Medical considerations

of the pregnancy in
dental treatment
Reporter : 碩一 吳和泰
Supervisor : 雷文天 大夫
高壽延 主任
 Maternal concerns
 Fetal concerns
 Radiography
 Medication
 Summary
 Maternal concerns
 Fetalconcerns
 Radiography
 Medication
 Summary
Maternal concerns
 Anatomic change
 Physiology changes
 Psychological changes
Anatomic changes
 Uterus weight from 70gm 1 kg
 Uterus volume from 10ml 5000 ml
 Supine hypotensive syndrome
Acute hypotensive episode
Supine hypotensive syndrome
 Third trimeter 10~15%
 Compression of inferior vena cava & aorta
 Decrease venous return to heart
 Decrease uteroplacental perfusion and fet
al distress
Prevention
 Left lateral decubitus position
 Elevation the right hip 10~12cm
 Sit up position
Physiologic changes
 Cardiovascular system
 Respiratory system
 Gastrointestinal system
 Renal system
 Hematological system
Cardiovascular system
 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
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
Gastrointestinal system
 Increase gastric acid production
 Decrease gastric mobility
 Incompetence of gastroesophageal sphinc
ter
 Esophageal reflux
 Pernicious vomiting
 Constipation
Renal system
 Increase GFR
 Increase renal plasma flow
 Urinary tract infection
Hematological system
 Plasma volume increase 40~70c.c./kg
 Red cell volume increase 25-30c.c./kg
 Hemoglobin & hematocrit volume decreas
e
 Plasma levels of factors VII, VIII, X and fibr
inogen increase
 Fibrinolytic activity decrease
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
 Maternal concerns
 Fetal concerns
 Radiography
 Medication
 Summary
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
Ovum period
 Conception( 受孕 ) to 17 days
 Cellular mitotic activity
 Sensitivity to toxic substances which may
precipitate spontaneous abortion
Embryonic period
 18-55 days (2nd~8th wk)
 Organogenesis
 Functional & morphologic malformation
Fetal period
 56 days until parturition
 Growth & development
 The Second Trimester

 The First Trimester (0-12 Weeks)

 The Second Trimester (13-28 Weeks)
 The Third Trimester (29-40 Weeks)
First 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
Fetal concerns
 Avoidance of fetal hypoxia
 Avoidance of premature abortion
 Avoidance of teratogens
Avoidance of fetal hypoxia
 Uteroplacental blood flow & maternal oxyg
enation
 Hgb = 17gm/dl enhanced ability to extract
oxygen from maternal circulation
 Maternal hypoxia from hypoventilation or h
ypotention
Avoidance of premature abortion

 Site of position
 No relationship between premature labor
( 分娩 ) & local anesthesia

 G.A.  increase of fetal loss

Avoidance of teratogens
 Before implantation (14days) death of
the ovum
 14-60 days major morphologic defects
(organogenesis)
 60 days later function impairment
(reduce intellect)
 Maternal concerns
 Fetal concerns

 Radiography
 Medication
 Summary
Radiography
 High dose (over 250rads) prior to 16 wks
 Microcephaly
 Mental retardation
 Cataracts ( 白內障 )
 Microphthalamia
 Growth retardation
 Spontaneous abortion
 High dose after 20 wks
 Hair loss
 Skin lesions
 Bone marrow suppression
Hazard from irradiation of
embryo
 Death of embryo
 Birth of a deformed child
 Increase frequency of malignancy
decrease in childhood e.g. leukemia
Hazard from irradiation of
embryo
 1 rad of utero radiation exposure has been
estimated to be approximately 0.1% malig
nant disease
 A dental periapical film 0.00001 rad (0.1
mrad)
 Naturally occurring 1/2000
Radiography
An adverse fetal effects is unlikely to result fro
m 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.
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
 Maternal concerns
 Fetal concerns
 Radiography

