Transcribed by Jazmin Lui

PREGNANCY CCP DR. CURRY

1. Pregnancy
There wont be a lot of notetaking. Im going to highlight the important
pieces that I want you to pay attention to. Because with most things its kind
of easy to get lost in the details and I would much rather you look at the big
picture. So Ive done a section where you look at what you need to know in
dentistry. So I think thatll be pretty straightforward.

2. Pregnancy: Keeping Mother and Baby Safe
So with respect to pregnancy I want you to remember that youre dealing
with more than one patient. Especially in the age when youve got multiple
gestations where youve got a mom thats undergone fertility treatment. There
may be more than one baby.

3. Pregnant Remodelling
And this morning what were going to accomplish in this next hour were
going to cover some anatomic and physiological changes that happen in
every organ systems and were going to see the changes that happen up to
and including the time of delivery, till the woman gets back to her pregnancy
state. The purpose is really to accommodate the fetal-maternal unit, and I
want to remind you of some important time considerations.

4. Timelines
A normal pregnancy in duration is approximately 40 weeks, although
having been pregnant twice I can tell you it feels like forever sometimes.
Especially towards the end, its like enough already. Term pregnancy can be
used to describe a woman who makes it to at least 37 weeks of gestation.
Anytime between 37 to 42, heaven forbid, when the baby comes, thats
usually considered normal term. Anything before that is usually premature.
Considerations you need to pay attention to as a dentist is which trimester is
Transcribed by Jazmin Lui
the woman in and the first trimester is from 0 time to 14 weeks, and thats
the time when theres a tremendous amount of production going on for
organogenesis. And at that point the fetus is most susceptible to
malformations from a variety of pathways, most important of which we cant
always control is what goes on in the environment, but certainly from a
medication standpoint, from radiation exposure, thats the key time. Second
trimester is 14-28 weeks and third trimester is 28-42. So having said that its,
you need to be cognizant mechanistically of when youre going to have to
pay attention to the patients position in the chair.

5. Uterine Height in Pregnancy: helpful pictures
The size, the uterine height is only going to really be true for one
pregnancy, one baby in a pregnancy. If theres multiple then the size is going
to be bigger than a woman would be for date (?).
6. [picture of umbilical heights]
At the level of the umbilicus, which is considered 20 weeks, when the
fundus comes up from the pelvis and comes up to that point, thats when
were going to talk later on in the lecture where the structure of the gravid
uterus, the pregnant uterus, can compress the inferior vena cava. And
when that happens when we compress the inferior vena cava, we interrupt
blood flow back to the heart. Thats when it can get pretty exciting, but not in
a good way, when the woman is lying supine in the chair. Well talk about the
dental modifications you do for her, when we get there later one. If you look
from the side, normally uterine height is going to be here at 20 weeks, but
the greatest height of pregnancy is usually at 36 weeks when the baby is
right underneath the womans diaphragm. And then the baby is considered
engaged when the baby drops, so that the pregnancy as the baby gets larger,
the uterus is actually a little bit lower and its easier for mom to breathe. I
want you to pay attention to the side view, because for those who have never
been pregnant, you can see in some way how this mass of the uterus can
interfere with the womans comfort in your chair and being able to breathe
Transcribed by Jazmin Lui
and speak easily. So being a little winded, a little short of breath is not
unusually for pregnancy. Because its a little hard for your diaphragm to be
moving freely when you take a breath in and out, when youve got the baby
displacing all your intestines around and definitely pushing up on the
diaphragm. So visualization helps a little more than just hearing the words.

7. Background information
Were going to touch on each of these systems, but I especially wanted to
bring your attention to hypertension. Every patient that you see in your chair
should have a blood pressure and pulse check at each visit. And remember
you are one of the few practitioners that a patient may ever see, ever. You
may be the only connection to the health care system. But especially when I
woman is pregnant, knowing about her blood pressure readings is crucial to
maintaining good quality blood flow from the mom to the baby. So if the
pressure is elevated, were not asking you to do any sort of intervention
except refer the woman back to her obstetrician. If its markedly elevated,
then that should probably be a phone call to the office that shes being sent
over to, she needs to be seen relatively urgently, especially when youre
looking at people in the 2
nd
or 3
rd
trimesters of pregnancy. And well talk
about what can happen during that time thats important.

8. Cardiovascular
When we look at first the cardiovascular system we recognize there has to
be some accommodation from the mom to accommodate this second person.
Theres an increase in cardiac output by about a third, 50% of that
increase happens within the first 8 weeks of pregnancy, so its really
amazing. Sodium and water retention, same mechanisms we use if we
suddenly lose a lot of volume. The renin and angiotensin system kicks in, this
increased sensitivity to hang on to more salt and water, so we can expand
the circulating blood volume. In a woman, in addition to doing that theres
some change in the autonomic regulation of blood. If there wasnt then
Transcribed by Jazmin Lui
thered be a problem with delivering this increased vascular volume through
the placenta to the baby so as a result of needing to provide now for 2
people, the moms vascular system favours blood flow through the placenta.
Ok.

