Medical considerations of the pregnancy in dental treatment

Reporter : 碩一 吳和泰Supervisor : 雷文天 大夫

高壽延 主任

Maternal concerns Fetal concerns Radiography Medication Summary

Maternal concernsMaternal concerns Fetal concerns Radiography Medication Summary

Maternal concernsMaternal concerns

Anatomic change Physiology changes Psychological changes

Anatomic changesAnatomic changes

Uterus weight from 70gm 1 kg Uterus volume from 10ml 5000 ml Supine hypotensive syndrome

Acute hypotensive episode

Supine hypotensive syndromeSupine hypotensive syndrome Third trimeter 10~15% Compression of inferior vena cava & aorta Decrease venous return to heart Decrease uteroplacental perfusion and fet

al distress

PreventionPrevention

Left lateral decubitus position Elevation the right hip 10~12cm Sit up position

Physiologic changesPhysiologic changes

Cardiovascular system Respiratory system Gastrointestinal system Renal system Hematological system

Cardiovascular systemCardiovascular system

Cardiac output increase 40% Mean arterial BP decrease Total blood volume increase 40~50%

(1500ml) 14th to 30th weeks heart rate increase

10 beats/min

Respiratory systemRespiratory system

Diaphragm is displaced upward 3~4cm & rib flare out with chest circumference of 5~7 cm

Oxygen consumption increase 15~20 % Respiratory rate increase

Gastrointestinal systemGastrointestinal system

Increase gastric acid production Decrease gastric mobility Incompetence of gastroesophageal sphinc

ter Esophageal reflux Pernicious vomiting Constipation

Renal systemRenal system

Increase GFR Increase renal plasma flow Urinary tract infection

Hematological systemHematological system

Plasma volume increase 40~70c.c./kg Red cell volume increase 25-30c.c./kg Hemoglobin & hematocrit volume decreas

e Plasma levels of factors VII, VIII, X and fibr

inogen increase Fibrinolytic activity decrease

Psychological changesPsychological changes

Hypersensitivity regarding her size & appearance

Fear of pain, disability, death and for baby Fear of dental procedures Sedation empathy and reassurance Minimize disturbance interruption & noises & to

adjust room temperature & to minimize possible irritability

Maternal concerns

Fetal concernsFetal concerns Radiography Medication Summary

Fetal concernFetal concern

Fetal developmentOvum- from fertilization to implantation periodEmbryonic period- from the second through

eighth weekFetal period- after the eighth week until term

Ovum periodOvum period

Conception( 受孕 ) to 17 days Cellular mitotic activity Sensitivity to toxic substances which may

precipitate spontaneous abortion

Embryonic periodEmbryonic period

18-55 days (2nd~8th wk) Organogenesis Functional & morphologic malformation

Fetal periodFetal period

56 days until parturition Growth & development

The First Trimester (0-12 Weeks) The Second Trimester (13-28 Weeks)The Second Trimester (13-28 Weeks) The Third Trimester (29-40 Weeks)

The Second TrimesterThe Second Trimester

First trimesterFirst trimester

Most of the baby structure begin to develop

Most susceptible to the risks of physical and mental abnormalities

50% of abortion 5~7 wks in uterus cleft in lips & palate

Fetal concernsFetal concerns

Avoidance of fetal hypoxia Avoidance of premature abortion Avoidance of teratogens

Avoidance of fetal hypoxiaAvoidance of fetal hypoxia

Uteroplacental blood flow & maternal oxygenation

Hgb = 17gm/dl enhanced ability to extract oxygen from maternal circulation

Maternal hypoxia from hypoventilation or hypotention

Avoidance of premature abortionAvoidance of premature abortion

Site of position No relationship between premature labor

( 分娩 ) & local anesthesia G.A. increase of fetal loss

Avoidance of teratogensAvoidance of teratogens

Before implantation (14days) death of the ovum

14-60 days major morphologic defects (organogenesis)

60 days later function impairment (reduce intellect)

Maternal concerns Fetal concerns

RadiographyRadiography Medication Summary

RadiographyRadiography

High dose (over 250rads) prior to 16 wks Microcephaly Mental retardation Cataracts ( 白內障 )

Microphthalamia Growth retardation Spontaneous abortion

High dose after 20 wks Hair loss Skin lesions Bone marrow suppression

Hazard from irradiation of Hazard from irradiation of embryoembryo Death of embryo Birth of a deformed child Increase frequency of malignancy

decrease in childhood e.g. leukemia

Hazard from irradiation of Hazard from irradiation of embryoembryo 1 rad of utero radiation exposure has been

estimated to be approximately 0.1% malignant disease

A dental periapical film 0.00001 rad (0.1 mrad)

Naturally occurring 1/2000

RadiographyRadiography

An adverse fetal effects is unlikely to result from exposure to less than 5 rads with lead apron in place the female gonadal dose from a single periapical radiographs is about 0.1 mrad.

