pregnancy in dental treatment

8/7/2019 pregnancy in dental treatment

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Medical considerations

of the pregnancy indental treatment

Reporter :

Supervisor :


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Maternal concerns

Fetal concerns

Radiography

Medication

Summary


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Maternal concernsMaternal concerns

Fetal concerns

Radiography

Medication

Summary


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Maternal concernsMaternal concerns Anatomic change

Physiology changes

Psychological changes


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Anatomic changesAnatomic changes Uterus weight from 70gm 1 kg

Uterus volume from 10ml 5000 ml

Supine hypotensive syndrome

Acute hypotensive episode


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Supine hypotensive syndromeSupine hypotensive syndrome Third trimeter10~15%

Compression of inferior vena cava & aorta

Decrease venous return to heart Decrease uteroplacental perfusion and

fetal distress


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Prevention

Prevention

Left lateral decubitus position

Elevation the right hip 10~12cm

Sit up position


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Physiologic changes

Physiologic changes

Cardiovascular system

Respiratory system

Gastrointestinal system

Renal system

Hematological system


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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


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Respiratory system

Respiratory 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


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Increase gastric acid production

Decrease gastric mobility

Incompetence ofgastroesophagealsphincter

Esophageal reflux

Pernicious vomiting Constipation


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Renal system

Renal system

Increase GFR

Increase renal plasma flow

Urinary tract infection


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Plasma volume increase 40~70c.c./kg

Red cell volume increase 25-30c.c./kg

Hemoglobin & hematocrit volumedecrease

Plasma levels of factors VII, VIII, X and

fibrinogen increase Fibrinolytic activity decrease


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Hypersensitivity regarding her size &

appearance

Fear of pain, disability, death and for baby

Fear of dental procedures

Sedation empathy and reassurance

Minimize disturbanceinterruption & noises & toadjustroomtemperature & tominimizepossible

irritability


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Maternal concerns

Fetal concernsFetal concerns

Radiography

Medication

Summary


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Fetal concernF

etal concern Fetal development

Ovum- from fertilization to implantation period

Embryonic period- from the second through

eighth week

Fetal period- after the eighth week until term


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Ovum periodOvum period Conception() to 17 days

Cellular mitotic activity

Sensitivity to toxic substances which may

precipitate spontaneous abortion


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Embryonic period

Embryonic period

18-55 days (2nd~8th wk)

Organogenesis

Functional & morphologic malformation


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Fetal periodF

etal period 56 days until parturition

Growth & development


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The First Trimester (0-12 Weeks)

The Second Trimester (13The Second Trimester (13--28 Weeks)28 Weeks)

The Third Trimester (29-40 Weeks)

The Second TrimesterThe Second Trimester


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First trimesterF

irst 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


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Fetal concernsF

etal concerns Avoidance of fetal hypoxia

Avoidance of premature abortion

Avoidance of teratogens


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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


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Avoidance ofpremature abortionAvoidance ofpremature abortion

Site of position

No relationship between premature labor(

) & local anesthesia

G.A. increase of fetal loss


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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)


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Maternal concerns

Fetal concerns

RadiographyRadiographyMedication

Summary


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Radiogra

phy

Radiogra

phy

High dose (over 250rads) prior to 16 wks Microcephaly

Mental retardation

Cataracts ()

Microphthalamia

Growth retardation

Spontaneous abortion

High dose after20 wks Hair loss

Skin lesions

Bone marrow suppression


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Hazard from irradiation ofHazard from irradiation of

embryoembryo Death of embryo

Birth of a deformed child

Increase frequency ofmalignancy

decrease in childhood e.g. leukemia


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Hazard from irradiation ofHazard 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


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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 asingle periapical radiographs is about 0.1

mrad.


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Procedure in making radiographsProcedure in making radiographs

forpregnancy patientsforpregnancy patients Make only the film absolutely essential for

diagnosing the conditions

Use lead-shielding Use long cone

Use propercollimation & shielding

Limited to affected tooth

Extra care should be used while taking essentialfilms to eliminate the need for repeated exposure


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Maternal concerns

Fetal concerns

Radiography

MedicationMedication

Summary


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MedicationMedication

Local anesthesia

Antibiotics

Analgesics

Corticosteroids

Sedatives


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Food and drug administrationFood and drug administration

(F.D.A) classification system(F.D.A) classification system


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Local anesthesiaLocal anesthesia

Local anesthesia are not teratogenic, and

may administered to pregnancy patient is

usual clinical doses.