9. Blood volume changes
And a lot of other changes occur, well talk about. This is in general,
because its a point of increased production youre manufacturing the raw
materials to helpa developing new person. You get what it means. Theres
always going to be mineralocorticoids, glucocorticoids, and sex steroids, that
happen. Were not mechanistically going to go through each of those, none
of you are going to be an obstetrician in this room I dont think. But just be
aware theres a tremendous amount of hormone facts beyond the usual
changes that happen with the estrogen and progesterone levels in pregnancy.
I reminded you about the renin angiotensin system in 2 ways. First by
expanding plasma volume and the second is changing the regulation
through the sensing of those blood vessels.

10. Blood volume
And finally when we look at blood volume theres definitely increased push
in the second and third trimester for the womans pituitary to be really
stimulated by the CRH, increases that come from the placenta, to stimulate
more and more of those steroid production. Because remember, were trying
to get the raw materials for forming fetus, ok?

11. Volume expansion
In terms of volume expansion I want you to understand what this means.
Definitely we retain a lot of salt and water but it can be as much as 6-8 liters
in addition, you know? So if we look at the average, most women are
going to gain an extra 5 L in volume. Pretty amazing. 5000 mL is 5 L. So not
all of this is intravascular. But because of that tremendous increase in blood
Transcribed by Jazmin Lui
volume not unusual to see a little peripheral edema, especially around the
ankles and feet. If its starting to look balloon like between the second and
third trimester and the blood pressure is high, thats an urgent referral to the
obstetrician.

12. Heart murmurs
Now as a result of this stretch in terms of circulation, mom may develop a
heart murmur. Its not pathologic its called physiologic. And thats because
with this increased volume thats going now from mom and the placenta into
the baby thats developing, you know theres a stretch of the valvular
apparatus. And there may be the onset of a murmur. Theres also increased
blood flow to the breast as the breast prepares to lactate to provide food and
nourishment to the child. Sometimes theres a murmur or a fibrill that
happens, palpable, like, feels like a humming like a washing machine type
feeling that a woman will describe within the chest. That can happen from the
increased blood flow to the tissues of the breast, and it will continue
potentially throughout breast feeding.

13. Beware: supine hypotension
Things to be aware of. Most important piece beyond the blood pressure were
going to talk about. Theres an element called supine hypotension.

14. Supine hypotension
So it means if a women is lying flat back in your chair, and that gravid uterus
is not shifted to one side for example, then were going to lose blood flow
back to the right heart. When we lose blood flow to the right heart, because
weve blocked blood volume, thats going to make her light headed, dizzy,
shes probably going to get, shes going to drop her heart rate, if you have
the thought to measure her change in heart rate, she can get nauseous, really
incredibly sweaty, she could vomit and then she could lose consciousness,
which is pretty scary. On paper it seems like Ok I get it, but the most
Transcribed by Jazmin Lui
important thing to recognize is if you can see the pregnancy is at the level of
the belly button, or she tells you shes at 20 weeks, then you have to make
sure you do a couple of adjustments for her in the chair. Some of the chairs
allow you to tilt to 30 degrees, laterally, you may be able to do that. Or you
may be able to take a rolled sheet and put it mechanically behind her right
hip, right behind the sacrum, in the area here. Because putting something
that rolled behind the right hip shifts the center of gravity from the uterus
being right in the center to the uterus being a little more on the left side. You
get it off the vena cava. And she can also manually push the uterus to the
left. So now in the chair she can maintain blood flow to her heart and not
have a problem, and you wont have one either. So its an important thing. If
you, you may have to do things in stages to make sure shes comfortable.
Because remember lying supine even with the uterus to the left, were
favouring good blood flow for the mom, were favouring good blood flow for
the baby, but she also has the issue of having just a lot of other organs kind
of distended in different places in her body. So make sure shes still able to
breath comfortably in the position in your chair.

15. Respiratory changes
And also be very sensitive to the fact, like I told you before there will be
respiratory changes. Because of limitations in the movement of the
diaphragm, she may breathe a little bit more rapidly at rest. In fact I would
expect that. Her tidal volume is going to increase a little bit, but the thing to
remember is a little bit of breathlessness, a bit of fatigability is normal. If you
give her a few minutes to collect herself and relax, you know she should be to
the point that shes able to tell you if she can breath normally or not. Im not
asking you to count it a great deal, how do you know whens someones
comfortable? Its easiest to ask them. But also use your eyes to look to see
how shes appearing. And adjust it for her comfort.

