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Pregnancy and Nursing Katie Daniels Emily Eggebrecht Jeff Eggert Sheena Eken Kara Engelbrektson Jamie Evavold Rhett Finley Ms. Serena Green • 25 year old female • Previous Med Hx is unremarkable • Seven months pregnant • Two healthy children (ages 2 and 4) • Fourth pregnancy • Miscarriage between the other two children • BP = 120 / 80 • HR = 70 bpm, regular Pregnancy Physiology • Approximately 40 week duration • 1st trimester – Organogenesis – Fetus most susceptible to malformations • 2nd and 3rd trimesters – Growth and maturation – Low chance for malformation • Except fetal dentition – Toxins, radiation, drugs Pregnancy Physiology • Increased hormones – Estrogen – Progesterone – hCG • Complications – Morning sickness – Pregnancy gingivitis • 1% progress to pyogenic granuloma Pregnancy Physiology • Increased blood volume – Volume ↑ 40 – RBCs only ↑ 15 – 20% • Complications – Anemia and ↓ hematocrit – Fatigue – Postural hypotension/syncope Pregnancy Physiology • Increase in blood clotting factors – Fibrinogen – vW – VII, VIII, IX, X • Complications – Thrombosis risk ↑ 7 – 10X Pregnancy Physiology • Compression of internal anatomy – Due to growth of fetus • Complications from compression – Supine Hypotensive Syndrome – Tachypnea and dyspnea – Polyuria Complications • Infection, Inflammation, Glucose abnormalities, Hypertension • At increased risk: – Smokers – Patients w/ pathogens • Complication ↑ risk for: – Preterm delivery – Perinatal mortality – Congenital abnormalities Gestational Diabetes • Insulin resistance • 2 – 6% of women • Increased risk for: – – – – – Periodontal disease Other infections Large birth weight babies Loss of fetus Developing diabetes postpartum Hypertension • End organ damage • Preeclampsia – Hypertension with: • Proteinuria • Edema • Blurred vision – Can progress to eclampsia • Seizures and coma Miscarriage • Natural termination before 20 wks • >15% of all pregnancies • Usually due to intrinsic fetal abnormalities • Dental Tx unlikely to cause – Prevent hypoxia – Do not use teratogens • Promptly treat – Odontogenic infection – Periodontitis Consulting with an OBGYN • 1992 survey – 91% did not want to discuss “routine” dental care – 88% did want to consult on antibiotics – 54% did want to consult on analgesics Preventative Dental Care • Periodontal disease causes inflammatory response – Low birth weight – Preterm birth • Maternal plaque control – Try to ↓ S. mutans in mom – Infant has ↓ risk of being infected and caries Preventative Dental Care • Oral hygiene instructions • Diet counseling – Reduce fermentable carbs • Scaling and polishing • Preventative plaque control – Chlorhexidine, etc. • Fluoride Treatment Timing • 1st Trimester – Avoid elective care • 2nd Trimester – Safest for routine care – Control active disease and prevent problems – Avoid extensive procedures/surgery • 3rd Trimester – 1st half – routine care OK – 2nd half – postpone elective care Radiographs • Avoid during pregnancy – Especially 1st Trimester • Use for Dx and Tx when needed • Reduce exposure – – – – – High speed film (≥ E) or digital Filtration Collimation – rectangle preferred Lead aprons (most important) Use selectively Radiation Dosage Source Dose (cGy) Chest film 0.008 Skull film 0.004 Natural background 0.0004 Full mouth w/ 0.00001 lead apron • 2 PAs are 700x less than 1 day of natural background Pregnant Personnel • Max dosage is 0.005 Gy or 5 mSv per year • Safety measures – Wear film badge – Stand > 6ft from cone head – Position 90 – 130° from beam Drugs During Pregnancy • Main concerns – Toxic – Teratogenic • Ideal is no drugs – Might not be possible • Make sure patient understands risks • Know FDA drug categories FDA Drug Categories (simple version) • A: Human studies OK • B: No human studies, but animals OK Animal studies BAD, but humans OK • C: Animal studies BAD (No human studies) • D: Human studies BAD (but may need to use in special situations) • X: Humans BAD, risk outweighs any benefit Drugs During Breastfeeding • Milk dose is 1 – 2% maternal dose • Reduce by – Taking after feeding infant – Avoid nursing for >4 hrs after drug (not usually possible w/newborns) • Definitely contraindicated – – – – Lithium Anticancer Radioactive Phenindione Ms. Serena Green • 25 year old female • Previous Med HX is unremarkable • Seven months pregnant • Has two healthy children (ages 2 and 4) • This is