Pregnancy and Nursing

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Pregnancy and Nursing

• Katie Daniels
• Emily Eggebrecht
• Jeff Eggert
• Sheena Eken
• Kara Engelbrektson
• Jamie Evavold
• Rhett Finley

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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

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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

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Pregnancy Physiology

• Increased hormones
• Estrogen
• Progesterone
• hCG
• Complications
• Morning sickness
• Pregnancy gingivitis
• 1 progress to pyogenic granuloma

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Pregnancy Physiology

• Increased blood volume
• Volume ? 40
• RBCs only ? 15 20
• Complications
• Anemia and ? hematocrit
• Fatigue
• Postural hypotension/syncope

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Pregnancy Physiology

• Increase in blood clotting factors
• Fibrinogen
• vW
• VII, VIII, IX, X
• Complications
• Thrombosis risk ? 7 10X

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Pregnancy Physiology

• Compression of internal anatomy
• Due to growth of fetus
• Complications from compression
• Supine Hypotensive Syndrome
• Tachypnea and dyspnea
• Polyuria

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Complications

• Infection, Inflammation, Glucose abnormalities,
  Hypertension
• At increased risk
• Smokers
• Patients w/ pathogens
• Complication ? risk for
• Preterm delivery
• Perinatal mortality
• Congenital abnormalities

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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

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Hypertension

• End organ damage
• Preeclampsia
• Hypertension with
• Proteinuria
• Edema
• Blurred vision
• Can progress to eclampsia
• Seizures and coma

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Miscarriage

• Natural termination before 20 wks
• gt15 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

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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

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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

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Preventative Dental Care

• Oral hygiene instructions
• Diet counseling
• Reduce fermentable carbs
• Scaling and polishing
• Preventative plaque control
• Chlorhexidine, etc.
• Fluoride

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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

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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

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Radiation Dosage

• 2 PAs are 700x less than 1 day of natural
  background

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Pregnant Personnel

• Max dosage is 0.005 Gy or 5 mSv per year
• Safety measures
• Wear film badge
• Stand gt 6ft from cone head
• Position 90 130 from beam

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Drugs During Pregnancy

• Main concerns
• Toxic
• Teratogenic
• Ideal is no drugs
• Might not be possible
• Make sure patient understands risks
• Know FDA drug categories

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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

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Drugs During Breastfeeding

• Milk dose is 1 2 maternal dose
• Reduce by
• Taking after feeding infant
• Avoid nursing for gt4 hrs after drug (not usually
  possible w/newborns)
• Definitely contraindicated
• Lithium
• Anticancer
• Radioactive
• Phenindione

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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

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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

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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

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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?

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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?

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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

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Dental Algorithm
A

• Anesthetics
• 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

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Dental Algorithm
B

• Bleeding
• 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.

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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).

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Dental Algorithm
D

• Drugs
• 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

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D
Dental Algorithm

• Drugs
• 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.

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D
Dental Algorithm

• Drugs
• 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.

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D
Dental Algorithm

• Drugs
• 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.

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D
Dental Algorithm

• Drugs
• 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 lt35 min.
  considered OK.

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Dental Algorithm
D

• Drugs
• Nitrous Oxide Use During Pregnancy
• Minimize exposure to lt30 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

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D
Dental Algorithm

• Drugs
• 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

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E
Dental Algorithm

• Equipment
• 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 lt 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.

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E
Dental Algorithm

• Equipment
• 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 lt25 ppm when a pregnant dental worker
  is involved)

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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
  non-invasive
• 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

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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

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Thanks!