16. Cell counts
Transcribed by Jazmin Lui
Now when you do any kind of blood work like you have to do a procedure, I
want to bring your attention to some changes which happen in her cell count.
As your response, which is normal, is to this expanded blood volume, even
though shes making more blood now, almost for 2 people, until the fetus is
big enough to make its own, in large volume, she will have something called
physiological anemia, because the expansion of her circulating blood volume
expands more of the water than it does of the red cell mass, although the red
cell mass does increase. So let me give you an example. Lets say her usual
hematocrit, actually hemoglobin is usually 13. With pregnancy, shes going to
now be 10, or 9. That may be physiologic, where she starts from, where she
ends up, shell likely be on vitamins in addition to potentially the prenatal, if
she needs additional iron supplementation but thats for the obstetric person
whos following her. If you look at her white cell count, we often think of
white cell count in terms of what? Were looking for infection most times
when were looking at patients white cell counts, correct? Well if normal
white cell count is let say 4000 to 10 000, you may be alarmed if you didnt
know this fact, that white blood cell count is 18 000. You may say Oh my
goodness, shes got an infection, let me see. No thats physiologic. Because
the process that goes on in her body is that shes got some level of
inflammation here. Even though shes pregnant, this second little person in
her circulation is a foreign substance. So her immune system is also
suppressed. Because even though this came from her, part of the baby did
not. You have to recognize that something has to occur for her immune
system to not reject the baby. So shes a little bit immune compromised by
the nature of just being pregnant. And the white cell count reflects some
degree of background inflammation that is happening as a result of this
physiologic process. It doesnt mean infection. How will you be able to tell if
you see someone who has a lesion in the mouth and youre concerned about
systemic infection? You would have to look at a differential count to see
which cells are up, way beyond the abnormal range. Ok. And its most
prominent for these changes to occur in the 2
nd
or 3
rd
trimesters. Usually
Transcribed by Jazmin Lui
its not an impressive change in the 1
st
. in general this issue of immune
suppression happens because the helper cells, the Th, changes in terms of
their ratio. And this is going to rebound in the post-partum state once shes
given birth to the baby. This system does not shut down that quickly. So
there may still be evidence of significant inflammation during the 1
st
month or
so after shes given birth. Which is something to think about.

17. Coagulation
In this section with respect to coagulation, it can be very misleading. And
what I want you to realize is that sometimes if theres blood work done, to
look at her PT, her INR, her APTT, which is her clotting factors. There may be
a minor shift or they can be completely normal. Behind the scenes theres
definitely a change thats going on, and you dont need to remember those
pieces for me. They become more important to you as youre dealing with
pregnant women, if theres any issue with bleeding, and if theres something
abnormal with the test you may want to have a conversation with the
obstetrician, in terms of has there been any particular problems that I need to
be aware of. But the reason for these changes are there are 2 edged process
happeing for her. Shes in the situation of trying to maintain blood flow with
this foreign material. So theres an effort on her bodys behalf in effort to clot.
Because theres also at some point, this recognition that theres increased
potential, with a pregnancy, to be at risk for a venous thrombosis because of
the increased flow and some relative stasis that happens with blood flow in
her own body and her legs. On the other side, to try combat that her system
is trying to adjust some of the other proteins to lessen the chance of clotting.
And that dichotomy exists in every pregnancy as a physiologic piece. So my
take home message is if you have to do a procedure on these individuals you
want to make sure that the 2 blood tests are normal, the complete blood
count which will give you and idea of whats her white blood count, whats
her hemoglobin, whats her platelet count? Because platelets are important for
clotting. And you may also want to know her PTINR because there may be
Transcribed by Jazmin Lui
these other factors that are a little bit out of whack. Even if you arent a 100%
sure and the labs seem a little bit abnormal, you take measures locally that
you take meticulous cleaning, that you do good closure, lets say she has to
have a tooth extracted, heaven forbid. Suture, if theres any issue with
bleeding. Direct pressure, there are other substances you can use in the
mouth to help facilitate clotting locally. But knowing this piece of information
that blood work can be a little off, youll have a better appreciation of what
you need to do as a dentist on what you need for particular individuals in
your chair. Ok. If you deal with a practice thats closely associated with an
OBGYN youll be much more familiar but its not my intention to make you
memorize some aspects that are not important to you clinically. Just be aware
of them and if you get blood work thats a little off you make the
preparations that you need to because you understand the physiologic cause
of that dichotomy. Of bleeding and clotting.

