Discomforts, Lifestyle & Oral Health 2011

Discomforts
Nausea and vomiting Heartburn

Lifestyle concerns with nutritional implications:

alcohol caffeine smoking Illicit drugs Non-nutritive sweeteners physical activity

oral health

Nausea & Vomiting:

Cochrane Intervention Review, 2010 Quinlan et al, Am Fam Phys, 2003

Background
70-85% of women experience nausea with pregnancy ~ experience vomiting 35% of women with employment lose time from work due to nausea an average of 62 hours Almost 50% of women report that their work efficiency is reduced by n&v

Stress Associated with N&V

Lack of understanding and support from others Inability to take vitamins or eat healthy Taking medications perceived as risky Missing out on the fun of being pregnant Loss of a normal pregnancy Lost work days or quitting work Putting life on hold Longing to eat and drink normally Money expended on care and support Lack of energy, fatigue Irritability and lack of enjoyment of life Memory loss or inability to think clearly Burden of care and time on others Lack of socialization, isolation

cont

 Inability to prepare for birth and arrival of baby Inability to care for family and home Wanting pregnancy over or to end the misery Others perception that hyperemesis is only in her mind Reluctance of doctors to treat because of cost or liability Weight loss or inadequate weight gain for gestational age of baby Sense of inadequacy and failure at being unable to cope or function Difficulty bonding with infant Lack of energy and socialization with other children Lack of excitement about infants arrival

Etiology
Unknown appears to have some association with rising levels of human chorionic gonadotropin (hCG) or estrogens
Nausea less common in those who subsequently experience miscarriage More common in twin pregnancies

Hyperemesis Gravidarum
Severe nausea and vomiting Affects one in 200 pregnancies Most common reason for hospitalization in early pregnancy Clinical features: Persistent vomiting, dehydration, ketonuria, electrolyte disturbances, weight loss 159 per million pregnant women died in England between 1931-1940 (before IV fluid replacement therapy was available) (Charlotte Bronte died of hyperemesis in her fourth month of pregnancy)

Use of non-pharmacological treatments

Commonly recommended by health professionals without evidence of effectiveness Safety unknown and unregulated
women and professionals are more likely to underestimate their possible risks

Cochrane 2010
Interventions for nausea and vomiting in early pregnancy 27 studies with 4041 women included
22 studies excluded

Acupressure
Comparison & studies
P6 vs vitamin B6 one study, 66 women P6 vs Placebo
4 studies- 408 women

Results
No sig difference, but more satisfied with P6 No sig differences No sig difference

Auricular (metal balls taped to point on ear) vs placebo

I study, 90 women

Acustimulation (low-level Data not simple to interpret nerve stimulation therapy over the volar aspect of the wrist at the P6 point) vs placebo
one study, 230 women

Acupuncture
Acupuncture versus placebo (sham acupuncture and no treatment)
two studies with 648 women

No sig difference or data not interpretable

Ginger
Comparison & studies Ginger versus placebo
4 studies, 283 women

Results Studies suggest benefit, but meta-analysis that controlled for study deficits found no benefit

Ginger versus vitamin B6

4 studies, 624 women

Pooled results show no benefit

Ginger versus Dimenhydrinate (Dramamine)

1 study, 170 women

Data not easily interpreted

Vitamin B6 versus placebo

2 studies, 416 women Results favored vitamin B6 for reduction in nausea after three days Comparing the number of patients vomiting post-treatment, there was no strong evidence that vitamin B6 reduced vomiting

Anti-emetic medication versus placebo

6 studies, 803 women Hydroxyzine, Debendox (Bendectin) Thiethylperazine,FluphenazinePyridoxine Review found substantial methodological problems with most studies and could not reach meaningful conclusion

Adverse Outcomes
Acupressure: reports of pain, numbness, soreness and hand-swelling Ginger: few studies reported adverse impacts, one statement about heartburn Antiemetic drugs: primary complaint was drowsiness.

Summary Statements
No acceptable studies of dietary or other lifestyle interventions Limited evidence regarding acupressure acupuncture not effective The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting.

Cochrane Conclusions:
Given the high prevalence of nausea and vomiting in early pregnancy, health professionals need to provide clear guidance to women, based on systematically reviewed evidence. There is a lack of high-quality evidence to support that advice. The difficulties in interpreting the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies.

