Medical considerations of the pregnancy in dental treatment

1
Medical considerations of the pregnancy in dental
treatment

• Reporter ?? ???
• Supervisor ??? ??
• ??? ??

2

• Maternal concerns
• Fetal concerns
• Radiography
• Medication
• Summary

3

• Maternal concerns
• Fetal concerns
• Radiography
• Medication
• Summary

4
Maternal concerns

• Anatomic change
• Physiology changes
• Psychological changes

5
Anatomic changes

• Uterus weight from 70gm ?1 kg
• Uterus volume from 10ml ?5000 ml
• Supine hypotensive syndrome?
• Acute hypotensive episode

6
Supine hypotensive syndrome

• Third trimeter ?1015
• Compression of inferior vena cava aorta
• Decrease venous return to heart
• Decrease uteroplacental perfusion and fetal
  distress

7
Prevention

• Left lateral decubitus position
• Elevation the right hip 1012cm
• Sit up position

8
Physiologic changes

• Cardiovascular system
• Respiratory system
• Gastrointestinal system
• Renal system
• Hematological system

9
Cardiovascular system

• Cardiac output ?increase 40
• Mean arterial BP decrease
• Total blood volume ?increase 4050 (1500ml)
• 14th to 30th weeks? heart rate increase 10
  beats/min

10
Respiratory system

• Diaphragm is displaced upward 34cm rib flare
  out with chest circumference of 57 cm
• Oxygen consumption increase 1520
• Respiratory rate increase

11
Gastrointestinal system

• Increase gastric acid production
• Decrease gastric mobility
• Incompetence of gastroesophageal sphincter
• Esophageal reflux
• Pernicious vomiting
• Constipation

12
Renal system

• Increase GFR
• Increase renal plasma flow
• Urinary tract infection

13
Hematological system

• Plasma volume increase 4070c.c./kg
• Red cell volume increase 25-30c.c./kg
• Hemoglobin hematocrit volume decrease
• Plasma levels of factors VII, VIII, X and
  fibrinogen increase
• Fibrinolytic activity decrease

14
Psychological 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

15

• Maternal concerns
• Fetal concerns
• Radiography
• Medication
• Summary

16
Fetal 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

17
Ovum period

• Conception(??) to 17 days
• Cellular mitotic activity
• Sensitivity to toxic substances which may
  precipitate spontaneous abortion

18
Embryonic period

• 18-55 days (2nd8th wk)
• Organogenesis
• Functional morphologic malformation

19
Fetal period

• 56 days until parturition
• Growth development

20
The Second Trimester

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

21
First trimester

• Most of the baby structure begin to develop
• Most susceptible to the risks of physical and
  mental abnormalities
• 50 of abortion
• 57 wks in uterus? cleft in lips palate

22
Fetal concerns

• Avoidance of fetal hypoxia
• Avoidance of premature abortion
• Avoidance of teratogens

23
Avoidance 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

24
Avoidance of premature abortion

• Site of position
• No relationship between premature labor(??)
  local anesthesia
• G.A. ? increase of fetal loss

25
Avoidance of teratogens

• Before implantation (14days) ?death of the ovum
• 14-60 days ?major morphologic defects
  (organogenesis)
• 60 days later? function impairment (reduce
  intellect)

26

• Maternal concerns
• Fetal concerns
• Radiography
• Medication
• Summary

27
Radiography

• High dose (over 250rads) prior to 16 wks
• Microcephaly
• Mental retardation
• Cataracts (???)
• Microphthalamia
• Growth retardation
• Spontaneous abortion
• High dose after 20 wks
• Hair loss
• Skin lesions
• Bone marrow suppression

28
Hazard from irradiation of embryo

• Death of embryo
• Birth of a deformed child
• Increase frequency of malignancy decrease in
  childhood e.g. leukemia

29
Hazard from irradiation of embryo

• 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

30
Radiography

• 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.