18. Thromboembolic disease
Having said that I did mention the thromboembolic risk. Some women will
have underlying thrombophilias that will become evident during pregnancy.
Factor V Leiden or prothrombin factor gene mutation. And it may present
with a superficial vein clot or a deeper vein clot, but thats the characteristics
times that people get into trouble and know that they have a haematological
disorder is their first dental visit when they have an extraction or some point
during pregnancy. Those are the 2 key pieces of time in otherwise healthy
individuals. I just wanted to bring your attention to that.

19. Dental considerations: pregnancy
More specific dental considerations for pregnancy Im going to let you know
about now.

20. Periodontal disease
Transcribed by Jazmin Lui
Theres always a change in the levels of estrogen and progesterone during
pregnancy but keep in mind that the levels of progesterone is also a very nice
food source for bacteria. So in pregnancy theres an increased risk of
periodontal disease. Because of the shift in these hormones. Now as a result
of that beyond belief, youre going to have to stress a little harder to have
some have meticulously good control of the care and hygiene of their mouth.
And theres also some conflicting evidence. So whats the difference if theres
a little periodontal disease? We cant say that periodontal disease treatment
would reverse the chance of preterm labour. We do know that in women
who have had significant periodontal disease that that is an independent
predictive factor of being a push or stress towards premature labour in
that individual. Theres a lto more studies that need to be done. As a result
of this particular point, if theres any infection, if theres an abscess or any
source for sepsis that you can see inside this womans mouth, please
recognize that this pregnancy is a situation of immune suppression. You need
to be aggressive in terms of the way this is treated. Because if not it has a
very easy opportunity in this individual, to become much more pathologic
than it would be than in someone who is not pregnant with the same
background.

21. Change in appetite
Other changes you need to be aware of is that sometimes in pregnancy
because of these hormones, women may have an increased appetite. And it
may not be for usual food stuff. Sometimes theres unusual cravings that
occur. And it may be highly processed food. A lot has been made of the ice
cream and pickle thing. But theres a lot of different people with as many
different choices and cravings during pregnancy as there are people. And as a
result if she picks something thats high in sugars thats also going to affect
her dentition and may also contribute to unwieldy weight gain thats not
healthy for her or the baby. And you know that sugar increases the risk of
caries. So if youre seeing something you may want to talk to her about
Transcribed by Jazmin Lui
cravings or what her diet is but most of all you want to give her an
opportunity to learn how to take care of her mouth much more
meticulously than she did previously.

22. Change in taste
With these changes in hormones sometimes theres also a taste alteration that
happens. That things dont taste the same. There is also potential for an
increased gag response. Women may have increased sensitivity of nausea,
some may actually vomit, especially early in the pregnancy. That condition
happens to be called hyperemesis gravidarum. It means theres an increased
likelihood, because shes pregnant, since shes gravid, to throw up on you and
be nauseous. So be very careful when you go in to examine her mouth and
pay attention to the clues that she gives you. Because if you dont you will
probably find out the hard way. We had our equivalent of this when I was in
the emergency room working with people in the rapid care area, when
individuals have like a sore throat. And we tell the students and the residents
not to be so quick to look in without taking your time, and of course weve
had many people vomit on the individuals who were trying to examine them.
So as a result because of this increased tendency for nausea and vomiting
not only do you want to be careful about how you examine but you also
want to look for changes that regurgitation can cause, for example bad
breath, or enamel erosion, ok? So it has some physiologic reasons for you to
pay attention.

23. Metabolic changes: mother
Now about the metabolic changes.

24. Placental hormones
And this gets a little bit more back to the particular things that there are
placental hormones, cause the placenta becomes an entity thats pretty
important as a manufacturing site, if you will. Especially in late pregnancy,
Transcribed by Jazmin Lui
thats late gestation, and placental hormones really come front and center.
Why am I stressing this piece? Well part of the physiologic reason for weight
gain for women beyond the expansion of blood volume is because of the
increased synthetic demand in having fuel stockpiled. So theres fat
deposition in different places and theres definitely an effect in the
womans distribution in fat supplies which are very much influenced by
the hormones. Not only the fat but protein and water are going to be stored
in the intracellular component in these regions of storage. So thatll definitely
add to the weight as well. Why is that important?

