management of pregnant patients in oral surgery
TRANSCRIPT
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MANAGEMENT OF PREGNANT PATIENTS IN ORAL SURGERY
SUBMITTED BYMANJARI RESHIKESHIII BDSDEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
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Pregnancy has been considered as an impediment to dental treatment,
preventive, emergency and routine dental procedures - suitable during various phases of pregnancy, with some modifications and initial planning
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STAGES OF PREGNANCYFIRST TRIMESTER(0-12WKS)
SECOND TRIMESTER(13-28WKS)
THIRD TRIMESTER(29-40WKS)
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MATERNAL CONCERSANATOMIC CHANGES
PHYSIOLOGICAL CHANGES
PSYCHOLOGIC CHANGES
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ANATOMIC CHANGESWEIGHT : Uterus weight from 70gm 1 kg
► VOLUME : Uterus volume from 10ml 5000 ml
SIZE: size increases
SHAPE: Pyriform to globular
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PHYSIOLOGIC CHANGESCardiovascular systemRespiratory systemGastrointestinal systemRenal systemHematological systemEndocrine system
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CARDIOVASCULAR SYSTEM Cardiac output increase 30% in first
trimester. Then
BP normal in 1st and in 2nd trimester
2nd trimester heart rate increases 10 beats/min
3-4% - pre eclampsia and eclampsia (hypertensive disorder of pregnancy)
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GASTROINTESTINAL TRACT Morning sickness-Nausea,
vomiting and giddiness Increase gastric acid production
Indigestion and hypo chlorhydria occur
Decrease gastric mobility&constipation
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RESPIRATORY SYSTEM►Overall activity increases
Diaphragm is displaced upward3~4cm&residual volume decrease
rib flare out with wide chest
►Oxygen consumption increase 15~20 %►Respiratory rate increases
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RENAL SYSTEMIncreased GFR and urine(diluted)
In first trimester frequency of urination increases –pressure exerted by bladder
Urinary tract infection common
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HEMATOLOGICAL CHANGESTotal blood volume
increase 40~50% (1500ml) Hemoglobin & hematocrit
volume decrease
Plasma levels of factors VII, VIII, X and fibrinogen increase
Fibrinolytic activity decrease
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ENDOCRINE CHANGES
Estrogen & progesterone increased. LH &FSH decrease Thyroxin, steroid and insulin level are also increased.
HPL causes increase size of breasts
45 % -fail to produce sufficient amount of insulin & develop gestational diabetes.
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PSYCHOLOGICAL CHANGESFIRST TRIMESTER Anxiety Sudden emotional
swings Fear of abortions
SECOND TRIMESTER Self conscious
about weight &Appearance
Regarding movemnts of baby
THIRD TRIMESTER• Anxiety about
labor and baby
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POSITIONING OF PATIENT IN EACH TRIMESTERS
LATTER PART OF 1st trimester-semi reclining
SECOND TRIMESTER-Semi Reclining position
THIRD TRIMESTER-LEFT LATERAL DECUBITUS POSITION(30° left lateral tilt) to prevent supine hypotensive syndrome
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SUPINE HYPOTENSION SYNDROME Third trimester 10-15% Compression of inferior vena
cava & aorta Decrease venous return to heart Decrease utero placental
perfusion and fetal distress
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LEFT LATERAL DECUBITUS POSITION Elevate the right hip 10-12cm by
keeping a small pillow –Left lateral displacement
Sit up position
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FOETAL CONCERNS
Ovum- from fertilization to implantation period (0-17 days)
Embryonic period- from the second through eighth week
Fetal period- after the eighth week until term
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OVUM PERIOD►Conception to 17 days
►Cellular mitotic activity
►toxic substances - spontaneous abortion
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EMBRYO PERIOD18-55 days (2nd~8th wk)
Organogenesis
Most vulnerable to teratogens
Functional & morphologic malformation may occur
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FETAL PERIOD• 56 days onwards
• Growth & development
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FIRST TRIMESTER(1-12 weeks) Stage of organogenesis when all the
major organs are laid down and starts functioning.
