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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:
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–
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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
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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
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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
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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:
•
•
•
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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:
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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:
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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!