25. Insulin levels/glucose
Once you understand the physiological reason this occurs you also have to
recognize that throughout that is, insulin levels and glucose levels are going
to be in a different range then they are in someone whos not pregnant. And
if the mom has not eaten say, if shes been in the chair for a period of a
couple of hours, for a procedure, that can put her at a risk for becoming
hypoglycaemic. Baby always takes what the baby needs, whether or not mom
has eaten. So if she hasnt eaten before a procedure with you and its
been 3 hours, close to 4 shes going to have a hypoglycaemic event. So
you need to be aware of when she last ate, is she able to eat lightly, if shes
had problems with known hypoglycaemia, whether this pregnancy or a
previous one, its important to know that. Because with hypoglycaemia, not
only can someone lose consciousness and feel pretty crappy, they can
potentially lose consciousness and also have a seizure. And thats
something you dont want. Because that can potentially cause harm to her
and you if your fingers are inside her mouth during the process. The seizures
are uncontrolled tonic/clonic activity usually. And it can be enough to severe
someones finger if someones bitten or significant damage can happen if she
clenches on an instrument thats in her mouth. So if youre paying attention
to time of last eating, how much time shes been in the chair, may be an
important consideration. And with this increased blood volume and increased
Transcribed by Jazmin Lui
affective hormones and eating, she may also because of the size of the
pregnancy, may not be able to stay long without bathroom breaks. So you
want to be sensitive to her needs so that shes comfortable in the chair and
that you dont have a problem either. Now theres definitely her glucose, if
you were to measure mechanically her blood glucose over time, her numbers
would be lower because theres increased utilization for production thats
happening outside of her own direct needs. In addition, if you were to look at
her glycogen stores, her glycogen stores would be affected, shes going to
have increased glucose utilization and shell have some decreased hepatic (?)
production because theres some tendency to use some of the stores. Now
its greatest during the third trimester but it does happen throughout the
rest of the trimesters but most pronounced during the 3
rd
because thats
when the baby has the greatest amount of mechanical growth to muscle and
to fat and the connective tissue.

26. Insulin resistence
If we look at levels of insulin resistance there is some, because of the
increased weight in the mom. And definitely from the increased placental
secretions of these diabetogenic hormones because the placenta is still
driving the fuel supply to feed this growing new person ok? So as a result
theres more growth hormone which is antagonistic to insulin, theres
definitely more factors that are stimulating moms release of cortisol to make
more of those hormones we talked about, theres more progesterone and
theres definitely going to be an alteration in the post receptor defect that
changes insulin sensitivity. So be aware of that. Well come back to that point
in a few moments. And this is in someone whos normal, let alone someone
whos body who cant address these changes and suddenly becomes diabetic
and pregnant, and well get to that in a moment.

27. Labour and beyond: intense
In addition to labour and beyond, just to complete the process -
Transcribed by Jazmin Lui

28. Hemodynamics shift
- theres always towards the 3
rd
trimester, the anxiety: when is it over, is the
baby going to be ok, is there movement? She may have some uterine
contractions, theyre called Braxton Hicks to get the uterus ready for the final
production, pushing out the baby. And her cardiac output during labour is
going to really flux a lot, but what also happens which is really kind of neat, is
theres an increased chance of losing a lot of blood at the time of delivery,
because its usually a pretty bloody procedure if it happens through the
vaginal canal. Less so if its a C-section. But because of this contraction, all the
blood supply that fed the uterus during pregnancy to maintain the baby and
all the blood supply that was in the placenta during the stage of labour, this
is a chance when that squeezing of vessels inside the wall now helps to push
that blood back into maternal circulation so in fact shes getting a little bit of
an autotransfusion to compensation for the blood loss that may happening
during the rest of labour. So its a nice protective mechanism, just to give a
piece of whats going on, expanding the volume, we talk about potentially
losing volume and we have a little bit of a cushion so its kind of neat to
know that.

29. Gestational diabetes: GDM
Getting back to what we just talked about a few moments ago with insulin
resistance there is an entity called gestational diabetes, where diabetes is
diagnosed in the pregnancy.

30. GDM
If a woman shows up for prenatal care and lets say, for example shes six
weeks pregnant and she finds out shes diabetic, thats not gestational
diabetes. Thats diabetes that was not diagnosed before, ok? Gestational
happens a little bit later, and lets see why this occurs. Moms pancreas does
not overcome insulin resistance completely. In a normal person she does, but
Transcribed by Jazmin Lui
in an abnormal situation she may not be able to overcome that resistance,
she still makes insulin, she still has glucose around, but theyre not really
coming together like theyre supposed to. If I were to look at her blood
sugars, lets say normal is between 70 for example and lets say 110, maybe
shell have sugars in the 130s to 150s, its fasting. It doesnt seem like a lot,
but its enough to get her into the diabetes club as a pregnant woman. And
that comes with it. And increased chance to have complications. Because
diabetic mothers tend to have bigger children. If the babys bigger, whats
optimal for the birth canal, there can be damage to mom as well as to baby.
And blood sugars also can make the baby have increased risk down the road
if the babys born large. Lets say 9, 10, 12, 15 pounds youve probably heard
in the last couple of months a baby was born that was 16 pounds. It makes
me shudder. But that child is also at risk for diabetes in the future. And mom
doesnt lose her increased risk of maintaining this diabetic state after
pregnancy if she has a lot of weight gain.