 Medication
 Summary
Medication
 Local anesthesia
 Antibiotics
 Analgesics
 Corticosteroids
 Sedatives
Food and drug administration
(F.D.A) classification system
Local anesthesia
 Local anesthesia are not teratogenic, and
may administered to pregnancy patient is
usual clinical doses.
 Large dose of prilocaine are know to caus
e methemoglobinemia ( 變性血紅素血症 ) which cou
ld cause maternal & fetal hypoxia.
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.
Local anesthesia
 Convulsion in a sensitized mother could al
so exert a teratogenic effect second to hyp
oxia
 The need for careful Hx taking & for aspira
tion & slow injected technique is obvious.
Antibiotics
Penicillin
 FDAB
 All trimester are safe
 No teratogenic
 Pass the placenta
 Inhibit cell wall synthesis
Tetracycline
 Contraindication
 Chelation with calcium & deposited in the
skeleton of the fetus resulting in depressio
n of bone growth
 Discoloration
 Maternal fatty liver degeneration
 FDAD
Chloramphenicol
 Bone marrow depression irreversible aplas
tic anemia agranulocytosis
 FDAC
 Gray-baby syndrome
 Contraindication
Aminoglycoside
 Ototoxicity
 Nephrotoxity
 FDAD
Analgesics
 Identify the cause of the pain
 Eliminate it rather than relying on
symptomatic relief with analgesic
medication
Acetaminophen
 No teratogenesis
 Most frequency used
 Analgesic and antipyretic but no anti-infla
mmation activity
Aspirin
 Oral clefts and other defects
 Intrauterin death,growth retardation,pulmonary h
ypertention
 Longer pregnancies & longer the average period
of labor
 Tetralogy of Fallot (Raot, RVhyperatrophy,Vsep def,Pula.ste
no)
 Increase the risk of antepartum and postpartum
hemorrhage.
NSAID
 Contraindication
 Inhibit synthesis of postaglandins.
 Constrict the ductus arteriosus & persisten
t pulmonary hypertension & increase mort
ality
Corticosteroid
 Cleft palate
 Inhibit brain growth
 Indicated only for treatment of severe
systemic maternal illness (e.g. RA)
Sedative agents
 Barbiturates
 Anxiolytic agents
 Inhalational sedative
Barbiturates
 Cross the placental membrane
 Chronic barbiturate use-withdrawal
syndrome
 Cleft palate-lip
Anxiolytic agents
 Diazepam
 Cleft lip and palate
 Chronic diazepam user-tremors in infants
 Accumulate in the tissue of fetus
Inhalation sedatives
 Increase the rate of spontanous abortion i
n chronic exposed perons
 Vit-B12cofactor of foliate metabolism
 Foliate metabolism-thymidine formation (D
NA base)
 N2Ooxidase Vit-B12
The most care & consideration should be give
n to use of nonpharmalogical technique such a
s good patient management verbal sedation.
Obstetrical emergences in dental
office
 Syncope
 Morning sickness
 Seizure
 Bleeding & cramping
Syncope
 All trimester
 Hypotensive, dehydration, anemia, hypogl
ycemia and neurogenic disorder
 Not revived with ammonia
 Oxygen, vital sign, drinking fluid.
 Cardiac dysrhythmia
Morning sickness
 Enhanced gag reflex and decreased gastri
c empting time
 Aspiration of vomiting matter
 Oropharygeal suction
 Recumbent position
 Chest compression
Seizure
 Eclampsia
 Mortality rate17%
 Under age 20, older than 35 and first-time
pregnancy, chronic hypertensive pregnanc
y, obese pregnancy, multiple gestation.
Seizure
 Aspiration of gastric content & hypoxia
 Control of airway
 On her left side
 Oxygen & suction
 Transfer
Preclampsia
 Generalized edema
 Elevated blood pressure
 Proteinuria over 300mg
 Hyperuremia
 Headache, blurred vision, abnormal pain
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
High risk pregnancy
 Recent cramping
 Light or intermittent bleeding or frank blee
ding
 Diabetes
 Hypertention preclampsis or elamposia
 Multiple spontaneous abortion
If question arise regarding a particular patient
status, consult the obstetrician before
beginning treatment.
Summary
 Supine hypotensive syndrome
 Radiography minimal
 Medication  penicillin , ACT
 Emergency  A,B,C

History taking, medical consultation, transfer

The End

Thanks for Ur Attention !