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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

2 Maternal concerns Fetal concerns Radiography Medication Summary

3 Maternal concerns 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  10~15% 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 10~12cm  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 40~50% (1500ml) 14th to 30th weeks  heart rate increase 10 beats/min

10 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

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 40~70c.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 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 ( 受孕 ) to 17 days Cellular mitotic activity Sensitivity to toxic substances which may precipitate spontaneous abortion

18 Embryonic period days (2nd~8th wk) Organogenesis Functional & morphologic malformation

19 Fetal period 56 days until parturition Growth & development

20 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 Trimester

21 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

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 ( 分 娩 ) & local anesthesia G.A.  increase of fetal loss

25 Avoidance of teratogens Before implantation (14days)  death of the ovum days  major morphologic defects (organogenesis) 60 days later  function impairment (reduce intellect)

26 Maternal concerns Fetal concerns Radiography Radiography Medication Summary

27 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

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  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 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 ( 變性血紅素血症 ) 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 Antibiotics Penicillin 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

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