31. Case: CCP
Lets look at a case though and lets see what happens with a regular
pregnant patient that comes in and things you may encounter.

32. Marla
We have a woman named Marla, shes 26 years old, shes 28 weeks pregnant.
Shes appeared to you and complained about a painful growth on her gums.
It bleeds when she brushes. Shes a primagravida. Prima means first so this is
her first pregnancy. Theres no past medical history and no past surgical
history. The only medicine she takes is prenatal vitamins. Where follates are
really important for spinal cord and nervous system development. Shes got
no known allergies, no family history of hypertension or diabetes. And her
review of systems reveals shes feeling a little tired, really pretty much all the
time now.

Transcribed by Jazmin Lui
33. Examination
Upon examination, because you remembered what I told you, you put a
wedge behind her right hip, tilting her to the left, her blood pressure is
beautiful, its 100/70, her pulse is 96 and regular, but you happen to notice on
her face shes got some hyperpigmented areas and when she opens her
mouth chatting you recognize theres erythema on her gums with a tumor,
which is swelling.

34. Facial findings
On her face this picture shows she has a slight increased pigmentation here,
theres a little bit here, theres little but on the forehead. This can be a normal
finding in pregnancy, its called the mask of pregnancy or melasma. And if
you look it at and you tried to feel it its not raised its flat into the same
surface of the skin so its described as macular. And its on the malar region, it
can be on the forehead as well as the chin. And it may not disappear after
pregnancy is completed. And its because of the increased stimulation of
melanocytes, which are the pigment containing cells which are in our skin.
And it gives her this colour. If anyones concerned about this, especially
people of colour, its important not to use over the counter products because
it can cause a problem with decreased pigmentation thats pretty obvious. Its
best treated by professionals. If you are of colour, most people are very light
can end up trying the bleaching agents that are over the counter, but again
with caution as long as the people arent sensitized by this. It can take
months for this to go away. If it is someone of colour I suggest they usually
get professional follow up in terms of the dermatologist.

35. Gingivitis
If you look at her gums, thank goodness this is not that woman, but theres a
lot of redness at the lines, right?

36. Oral lesion
Transcribed by Jazmin Lui
And then if we go to this picture, obviously not the same person, the swelling
is the pyogenic granuloma. It can happen in pregnancy, its more common
usually in the 2
nd
trimester. It can bleed, its soft, sometimes it may be flat
which is considered sessile or may be pedunculated on stalk (?). And it may
simply regress after pregnancy with meticulous care. Unusual but occasionally
have to be removed.

37. Gingivitis and pregnancy tumours
And occasionally its referred to as a pregnancy gingivitis. And it happens to
be very exaggerated inflammatory response to the fact that her oral hygiene
is not as meticulous. Or maybe its a function of her diet and she hasnt really
cleaned well afterwards. And remember that potentially throughout all of
pregnancy theres an exaggerated inflammatory response, so that makes
sense. That increased production of estrogen but particularly progesterone is
going to feed more of the bacteria and make it a wonderful environment ok?
And by characteristic location its marginal interdental especially in the 2
nd

month like I mentioned. Ok.

38. Continued
It can be very fiery red, it can be very tender, and sometimes theyll develop
that tumor.

39. Dental guidelines
So in general if were looking to guidelines, whats the important you start
with when you meet a pregnant patient? You want to assess her general
health, getting her medical history, review her systems like you do for
everyone, including what status of pregnancy is she. If she hasnt for prenatal
care yet, the earlier the better. You want to confirm thats been established. If
it hasnt been you ask her where, you know where to go, ask her where she
lives, if she lives close by, depending on what her preferences are theres
plenty of choices here on hospital row here on 1
st
Ave, Belleview and NYU
Transcribed by Jazmin Lui
among them. If she has a provider you want to know their contact
information and you want to potentially talk about any potential problems
that come up during pregnancy, knowing the name of the individual, where
the number is located which should be easy to obtain and document in the
chart. If shes on medications, including the prenatal, its a very important
thing to do, to list them. If she has allergies you need to know them and what
type of allergies. Youre still going to ask the social history the same things as
everyone else. Dont assume just because shes pregnant thats shes not
smoking, drinking, or using drugs. Ok. If she has had previous pregnancies
you want to know if she was diabetic during them, did she have gestational
diabetes. Has she ever had miscarriages? If shes had multiple she may have
one of those factors, thrombophilic for example factor V Leiden. Does she
have high hypertension during pregnancy? Did she have morning sickness,
did she have asthma? Did she have anything that would potentially interfere
with her ability to breathe beyond the pregnancy?