her fourth pregnancy • Had a miscarriage between the other two children • BP = 120 / 80 • HR = 70 bpm, regular Chief Concern • Molar area sensitive to heat, cold, and percussion • Upon examination you find a large carious lesion on mesial surface of #31 – (pregnancy often leads to an altered diet high in sugars) • Patient desires treatment to exacerbate the discomfort Dental History • Tooth # 31 with a large carious lesion on the mesial • Quite sensitive to cold and percussion • A little sensitive to heat • Good personal oral hygiene • AAP case type I perio(marginal gingivitis) • Slight plaque and calculus deposits • Missing two of her other first molars • She is interested in a fixed prosthesis Questions to Ask? • How long have you been pregnant? What trimester? • Have you received prenatal care? • Any complications with this pregnancy? • Do you have a primary physician? – Name? – Phone Number? • Do you have an obstetrician? – Name? – Phone Number? Questions to Ask? • Any preexisting medical conditions? • Changes in dietary habits with pregnancy? • Current oral hygiene routine? • Do you monitor your blood pressure regularly? – If so, what was your most recent BP? Dental Algorithm A • Antibiotics – Penicillin, erythromycin, cephalosporins= safe for mother and child – Tetracycline= Contraindicated! • Binds hydroxyapatitie causing discoloration of teeth, hypoplastic enamel, and skeletal abnormalities • Analgesics – Acetaminophen= drug of choice (category B) – Aspirin and NSAIDS are risky when used during the 3rd trimester – Avoid opioids! • Prolonged or high doses are associated with congenital abnormalities and respiratory depression Dental Algorithm • Anesthetics A – Local Anesthetic with Epinephrine considered safe (risk category B,C) • The amount crossing the placental barrier is subtoxic – Limit dose to the amount required for the procedure – Avoid Bupivicaine – May want to avoid in 1st trimester • Anxiolytics – Nitrous Oxide guidelines: • Minimize administration to 30 minutes • Administer at least 50% O2 to avoid diffusion hypoxia – 2nd and 3rd trimesters are safer than 1st (organogenesis) – Best to consult with Physician prior to use of nitrous oxide Dental Algorithm • Bleeding B – Blood changes during pregnancy: • Platelets are unaffected • But several clotting factors are increased • Hypercoagulation state increases risk of thrombosis 7-10 fold. • Breathing – Pregnant patient has an increased demand on the lungs for O2 – And a reduced expiratory reserve volume caused by enlarged uterus – These changes may cause tachypnea and dyspnea (aggravated by supine position). • Blood pressure – During late pregnancy, risk of supine hypotensive syndrome. Compression of the inferior vena cava by the fetus impairs venous return to the heart. Symptoms: abrupt fall in blood pressure, bradycardia, sweating, nausea, and weakness. Remedy: roll pt. onto left side. Blood pressure should rapidly return to normal. Dental Algorithm C • Complications – – – – Infection Inflammatory response Glucose abnormalities Hypertension – While unlikely that any dental treatment would be implicated in spontaneous abortion (miscarriage), prompt treatment of odontogenic infection and periodontitis is advised to prevent febrile illness and sepsis (both linked to miscarriage). Dental Algorithm Drugs D – Main concern: medications that cross the placenta or are toxic/teratogenic to the developing fetus. • FDA categorization of prescription drugs for pregnancy: (based on the risk of fetal injury) * A: Human studies fail to demonstrate risk to the fetus * B: Animal studies do not show fetal risk and human studies have not been conducted C: Animal studies have shown a risk and human studies have not been conducted D: Positive evidence for risk to fetus exists, but drug may be used in certain situations X: Evidence of human fetal risk exists and the risk outweighs any possible benefit * Preferred drugs to be used during pregnancy Dental Algorithm Drugs D Anesthetics: – LA administered with epinephrine considered relatively safe – Category B (etidocaine, lidocaine, prilocaine) – Category C (articaine, bupivacaine mepivacaine) – Limit to the amount required. – Risk for methemogloinemia with high doses of prilocaine and articaine. Dental Algorithm Drugs D Analgesics: – Acetaminophen is the analgesic of choice. – Aspirin and NSAIDs associated with a risk for constriction of the ductus arteriosus, post