MANAGEMENT OF PREGNANT PATIENTS IN ORAL SURGERY

SUBMITTED BYMANJARI RESHIKESHIII BDSDEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

Pregnancy has been considered as an impediment to dental treatment,

preventive, emergency and routine dental procedures - suitable during various phases of pregnancy, with some modifications and initial planning

STAGES OF PREGNANCYFIRST TRIMESTER(0-12WKS)

SECOND TRIMESTER(13-28WKS)

THIRD TRIMESTER(29-40WKS)

MATERNAL CONCERSANATOMIC CHANGES

PHYSIOLOGICAL CHANGES

PSYCHOLOGIC CHANGES

ANATOMIC CHANGESWEIGHT : Uterus weight from 70gm 1 kg

► VOLUME : Uterus volume from 10ml 5000 ml

SIZE: size increases

SHAPE: Pyriform to globular

PHYSIOLOGIC CHANGESCardiovascular systemRespiratory systemGastrointestinal systemRenal systemHematological systemEndocrine system

CARDIOVASCULAR SYSTEM Cardiac output increase 30% in first

trimester. Then

BP normal in 1st and in 2nd trimester

2nd trimester heart rate increases 10 beats/min

3-4% - pre eclampsia and eclampsia (hypertensive disorder of pregnancy)

GASTROINTESTINAL TRACT Morning sickness-Nausea,

vomiting and giddiness Increase gastric acid production

Indigestion and hypo chlorhydria occur

Decrease gastric mobility&constipation

RESPIRATORY SYSTEM►Overall activity increases

Diaphragm is displaced upward3~4cm&residual volume decrease

rib flare out with wide chest

►Oxygen consumption increase 15~20 %►Respiratory rate increases

RENAL SYSTEMIncreased GFR and urine(diluted)

In first trimester frequency of urination increases –pressure exerted by bladder

Urinary tract infection common

HEMATOLOGICAL CHANGESTotal blood volume

increase 40~50% (1500ml) Hemoglobin & hematocrit

volume decrease

Plasma levels of factors VII, VIII, X and fibrinogen increase

Fibrinolytic activity decrease

ENDOCRINE CHANGES

Estrogen & progesterone increased. LH &FSH decrease Thyroxin, steroid and insulin level are also increased.

HPL causes increase size of breasts

45 % -fail to produce sufficient amount of insulin & develop gestational diabetes.

PSYCHOLOGICAL CHANGESFIRST TRIMESTER Anxiety Sudden emotional

swings Fear of abortions

SECOND TRIMESTER Self conscious

about weight &Appearance

Regarding movemnts of baby

THIRD TRIMESTER• Anxiety about

labor and baby

POSITIONING OF PATIENT IN EACH TRIMESTERS

LATTER PART OF 1st trimester-semi reclining

SECOND TRIMESTER-Semi Reclining position

THIRD TRIMESTER-LEFT LATERAL DECUBITUS POSITION(30° left lateral tilt) to prevent supine hypotensive syndrome

SUPINE HYPOTENSION SYNDROME Third trimester 10-15% Compression of inferior vena

cava & aorta Decrease venous return to heart Decrease utero placental

perfusion and fetal distress

LEFT LATERAL DECUBITUS POSITION Elevate the right hip 10-12cm by

keeping a small pillow –Left lateral displacement

Sit up position

FOETAL CONCERNS

Ovum- from fertilization to implantation period (0-17 days)

Embryonic period- from the second through eighth week

Fetal period- after the eighth week until term

OVUM PERIOD►Conception to 17 days

►Cellular mitotic activity

►toxic substances - spontaneous abortion

EMBRYO PERIOD18-55 days (2nd~8th wk)

Organogenesis

Most vulnerable to teratogens

Functional & morphologic malformation may occur

FETAL PERIOD• 56 days onwards

• Growth & development

FIRST TRIMESTER(1-12 weeks) Stage of organogenesis when all the

major organs are laid down and starts functioning.

50% of abortions MOST SUSCEPTIBLE TO ADV EFFECTS OF

TERATOGENS AVOID ALL ELECTIVE CARE BUT PROVIDE

CARE AS NEEDED AVOID X RAYS Tooth extraction-Latter part of 1st

trimester

SECOND TRIMESTER(13-28weekS)

• Organogenesis complete

• Fetal growth and maturation

• Gains weight rapidly

• SAFEST PERIOD TO PROVIDE DENTAL CARE

THIRD TRIMESTER(29-40weeks)

• Fetus fully developed and ready for delivery

• Dental treatments are contraindicated

• Premature labor or abortion

• Extraction- First month of last trimester

RADIOGRAPHY Dose given & time of gestation Fetus - susceptible to radiation

during first trimester(2nd -6th wks) Single dental x ray - 0.01 milli

rads

HAZARDS OF IRRADIATION• Death of embryo

• Birth of deformed child

• Increased frequency of malignancy.eg.Leukemia

PREVENTION OF IRRADIATION HAZARD Make the film if it is absolutely essential for

diagnosis(RCT,Trauma)