40. pregnant patients
For pregnant patients theres always a treatment strategy for you and theres
always going to be limitations based on that particular patients. Whats the
safest trimester for dental treatment? What about radiology usage? What
about medications? What about risk for periodontal disease, weve talked a
little bit about it. And weve also mentioned that infections could increase risk
for preterm labour. But one thing youre always going to make sure you do
is measure her blood pressure.

41. Treatment schedules for all trimesters except as listed.
Now the general consensus anytime you need to treat a patient and you can,
first trimester they stress urgent care, not really elective surgeries. If she
wanted to have an implant for example, not a good thing. Lets say she had
trauma and she has to have one, you need to have a discussion about risk
and benefits with the medicines, you know, anaesthesia in terms of potential
Transcribed by Jazmin Lui
harm to the baby. You want to talk about local care, you can do all the
routine things you need to do, you may need to make adjustments during the
2
nd
and 3
rd
trimester depending on her level of comfort. And thats, unless
theres some particular problem, lets say shes a gestational diabetic whos
difficult, or she has blood pressure problems, you may want to have a
discussion with her OB to see what procedures are safe for her and using
what.

42. Baby teeth?
Now a lot of people talk about fetal dentition in terms of potential
malformations and its mostly a function of any toxins or infections or
exposure to radiation. Some medications can cause tooth discolouration but
thank goodness weve known for many years, many decades that tetracycline
for example will stain teeth. And some people have looked to some
occasional studies that looked at giving fluoride to moms during 2
nd
and 3
rd

trimester and they look at those offspring, theyve maintained pretty good
protection against caries for about a 10 year period. So its something you
may want to review with your dental faculty when youre actually in the clinic.

43. When is it safe to treat?
What is the best trimester? Its the 2
nd
trimester, but you can treat in any
trimester.

44. Can pregnancy be complicated?
Remember pregnancy is exaggerated inflammation, always pay attention to
hypertension, periodontal disease also goes hand in hand. So if it doesnt
seem to be related to diet think about is there a problem with glucose?
Because maybe she needs to be followed up earlier than later with her OB,
and GDM is gestational diabetes mellitus, and if she develops that it
further increases her risk of infections if its not well controlled.

Transcribed by Jazmin Lui
45. Remember
Because of her increased need for glucose remember and the babys
increased demand she probably needs to eat every 4 hours, something small.
And remember the hypoglycemia we talked about. Overall her calorie intake
over her baseline should be only 500 extra and she definitely has an increased
need to increase her water intake because shes expanded her blood volume.

46. Coming to terms: impt information/definitions
When she comes to terms there are definitely things you have to think about.
Second and third trimester in these women.

47. High blood pressure
If we notice an increased blood pressure in these women, lets say because
youve been seeing her throughout her pregnancy and she never had that
before dont assume shes nervous. Take it 10-15 minutes later, take it at the
end of the appointment. If shes still high thats very worrisome. Because
preeclampsia is a condition caused by hypertension and that develops in
the 2
nd
trimester or 3
rd
trimester of pregnancy. It begins after 20 weeks.
Youre not checking for protein in the urine, thats her OBs job, but you will
see evidence of hypertension, high blood pressure readings, she may
complain to you of a change in her vision, that looks a little blurry and she
thinks she may need glasses now. That could be a red flag because that could
signify an increased problem thats going on in the region of her nervous
system. She can go on to develop something called eclampsia which is life
threatening further down the pathway in pregnancy, where seizures will
occur and potentially coma. We dont know the reasons for it but theres a
tremendous increase in blood pressure for these individuals which may be
very difficult to control. Her OBGYN has to place her on medications to treat
her. If her numbers maintain a very high number, then she has a series of
problems.

Transcribed by Jazmin Lui
48. Eclampsia group findings
Theres a sympathetic over activity in the nervous system. This is sympathetic
increase in the vaso-motor tone of all of her blood vessels. Theres a lot of
insulin resistance, the renin angiotensin system is fighting this whole situation,
tremendous inflammatory mediators, and what can happen if she has an
increase in pressure, talks to you about change in vision, shes got increased
leg edema, shes at risk at having a major problem with potentially a stroke
for herself and can potentially cut off significant blood supply to her baby.
When a woman is eclamptic, and it has happened when they come into the
ER, including a colleague, she was blind when she was shopping at Macys.
Sudden loss of vision. Couldnt even dial her phone. Had to have someone
else get help for her and get her to the hospital. The way they treat it is with
magnesium and eventually when the magnesium doesnt calm the system
down then urgent delivery of the baby has to occur, or you potentially lose
mom and baby.

