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
 Fetal

concerns

concerns  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 fetal 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 sphincter  Esophageal reflux  Pernicious vomiting  Constipation  .

Renal system Increase GFR  Increase renal plasma flow  Urinary tract infection  .

X and fibrinogen increase  Fibrinolytic activity decrease  .c.Hematological system Plasma volume increase 40~70c./kg  Hemoglobin & hematocrit volume decrease  Plasma levels of factors VII.c./kg  Red cell volume increase 25-30c. VIII.

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 .

after the eighth week until term .Fetal concern  Fetal development  Ovum- from fertilization to implantation period  Embryonic period.from the second through eighth week  Fetal period.

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 oxygenation  Hgb = 17gm/dl enhanced ability to extract oxygen from maternal circulation  Maternal hypoxia from hypoventilation or hypotention

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 .

g.Hazard from irradiation of embryo Death of embryo  Birth of a deformed child  Increase frequency of malignancy decrease in childhood e. leukemia  .

1% malignant disease  A dental periapical film 0.Hazard from irradiation of embryo 1 rad of utero radiation exposure has been estimated to be approximately 0.00001 rad (0.1 mrad)  Naturally occurring 1/2000  .

.1 mrad.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.

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.A) classification system .D.

and may administered to pregnancy patient is usual clinical doses.Local anesthesia Local anesthesia are not teratogenic.  .  Large dose of prilocaine are know to cause methemoglobinemia (變性血紅素血症) which could 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 also exert a teratogenic effect second to hypoxia  The need for careful Hx taking & for aspiration & 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 depression of bone growth  Discoloration  Maternal fatty liver degeneration  FDAD  .

Chloramphenicol Bone marrow depression irreversible aplastic 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 antiinflammation activity  .

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

 Constrict the ductus arteriosus & persistent pulmonary hypertension & increase mortality  .NSAID Contraindication  Inhibit synthesis of postaglandins.

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 in chronic exposed perons  Vit-B12cofactor of foliate metabolism  Foliate metabolism-thymidine formation (DNA base)  N2Ooxidase Vit-B12  .

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

Obstetrical emergences in dental office Syncope  Morning sickness  Seizure  Bleeding & cramping  .

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

Morning sickness Enhanced gag reflex and decreased gastric empting time  Aspiration of vomiting matter  Oropharygeal suction  Recumbent position  Chest compression  .

Seizure Eclampsia  Mortality rate17%  Under age 20. multiple gestation.  . older than 35 and first-time pregnancy. chronic hypertensive pregnancy. obese pregnancy.

Seizure Aspiration of gastric content & hypoxia  Control of airway  On her left side  Oxygen & suction  Transfer  .

blurred vision. abnormal pain  .Preclampsia Generalized edema  Elevated blood pressure  Proteinuria over 300mg  Hyperuremia  Headache.

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 bleeding  Diabetes  Hypertention preclampsis or elamposia  Multiple spontaneous abortion  .

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

C History taking. ACT  Emergency  A. medical consultation. transfer  .Summary Supine hypotensive syndrome  Radiography minimal  Medication  penicillin .B.

The End Thanks for Ur Attention ! .

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