Procedure in making radiographs Procedure in making radiographs for pregnancy patientsfor pregnancy patients Make only the film absolutely essential for

diagnosing the conditions Use lead-shielding Use long cone Use proper collimation & shielding Limited to affected tooth Extra care should be used while taking essential

films to eliminate the need for repeated exposure

Maternal concerns Fetal concerns Radiography

MedicationMedication Summary

MedicationMedication

Local anesthesia Antibiotics Analgesics Corticosteroids Sedatives

Food and drug administration Food and drug administration (F.D.A) classification system(F.D.A) classification system

Local anesthesiaLocal anesthesia

Local anesthesia are not teratogenic, and may administered to pregnancy patient is usual clinical doses.

Large dose of prilocaine are know to cause methemoglobinemia ( 變性血紅素血症 ) which could cause maternal & fetal hypoxia.

VasoconstrictorsVasoconstrictors

Local vasoconstriction Delay uptake from the site of injection Increase the effectiveness & duration

There is no specific contraindication to these vasoconstrictors in a pregnant patient although it is prudent to use minimal effective dose.

Local anesthesiaLocal anesthesia

Convulsion in a sensitized mother could also exert a teratogenic effect second to hypoxia

The need for careful Hx taking & for aspiration & slow injected technique is obvious.

AntibioticsAntibioticsPenicillinPenicillin FDAB All trimester are safe No teratogenic Pass the placenta Inhibit cell wall synthesis

TetracyclineTetracycline

Contraindication Chelation with calcium & deposited in the

skeleton of the fetus resulting in depression of bone growth

Discoloration Maternal fatty liver degeneration FDAD

Chloramphenicol

Bone marrow depression irreversible aplastic anemia agranulocytosis

FDAC Gray-baby syndrome Contraindication

AminoglycosideAminoglycoside

Ototoxicity Nephrotoxity FDAD

AnalgesicsAnalgesics

Identify the cause of the pain Eliminate it rather than relying on

symptomatic relief with analgesic medication

AcetaminophenAcetaminophen

No teratogenesis Most frequency used Analgesic and antipyretic but no anti-infla

mmation activity

AspirinAspirin

Oral clefts and other defects Intrauterin death,growth retardation,pulmonary h

ypertention Longer pregnancies & longer the average period

of labor Tetralogy of Fallot (Raot, RVhyperatrophy,Vsep def,Pula.ste

no)

Increase the risk of antepartum and postpartum hemorrhage.

NSAIDNSAID

Contraindication Inhibit synthesis of postaglandins. Constrict the ductus arteriosus & persisten

t pulmonary hypertension & increase mortality

CorticosteroidCorticosteroid

Cleft palate Inhibit brain growth Indicated only for treatment of severe

systemic maternal illness (e.g. RA)

Sedative agentsSedative agents

Barbiturates Anxiolytic agents Inhalational sedative

BarbituratesBarbiturates

Cross the placental membrane Chronic barbiturate use-withdrawal

syndrome Cleft palate-lip

Anxiolytic agentsAnxiolytic agents

Diazepam Cleft lip and palate Chronic diazepam user-tremors in infants Accumulate in the tissue of fetus

Inhalation sedativesInhalation sedatives

Increase the rate of spontanous abortion in chronic exposed perons

Vit-B12cofactor of foliate metabolism Foliate metabolism-thymidine formation (D

NA base) N2Ooxidase Vit-B12

The most care & consideration should be given to use of nonpharmalogical technique such as good patient management verbal sedation.

Obstetrical emergences in dental Obstetrical emergences in dental officeoffice Syncope Morning sickness Seizure Bleeding & cramping

SyncopeSyncope

All trimester Hypotensive, dehydration, anemia, hypogl

ycemia and neurogenic disorder Not revived with ammonia Oxygen, vital sign, drinking fluid. Cardiac dysrhythmia

Morning sicknessMorning sickness

Enhanced gag reflex and decreased gastric empting time

Aspiration of vomiting matter Oropharygeal suction Recumbent position Chest compression

SeizureSeizure

Eclampsia Mortality rate17% Under age 20, older than 35 and first-time

pregnancy, chronic hypertensive pregnancy, obese pregnancy, multiple gestation.

SeizureSeizure

Aspiration of gastric content & hypoxia Control of airway On her left side Oxygen & suction Transfer

PreclampsiaPreclampsia

Generalized edema Elevated blood pressure Proteinuria over 300mg Hyperuremia Headache, blurred vision, abnormal pain

Bleeding & crampingBleeding & cramping

Precedes miscarriage Active bleeding or painful contraction on

left site and oxygen,transfer Minor contraction not painful on left site

not an emergency

High risk pregnancyHigh risk pregnancy

Recent cramping Light or intermittent bleeding or frank blee

ding Diabetes Hypertention preclampsis or elamposia Multiple spontaneous abortion

If question arise regarding a particular patient status, consult the obstetrician before beginning treatment.

SummarySummary

Supine hypotensive syndrome Radiography minimal Medication penicillin , ACT Emergency A,B,C

History taking, medical consultation, transfer

Thanks for Ur Attention !

The End