31
Procedure in making radiographs for 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

32

• Maternal concerns
• Fetal concerns
• Radiography
• Medication
• Summary

33
Medication

• Local anesthesia
• Antibiotics
• Analgesics
• Corticosteroids
• Sedatives

34
Food and drug administration (F.D.A)
classification system
35
Local 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 (???????) which could cause
  maternal fetal hypoxia.

36
Vasoconstrictors

• 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.

37
Local 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.

38
AntibioticsPenicillin

• FDA?B
• All trimester are safe
• No teratogenic
• Pass the placenta
• Inhibit cell wall synthesis

39
Tetracycline

• Contraindication
• Chelation with calcium deposited in the
  skeleton of the fetus resulting in depression of
  bone growth
• Discoloration
• Maternal fatty liver degeneration
• FDA?D

40
Chloramphenicol

• Bone marrow depression irreversible aplastic
  anemia agranulocytosis
• FDA?C
• Gray-baby syndrome
• Contraindication

41
Aminoglycoside

• Ototoxicity
• Nephrotoxity
• FDA?D

42
Analgesics

• Identify the cause of the pain
• Eliminate it rather than relying on symptomatic
  relief with analgesic medication

43
Acetaminophen

• No teratogenesis
• Most frequency used
• Analgesic and antipyretic but no
  anti-inflammation activity

44
Aspirin

• Oral clefts and other defects
• Intrauterin death,growth retardation,pulmonary
  hypertention
• Longer pregnancies longer the average period of
  labor
• Tetralogy of Fallot (Raot, RVhyperatrophy,Vsep
  def,Pula.steno)
• Increase the risk of antepartum and postpartum
  hemorrhage.

45
NSAID

• Contraindication
• Inhibit synthesis of postaglandins.
• Constrict the ductus arteriosus persistent
  pulmonary hypertension increase mortality

46
Corticosteroid

• Cleft palate
• Inhibit brain growth
• Indicated only for treatment of severe systemic
  maternal illness (e.g. RA)

47
Sedative agents

• Barbiturates
• Anxiolytic agents
• Inhalational sedative

48
Barbiturates

• Cross the placental membrane
• Chronic barbiturate use-withdrawal syndrome
• Cleft palate-lip

49
Anxiolytic agents

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

50
Inhalation sedatives

• Increase the rate of spontanous abortion in
  chronic exposed perons
• Vit-B12?cofactor of foliate metabolism
• Foliate metabolism-thymidine formation (DNA base)
• N2O?oxidase Vit-B12

51

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

52
Obstetrical emergences in dental office

• Syncope
• Morning sickness
• Seizure
• Bleeding cramping

53
Syncope

• All trimester
• Hypotensive, dehydration, anemia, hypoglycemia
  and neurogenic disorder
• Not revived with ammonia
• Oxygen, vital sign, drinking fluid.
• Cardiac dysrhythmia

54
Morning sickness

• Enhanced gag reflex and decreased gastric empting
  time
• Aspiration of vomiting matter
• Oropharygeal suction
• Recumbent position
• Chest compression

55
Seizure

• Eclampsia
• Mortality rate?17
• Under age 20, older than 35 and first-time
  pregnancy, chronic hypertensive pregnancy, obese
  pregnancy, multiple gestation.

56
Seizure

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

57
Preclampsia

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

58
Bleeding cramping

• Precedes miscarriage
• Active bleeding or painful contraction? on left
  site and oxygen,transfer
• Minor contraction not painful ? on left site not
  an emergency

59
High risk pregnancy

• Recent cramping
• Light or intermittent bleeding or frank bleeding
• Diabetes
• Hypertention preclampsis or elamposia
• Multiple spontaneous abortion

60

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

61
Summary

• Supine hypotensive syndrome
• Radiography? minimal
• Medication ? penicillin , ACT
• Emergency ? A,B,C
• History taking, medical consultation, transfer

62
Thanks for Ur Attention !
The End