49. Fetal demise
Fetal demise can occur sadly and it can spontaneously happen. Natural
termination before the 20
th
week is called a spontaneous abortion. It
sometimes happens because of some underlying intrinsic fetal abnormalities
but not all studies done with the first pregnancy lost. It tends to be looked at,
if theres multiple losses. History of miscarriages that are multiple. Its very
unlikely that a dental procedure will result in a spontaneous abortion, but its
much more likely if someone were under anaesthesia or under nitrous, and
was on it too long, or had significant fetal hypoxia because mom wasnt being
monitored for her oxygen content and having that kept that at the higher 90s
versus the lower. If she had been exposed to some substance that may have
been teratogenic at some point in the pregnancy. But infections especially
with fevers can get her into trouble.

50. Dental guidelines
Transcribed by Jazmin Lui
So from a dental standpoint where can you get for references and Ive
included one of them.

51. ADA News
There was a consortium that met a number of years ago and they talked
about paying attention to a variety of things.

52. Note
You always want to get good anaesthesia, you want to make sure you arent
injecting intravascular if youre using epinephrine although youre using it
in very tiny amounts compared to the doses that I use in medical treatment
of things say in the reactive airway. Pay attention to chairs, you limit your x-
rays, and you pay attention to the use of shielding, the aprons as well as the
thyroid shield.

53. Radiation
With radiation you want to avoid it if you can during 1
st
trimester, but if
you need to do it then you do it to care of the mom, using the appropriate
shielding.

54. Radiographs
Your clinical faculty will talk to you about the nature of which types of x-rays,
obviously the more local the better, but you get what you need to get in
order to treat the mom.

55. To explain to the patient
And to explain to a patient that the gonad or fetal dose of radiation you
would administer is really 700x less than the background radiation thats in
the atmosphere.

56. Table
Transcribed by Jazmin Lui
I also provide a table, its far less than a chest x-ray, which is still insignificant
compared to a lot of other things that can occur. But you dont want to do
more than you need to.

57. The new consensus statement
And this is the actual another way to look at the cited references. What they
went on to stress, any medication that you give the patient has to be broken
down into a number of categories.

58. Drugs
Any drug, get into the process of looking it up if you give it to a pregnant
woman. A and B categories are safe, C you have to use caution, forget about
D and X. Youre going to avoid them.

59. FDA Pregnancy Categories
And this is what it means for each of the categories based on evidentiary
data.

60. Table
And I took the time to give you a list of some of them, what can be used
during pregnancy, what cannot be used, its all colour coded.

63. Drugs
The important thing is if you look at the drug lists, you can use penicillin and
amoxicillin among them. And it gives you a list of several medicines. If you
start to look at narcotics there are Cs and Ds. Lets say shes anaphylactic to
NSAIDs. NSAIDs you dont want to really use, or aspirin during pregnancy
especially during the 3
rd
trimester. Because if you give it during 3
rd

trimester, it stimulates the patent ductus which helps with the fetal
circulation to close prematurely. And that is not acceptable. So thinking
about Tylenol is great, if you have to use anything else look it up, and have a
Transcribed by Jazmin Lui
conversation with the OB. But ultimately you are responsible for the
medications that you ask.

64. Drugs
If you have to use nitrous, again, you want to think better in the 2
nd
or 3
rd

trimester and you have to make sure its administered with sufficient oxygen.
And you pay attention to the timing.

65. Mercury
People ask about mercury. Amalgam studies were pretty flawed. The more
important sources of mercury happen with fish. Ok?

66. Mercury harms
Tuna, tile fish, mackerel, shark, kingfish. And women have to pay attention to
dietary intake because this is much more deadly than having a filling. There
are choices now, in terms of the composites.

67. Lose a tooth?
Women also have heard the old wives tale of losing a tooth for each
pregnancy. It shouldnt happen. Ok.

68. What about mobility?
Mobility. Its probably a sign of gingival disease. Vitamin deficiencies can also
contribute. And you want to educate the patients about using good hygiene
and what are the benefits of some of the multivitamins out there.

69. Pregnancy and dental care
I want you to remember you have 2 patients in one, maybe more. You need
to know the stages of pregnancies. Know her provider, the name and the
numbers. Do blood pressure each visit, pay attention to keeping the visit
short. Position her with caution in your chair.
Transcribed by Jazmin Lui

70. Pregnancy
Educate her on the benefits of oral hygiene which is something you do really
well and preventative care. And if you have anything you arent clear about in
a pregnant person dont be afraid to reach out to the resource of the OB
whos caring for her. Youre all part of the same process. And youre always
going to maintain blood pressure and position of the chair emblazed on your
forehead. Ok? Cause youre obviously make a pretty big difference to a lot of
people but especially a pregnant mom. If you have no questions then have a
great day. If you do have them you can certainly email me. Its been a
pleasure to see you, good luck with your exams, and hopefully Ill see you
next year. Thank you.