Recommendation about medicines use ranged from 32% (heavy legs) to 71% (back pain) in Serbia and from 3% (heavy legs) to 92% (constipation) in Norway. Several pharmacists' recommendations on medicines and supplements use were inappropriate. Recommendation about non-pharmacological treatments ranged from 11% (nausea) to 50% (heavy legs) in Serbia and from 12% (constipation) to 63% (cold) in Norway. Approximately 12% of the Norwegian and Serbian pharmacists offered referral to a physician as only advice for nausea in pregnancy, indicating a lack of confidence in or knowledge about this common ailment in pregnancy. Key conclusions and implications for practiceLarge differences in counselling of pregnant women by pharmacists in Serbia and Norway were observed. Enhancement of pharmacists' knowledge about treatment of common ailments in pregnancy is needed and will enhance pharmacists' role in improving maternal health.

Prevention of constipation during pregnancy with the hydration.

Introduction: Constipation is a functional bowel disorder characterized by pain and discomfort, straining, hard stools and feeling of incomplete bowel movement. Pregnancy predisposes to constipation, about a third of pregnant women report suffering from constipation. It is more common in multiparous than primiparous. Objective: Knowing how hydration affects the prevention of constipation during pregnancy. Method: A literature search was performed in the following databases: Cochrane, IME, Pubmed, Cuiden and the website of the Spanish Society of Obstetrics and Gynecology. Results: Constipation in pregnancy is probably due to reduced gastrointestinal motility by an increase in the concentration of circulating progesterone during pregnancy, resulting in a slowing of gastric emptying and intestinal transit for its relaxing effect on the smooth muscle. Conduct an adequate fluid intake helps prevent constipation. This should include about 8 glasses of water a day and a glass of fruit juice, especially plums. Conclusions: In pregnancy is important to have a balanced diet and drink adequate amount of fluids within an active lifestyle and healthy life. Proper hydration during pregnancy benefits the fetus and the mother.

Management of opioid-induced constipation in pregnancy: a concise review with emphasis on the PAMORAs.

Opioid-induced constipation (OIC) is one of the most common opioid-induced adverse effects. Pregnancy also predisposes to bowel dysfunctions due to the associated endocrine changes. Pregnant women are thus at greater risk of OIC. We review the non-pharmacologic and pharmacologic treatment options as a guide for achieving a clinically optimal strategy for the management of OIC during pregnancy. The published literature was searched for current therapeutic options, including non-pharmacologic dietary modifications, laxatives, and the peripherally acting mu-opioid receptor antagonists (PAMORAs). Each was assessed for efficacy and safety, particularly as they relate to pregnancy. Non-pharmacologic approaches such as dietary change are generally safe, but generally insufficient when used alone to control OIC in pregnancy. Laxatives (bulking, osmotic, stimulant) can be effective, but have potential adverse effects that might be particularly troublesome during pregnancy (e.g. electrolyte disturbances, dehydration, abdominal pain, and pulmonary oedema or hypermagnesaemia in the extreme). PAMORAs, which attenuate OIC without affecting opioid-induced analgesia, have been associated with only minimal side effects during the clinical studies to date. Conventional non-pharmacologic and pharmacologic options for the management of OIC in pregnancy are often suboptimal due to insufficient efficacy or adverse effects particularly troublesome during pregnancy. The PAMORA strategy appears to provide a safe and effective new option superior to conventional therapies for the management of OIC during pregnancy.