50% of abortions MOST SUSCEPTIBLE TO ADV EFFECTS OF
TERATOGENS AVOID ALL ELECTIVE CARE BUT PROVIDE
CARE AS NEEDED AVOID X RAYS Tooth extraction-Latter part of 1st
trimester
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SECOND TRIMESTER(13-28weekS)
• Organogenesis complete
• Fetal growth and maturation
• Gains weight rapidly
• SAFEST PERIOD TO PROVIDE DENTAL CARE
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THIRD TRIMESTER(29-40weeks)
• Fetus fully developed and ready for delivery
• Dental treatments are contraindicated
• Premature labor or abortion
• Extraction- First month of last trimester
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RADIOGRAPHY Dose given & time of gestation Fetus - susceptible to radiation
during first trimester(2nd -6th wks) Single dental x ray - 0.01 milli
rads
HAZARDS OF IRRADIATION• Death of embryo
• Birth of deformed child
• Increased frequency of malignancy.eg.Leukemia
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PREVENTION OF IRRADIATION HAZARD Make the film if it is absolutely essential for
diagnosis(RCT,Trauma)
Use lead-shielding
Use long cone, proper collimation & shielding
Limited to affected tooth
Extra care taken while making films to eliminate the need for repeated exposure
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MEDICATIONS†Local anesthesia†Antibiotics†Analgesics†Corticosteroids†Sedatives
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MEDICATIONS &GENERAL EFFECTS OF DRUGS IN PREGNANCYFIRST TRIMESTER: Congenital malformations(teratogenesis)
SECOND TRIMESTER: Affect growth & Fetal development or toxic effects on fetal tissues
THIRD TRIMESTER: Adverse effects on labour or neonate after delivery
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DRUG CATEGORIES
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Some of the X category drugs are:1. Ribavirin2. -Accutane(isoretinoine)3. Thalidomide - phocomelia4. Sodium valproate5. Phenytoin6. Phenobarbitone7. Methotrexate8. Warfarin(Fetal warfarin syndrome)
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LOCAL ANESTHESIA• Not teratogenic
• used in pregnancy with no proven ill effects
• intravascular injections -the concn - too low to harm fetus
• Prilocaine may cause methemoglobinemia
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LOCAL ANAESTHETICS USED IN PREGNANCY
CLASS B• Lidocaine• Etidocaine• Prilocaine
CLASS C• Procaine• Bupivacaine• Mepivacaine
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ANTIBIOTICS USED IN PREGNANCYPENICILLIN FDAB safe- all trimesters No teratogenic effects Pass the placenta
CEPHALOSPORIN Cephalexin-FDA B Erythromycin(BASE) FDA-B
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ANTIBIOTICS TO AVOID DURING PREGNANCY • Erythromycin (estolate form)
• Vancomycin
• Tetracycline(D)-tendonitis ,tendon rupture
• Chloramphenicol(C) –greybaby synd, BD,
• Aminoglycosides(D)-oto-toxicity, nephrotoxicity
• Trimethoprim-decreased folicacd synthesis
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MNEMONICS
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OTHER ANTIMICROBIAL AGENTS USED IN PREGNANCY
• Nystatin (B)
• Chlorhexidine rinse (B)
• Clotrimazole (C)
• Ketoconazole (C)
• Fluconazole (C)
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ANALGESICS Identify cause- avoid use
ANALGESICS USED IN PREGNANCY1. Paracetamol (B)- safest2. Acetaminophen(B)-safe
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CONT… Ibuprofen( B/C) Avoid in 3rd trimester
Cox-2 inhibitors (C) Avoid in 3rd trimester
Codeine (C) Avoid in 3rd trimester
Morphine (B) Fentanyl (B)
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ANALGESICS TO AVOID DURING PREGNANCYNSAIDSAspirin- tetralogy of fallot prolonged pregnancy and labor increased risk of hemorrhage Premature closure of DAIbuprofen avoided in 3rd-circulatory
problrms
Codeine-3rd trimester-fetal withdrawal &Respirtory depressn
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CORTICOSTEROIDSNot commonly used in
pregnant patients:1. Inhibit brain growth 2. Cleft palate Indicated only for treating severe
systemic illnessPREDNISOLONE(B)-used
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SEDATIVESSedatives/anxiolytics are rated as FDA-D Can cause oral clefts on prolonged exposure
BARBITURATESa) Cross the placental membraneb) Chronic barbiturate use-withdrawal syndromec) Cleft palate-lip
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BENZODIAZEPINES(Diazepam)1. Cleft lip and palate2. Chronic diazepam user-tremors in infants
INHALATIONAL SEDATVES Increase rate of spontanous abortion NO2 not be used in 1st trimester If used in 2nd and 3rd,do not go below 50%
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OBSTETRIC EMERGENCIES IN DENTAL OFFICESYNCOPE
MORNING SICKNESS
SEIZURES
BLEEDING AND CRAMPING
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SYNCOPE All trimester causes-1. Hypotension,2. dehydration, 3. anemia,4. hypoglycemia and 5. neurogenic disorder
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Turned to left sideAdminister O2 &maintain vital signsNot revived with ammonia
Sugar containing fluids given
MANAGEMENT
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MORNING SICKNESSNausea & vomiting
• Avoid morning appointments• Enhanced gag reflex• Oropharygeal suction –prevent
aspiration • Chest compression- advanced
stages of pregnancy
MANAGEMENT
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SEIZURES Cause- Eclampsia Signs- generalized edema elevated BP (sys>140 & dia> 90), severe headaches, blurred vision,
or abdominal pain . Seizure with aspiration of
gastric contents - maternal death.
Hypoxia - fetal death.
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MANAGEMENT
IF seizure develop during dental treatment
administer oxygen by placing her on her left lateral position,
apply suction to the airway
provide emergency transport to a hospital.
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BLEEDING AND CRAMPINGvaginal bleeding -sign of impending miscarriage.
MANAGEMENT
place on left side,
administer oxygen
transport to the nearest hospital
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THANK YOU