medical considerations of the pregnancy in dental treatment reporter : 碩一 吳和泰 supervisor :...
TRANSCRIPT
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 concernsMaternal concerns Fetal concerns Radiography Medication Summary
Maternal concernsMaternal concerns
Anatomic change Physiology changes Psychological changes
Anatomic changesAnatomic changes
Uterus weight from 70gm 1 kg Uterus volume from 10ml 5000 ml Supine hypotensive syndrome
Acute hypotensive episode
Supine hypotensive syndromeSupine hypotensive syndrome Third trimeter 10~15% Compression of inferior vena cava & aorta Decrease venous return to heart Decrease uteroplacental perfusion and fet
al distress
PreventionPrevention
Left lateral decubitus position Elevation the right hip 10~12cm Sit up position
Physiologic changesPhysiologic changes
Cardiovascular system Respiratory system Gastrointestinal system Renal system Hematological system
Cardiovascular systemCardiovascular 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 systemRespiratory 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 systemGastrointestinal system
Increase gastric acid production Decrease gastric mobility Incompetence of gastroesophageal sphinc
ter Esophageal reflux Pernicious vomiting Constipation
Renal systemRenal system
Increase GFR Increase renal plasma flow Urinary tract infection
Hematological systemHematological 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 changesPsychological 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 concernsFetal concerns Radiography Medication Summary
Fetal concernFetal concern
Fetal developmentOvum- from fertilization to implantation periodEmbryonic period- from the second through
eighth weekFetal period- after the eighth week until term
Ovum periodOvum period
Conception( 受孕 ) to 17 days Cellular mitotic activity Sensitivity to toxic substances which may
precipitate spontaneous abortion
Embryonic periodEmbryonic period
18-55 days (2nd~8th wk) Organogenesis Functional & morphologic malformation
Fetal periodFetal period
56 days until parturition Growth & development
The First Trimester (0-12 Weeks) The Second Trimester (13-28 Weeks)The Second Trimester (13-28 Weeks) The Third Trimester (29-40 Weeks)
The Second TrimesterThe Second Trimester
First trimesterFirst 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 concernsFetal concerns
Avoidance of fetal hypoxia Avoidance of premature abortion Avoidance of teratogens
Avoidance of fetal hypoxiaAvoidance 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 abortionAvoidance of premature abortion
Site of position No relationship between premature labor
( 分娩 ) & local anesthesia G.A. increase of fetal loss
Avoidance of teratogensAvoidance 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
RadiographyRadiography Medication Summary
RadiographyRadiography
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 Hazard from irradiation of embryoembryo Death of embryo Birth of a deformed child Increase frequency of malignancy
decrease in childhood e.g. leukemia
Hazard from irradiation of Hazard from irradiation of embryoembryo 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
RadiographyRadiography
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.
Procedure in making radiographs Procedure in making radiographs for pregnancy patientsfor 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
MedicationMedication Summary
MedicationMedication
Local anesthesia Antibiotics Analgesics Corticosteroids Sedatives
Food and drug administration Food and drug administration (F.D.A) classification system(F.D.A) classification system
Local anesthesiaLocal 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 ( 變性血紅素血症 ) which could cause maternal & fetal hypoxia.
VasoconstrictorsVasoconstrictors
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 anesthesiaLocal 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.
AntibioticsAntibioticsPenicillinPenicillin FDAB All trimester are safe No teratogenic Pass the placenta Inhibit cell wall synthesis
TetracyclineTetracycline
Contraindication Chelation with calcium & deposited in the
skeleton of the fetus resulting in depression of bone growth
Discoloration Maternal fatty liver degeneration FDAD
Chloramphenicol
Bone marrow depression irreversible aplastic anemia agranulocytosis
FDAC Gray-baby syndrome Contraindication
AminoglycosideAminoglycoside
Ototoxicity Nephrotoxity FDAD
AnalgesicsAnalgesics
Identify the cause of the pain Eliminate it rather than relying on
symptomatic relief with analgesic medication
AcetaminophenAcetaminophen
No teratogenesis Most frequency used Analgesic and antipyretic but no anti-infla
mmation activity
AspirinAspirin
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.
NSAIDNSAID
Contraindication Inhibit synthesis of postaglandins. Constrict the ductus arteriosus & persisten
t pulmonary hypertension & increase mortality
CorticosteroidCorticosteroid
Cleft palate Inhibit brain growth Indicated only for treatment of severe
systemic maternal illness (e.g. RA)
Sedative agentsSedative agents
Barbiturates Anxiolytic agents Inhalational sedative
BarbituratesBarbiturates
Cross the placental membrane Chronic barbiturate use-withdrawal
syndrome Cleft palate-lip
Anxiolytic agentsAnxiolytic agents
Diazepam Cleft lip and palate Chronic diazepam user-tremors in infants Accumulate in the tissue of fetus
Inhalation sedativesInhalation sedatives
Increase the rate of spontanous abortion in chronic exposed perons
Vit-B12cofactor of foliate metabolism Foliate metabolism-thymidine formation (D
NA base) N2Ooxidase 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 Obstetrical emergences in dental officeoffice Syncope Morning sickness Seizure Bleeding & cramping
SyncopeSyncope
All trimester Hypotensive, dehydration, anemia, hypogl
ycemia and neurogenic disorder Not revived with ammonia Oxygen, vital sign, drinking fluid. Cardiac dysrhythmia
Morning sicknessMorning sickness
Enhanced gag reflex and decreased gastric empting time
Aspiration of vomiting matter Oropharygeal suction Recumbent position Chest compression
SeizureSeizure
Eclampsia Mortality rate17% Under age 20, older than 35 and first-time
pregnancy, chronic hypertensive pregnancy, obese pregnancy, multiple gestation.
SeizureSeizure
Aspiration of gastric content & hypoxia Control of airway On her left side Oxygen & suction Transfer
PreclampsiaPreclampsia
Generalized edema Elevated blood pressure Proteinuria over 300mg Hyperuremia Headache, blurred vision, abnormal pain
Bleeding & crampingBleeding & 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 pregnancyHigh 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.
SummarySummary
Supine hypotensive syndrome Radiography minimal Medication penicillin , ACT Emergency A,B,C
History taking, medical consultation, transfer
Thanks for Ur Attention !
The End