Large dose ofprilocaine are know to

cause methemoglobinemia () which

could cause maternal & fetal hypoxia.


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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 itis prudent to use minimal effective dose.


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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.


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AntibioticsAntibiotics

PenicillinPenicillin FDAB

All trimester are safe

No teratogenic

Pass the placenta

Inhibit cell wall synthesis


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TetracyclineTetracycline

Contraindication

Chelation with calcium & deposited in the

skeleton of the fetus resulting indepression of bone growth

Discoloration

Maternal fatty liver degeneration FDAD


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Chloramphenicol

Bone marrow depression irreversible

aplastic anemia agranulocytosis

FDAC

Gray-baby syndrome

Contraindication


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AminoglycosideAminoglycoside

Ototoxicity

Nephrotoxity

FDAD


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AnalgesicsAnalgesics

Identify the cause of the pain

Eliminate it rather than relying on

symptomatic relief with analgesic

medication


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AcetaminophenAcetaminophen

No teratogenesis

Most frequency used

Analgesic and antipyretic but no anti-

inflammation activity


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AspirinAspirin

Oral clefts and other defects

Intrauterin death,growth retardation,pulmonary

hypertention Longer pregnancies & longer the average period

of labor

Tetralogy of Fallot(Raot, RVhyperatrophy,Vsepdef,Pula.steno)

Increase the risk of antepartum and postpartumhemorrhage.


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NSAIDNSAID

Contraindication

Inhibit synthesis of postaglandins.

Constrict the ductus arteriosus &

persistent pulmonary hypertension &

increase mortality


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CorticosteroidCorticosteroid

Cleft palate

Inhibit brain growth

Indicated only for treatment of severe

systemic maternal illness (e.g. RA)


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Sedative agentsSedative agents

Barbiturates

Anxiolytic agents

Inhalational sedative


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BarbituratesBarbiturates

Cross the placental membrane

Chronic barbiturate use-withdrawal

syndrome

Cleft palate-lip


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Anxiolytic agentsAnxiolytic agents

Diazepam

Cleft lip and palate

Chronic diazepam user-tremors in infants

Accumulate in the tissue of fetus


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Inhalation sedativesInhalation sedatives

Increase the rate of spontanous abortion

in chronic exposed perons

Vit-B12cofactor of foliate metabolism

Foliate metabolism-thymidine formation

(DNA base)

N2Ooxidase Vit-B12


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The most care & consideration should be

given to use ofnonpharmalogical technique

such as good patient management verbalsedation.


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Obstetrical emergences in dentalObstetrical emergences in dental

officeoffice Syncope

Morning sickness

Seizure

Bleeding & cramping


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SyncopeSyncope

All trimester

Hypotensive, dehydration, anemia,

hypoglycemia and neurogenic disorder

Not revived with ammonia

Oxygen, vital sign, drinking fluid.

Cardiac dysrhythmia


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Morning sicknessMorning sickness

Enhanced gag reflex and decreased

gastric empting time

Aspiration of vomiting matter

Oropharygeal suction

Recumbent position

Chest compression


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SeizureSeizure

Eclampsia

Mortality rate17%

Under age 20,older than 35 and first-time

pregnancy,chronic hypertensive

pregnancy,obese pregnancy,multiple

gestation.


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SeizureSeizure

Aspiration of gastric content & hypoxia

Control ofairway

On herleft side

Oxygen & suction

Transfer


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PreclampsiaPreclampsia

Generalized edema

Elevated blood pressure

Proteinuria over 300mg

Hyperuremia

Headache, blurred vision, abnormal pain


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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


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High risk pregnancyHigh risk pregnancy

Recent cramping

Light or intermittent bleeding or frank

bleeding

Diabetes

Hypertention preclampsis or elamposia

Multiple spontaneous abortion


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If question arise regarding a particular patient

status, consult the obstetrician before

beginning treatment.


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SummarySummary

Supine hypotensive syndrome

Radiography minimal

Medication penicillin ,ACT

Emergency A,B,C

History taking, medical consultation, transfer


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Thanks forUrAttention !

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pregnancy in dental treatment