partum hemorrhage, and delayed labor • use with caution and avoid during the 3rd trimester. – Opioids should be avoided! • association with congenital abnormalities and respiratory depression. Dental Algorithm Drugs D Antibiotics: – Penicillins, erythromycin and cephalosporins are safe. – Antibiotics may have lower maternal blood levels because of the increased volume of distribution and decreased half-life – may have to increase the dose/frequency if infection is persisting. – Tetracycline is contraindicated – it binds to hydroxyapatite resulting in brown teeth, hypoplastic enamel, and decreased bone growth. Dental Algorithm Drugs D Anxiolytics: – Few considered safe! – Chronic exposure to nitrous oxide could cause altered DNA metabolism • (interferes with methionine synthetase and vitamin B12). • appropriate scavenging equipment should be used to limit the exposure to female dental staff. – Single exposure to nitrous oxide <35 min. considered OK. Dental Algorithm Drugs D Nitrous Oxide Use During Pregnancy: Minimize exposure to <30 min Deliver with at least 50% oxygen Give oxygen at termination of administration to avoid diffusion hypoxia Avoid repeated and prolonged exposures Second and third trimester are the best times to treat Dental Algorithm Drugs D During Breast Feeding: – Potential for drug to be administered the infant through the breast milk. • Usually the amount excreted in breast milk in 1-2% of the maternal dose. • Therefore, most drugs are of little pharmacologic significance to the infant. – Suggest that the mother take the drug just after breast feeding and avoid nursing for 4 hrs. – Drugs which are contraindicated in nursing mothers: • • • • Lithium Anticancer drugs Radioactive pharmaceutical Phenindione Dental Algorithm Equipment E Radiographs: – Should be avoided (especially the 1st trimester). – Only when necessary to aid in diagnosis and treatment. – Follow these measures to reduce radiation: • • • • • Rectangular collimation E-speed film or faster Lead shielding (abdominal and thyroid collar) High kV or constant beams Ongoing quality assurance program – When the above are followed, the amount of radiation to the fetus is < 0.01 µSv, which is significantly less than 1 day of average exposure to natural background radiation. – The risk of first generation fetal defects from a dental radiograph exam is estimated to be 9 in 1 billion. Dental Algorithm Equipment E Nitrous Oxide Equipment: – Chronic exposure could result in altered DNA metabolism • leading to cellular abnormalities • increased risk of spontaneous abortion. – Follow these guidelines to control the amount of trace nitrous oxide in the dental office: • • • • • • • Regular inspection of equipment – replace defective tubing and parts Check pressure connections for leaks and fix any found Ensure that masks fit well and that the reservoir bag is not over inflated or under inflated Provide operatory ventilation of 10+ room air exchanges per hour Use a scavenging system (vacuum should provide up to 45 L/min) Connect and turn on scavenging system before providing nitrous oxide Conduct regular air sampling (exposure limits should be <25 ppm when a pregnant dental worker is involved) ASA II • No other medical conditions • Early part of 3rd trimester – which is still considered a good time to provide routine dental care • Routine dental care is indicated because – She is early in her 3rd trimester – Procedures required are fairly minor and noninvasive – Afore mentioned guidelines are taken into account • Contraindications for routine care during pregnancy include: – First trimester- danger to developing fetus – Late in third trimester- increased feeling of discomfort and supine hypotension – Extensive surgical procedures during any trimester What To Do….. • Treat large carious lesion on #31 and provide prophy for calculus and plaque control. • • Complications occur more often in expecting mothers who harbor pathogens Radiograph will need to be taken of #31 before treatment • Elective dental care and reconstruction/crown and bridge procedures should be delayed until after pregnancy (i.e. wait to do fixed prosthesis). • Considerations during Treatment: • Follow dental algorithm. • Supine hypotensive syndrome: decreased venous return to heart from compression of the inferior vena cava • If this occurs, roll the pt. onto her left side to lift the uterus off the vena cava Thanks!