Use lead-shielding

Use long cone, proper collimation & shielding

Limited to affected tooth

Extra care taken while making films to eliminate the need for repeated exposure

MEDICATIONS†Local anesthesia†Antibiotics†Analgesics†Corticosteroids†Sedatives

MEDICATIONS &GENERAL EFFECTS OF DRUGS IN PREGNANCYFIRST TRIMESTER: Congenital malformations(teratogenesis)

SECOND TRIMESTER: Affect growth & Fetal development or toxic effects on fetal tissues

THIRD TRIMESTER: Adverse effects on labour or neonate after delivery

DRUG CATEGORIES

Some of the X category drugs are:1. Ribavirin2. -Accutane(isoretinoine)3. Thalidomide - phocomelia4. Sodium valproate5. Phenytoin6. Phenobarbitone7. Methotrexate8. Warfarin(Fetal warfarin syndrome)

LOCAL ANESTHESIA• Not teratogenic

• used in pregnancy with no proven ill effects

• intravascular injections -the concn - too low to harm fetus

• Prilocaine may cause methemoglobinemia

LOCAL ANAESTHETICS USED IN PREGNANCY

CLASS B• Lidocaine• Etidocaine• Prilocaine

CLASS C• Procaine• Bupivacaine• Mepivacaine

ANTIBIOTICS USED IN PREGNANCYPENICILLIN FDAB safe- all trimesters No teratogenic effects Pass the placenta

CEPHALOSPORIN Cephalexin-FDA B Erythromycin(BASE) FDA-B

ANTIBIOTICS TO AVOID DURING PREGNANCY • Erythromycin (estolate form)

• Vancomycin

• Tetracycline(D)-tendonitis ,tendon rupture

• Chloramphenicol(C) –greybaby synd, BD,

• Aminoglycosides(D)-oto-toxicity, nephrotoxicity

• Trimethoprim-decreased folicacd synthesis

MNEMONICS

OTHER ANTIMICROBIAL AGENTS USED IN PREGNANCY

• Nystatin (B)

• Chlorhexidine rinse (B)

• Clotrimazole (C)

• Ketoconazole (C)

• Fluconazole (C)

ANALGESICS Identify cause- avoid use

ANALGESICS USED IN PREGNANCY1. Paracetamol (B)- safest2. Acetaminophen(B)-safe

CONT… Ibuprofen( B/C) Avoid in 3rd trimester

Cox-2 inhibitors (C) Avoid in 3rd trimester

Codeine (C) Avoid in 3rd trimester

Morphine (B) Fentanyl (B)

ANALGESICS TO AVOID DURING PREGNANCYNSAIDSAspirin- tetralogy of fallot prolonged pregnancy and labor increased risk of hemorrhage Premature closure of DAIbuprofen avoided in 3rd-circulatory

problrms

Codeine-3rd trimester-fetal withdrawal &Respirtory depressn

CORTICOSTEROIDSNot commonly used in

pregnant patients:1. Inhibit brain growth 2. Cleft palate Indicated only for treating severe

systemic illnessPREDNISOLONE(B)-used

SEDATIVESSedatives/anxiolytics are rated as FDA-D Can cause oral clefts on prolonged exposure

BARBITURATESa) Cross the placental membraneb) Chronic barbiturate use-withdrawal syndromec) Cleft palate-lip

BENZODIAZEPINES(Diazepam)1. Cleft lip and palate2. Chronic diazepam user-tremors in infants

INHALATIONAL SEDATVES Increase rate of spontanous abortion NO2 not be used in 1st trimester If used in 2nd and 3rd,do not go below 50%

OBSTETRIC EMERGENCIES IN DENTAL OFFICESYNCOPE

MORNING SICKNESS

SEIZURES

BLEEDING AND CRAMPING

SYNCOPE All trimester causes-1. Hypotension,2. dehydration, 3. anemia,4. hypoglycemia and 5. neurogenic disorder

Turned to left sideAdminister O2 &maintain vital signsNot revived with ammonia

Sugar containing fluids given

MANAGEMENT

MORNING SICKNESSNausea & vomiting

• Avoid morning appointments• Enhanced gag reflex• Oropharygeal suction –prevent

aspiration • Chest compression- advanced

stages of pregnancy

MANAGEMENT

SEIZURES Cause- Eclampsia Signs- generalized edema elevated BP (sys>140 & dia> 90), severe headaches, blurred vision,

or abdominal pain . Seizure with aspiration of

gastric contents - maternal death.

Hypoxia - fetal death.

MANAGEMENT

IF seizure develop during dental treatment

administer oxygen by placing her on her left lateral position,

apply suction to the airway

provide emergency transport to a hospital.

BLEEDING AND CRAMPINGvaginal bleeding -sign of impending miscarriage.

MANAGEMENT

place on left side,

administer oxygen

transport to the nearest hospital

THANK YOU