Nausea and vomiting of pregnancy: an evidence-based review

(Davis, J Perinat Neonatal Nurs. 2004)

First step is dietary & lifestyle changes

American Gastroenterological Association Institute Medial Position Statement on the Use of Gastrointestinal Medication in Pregnancy (2006) Metoclopramide, prochlorperazine, promethazine, trimethobenzamide and ondansetron* are considered low-risk drugs based on studies in pregnant women and can be used for nausea and vomiting and for hyperemesis gravidarum. Granisetron and dolasetron have not been studied in human pregnancies.
*Reglan, Compazine , Phenergan , Tebamide, Zofran

Interventions for Heartburn in Pregnancy Cochrane, 2008

Up to 80% of women in third trimester Not well understood pregnancy hormones influence
Lower esophageal sphincter Gastric clearance

3 studies, 286 women

little information to draw conclusions about the overall effectiveness of interventions to relieve heartburn in pregnancy.

The management of heartburn in pregnancy (Richter, 2005. Alimentary Pharmacology & Therapeutics) Staged approach: Lifestyle modification: Smaller meals, no late night eating, elevate head of bed, avoiding foods/mediations causing heartburn Discuss risk/benefits of drug TX (RCTs not done)

The management of heartburn in pregnancy (Richter, 2005. Alimentary Pharmacology & Therapeutics)

Adverse effects of substance use determined by:

Timing Dosage Duration Number of substances Environment (nutrition, health status) Individual susceptibility

Effects of substance abuse include:

Increased health problems, including risk of AIDS Compromised nutritional status/weight gain Higher rates of OB complications Psychosocial/economic/legal problems Parenting difficulties Higher rates of child abuse/neglect

Alcohol: Background
Per capita alcohol consumption has risen through the second half of this century in the US 70% of individuals between the ages of 20 and 34 consume alcohol Alcohol consumption peaks in the 20-40 year old group

Percentage of women aged 18--44 years who reported any alcohol use or binge drinking, by pregnancy status --- Behavioral Risk Factor Surveillance System (BRFSS) surveys, United States

MMWR: May 22, 2009 / 58(19);529-532

Alcohol: Background, cont.

Women are at disadvantage because less gastric first pass metabolism due to lower levels of alcohol dehydrogenate in intestinal mucosa Fetus has no alcohol dehydrogenase activity Alcohol crosses placenta easily by passive diffusion fetal levels mimic maternal levels The amniotic fluid acts as a reservoir for alcohol.

FAS Diagnostic Criteria- Fetal Alcohol Study Group of the Research Society on Alcoholism

Prenatal and/or postnatal growth retardation (<10th % ca) Central nervous system involvement (neurologic abnormality, developmental delay or intellectual impairment) Characteristic facial dysmorphology with at least 2 of these 3 signs:
Microcephally ( OFC < 3rd %ile) Micoopthalmia and/or short palpevral fissures Poorly developed philtrum, thin upper lip, and or flattening of the maxillary area

FAS, cont.
Other organ systems often involved. Some with nutritional implications:
Cleft palate Eustachian tube dysfunction Array of cardiac, renal, and skeletal defects that may require surgical repair

FAE Fetal Alcohol Effects or PFAE

Exhibit some components of FAE, but not all Most common sign is retarded growth both pre and postnatal Can have significant developmental and behavioral components

Fetal Alcohol Spectrum Disorders (FASD)

Surgeon Generals Advisory (2005)
FASD is the full spectrum of birth defects caused by prenatal alcohol exposure. The spectrum may include mild and subtle changes, such as a slight learning disability and/or physical abnormality, through full-blown Fetal Alcohol Syndrome, which can include severe learning disabilities, growth deficiencies, abnormal facial features, and central nervous system disorders.

FAS/FAE Incidence
FAS 1.9 per 1000 births, 25 per 1000 among women who drink heavily FAE 3 to 5 per 1000 births, 90 per 1000 among women who drink heavily FASD is leading cause of mental retardation in the western world

Pathophysiology
Combination of
Toxic effects of ethanol and its derivatives Nutritional factors Genetic predisposition

Toxic effects
Both alcohol and derivative acetaldehyde directly damage developing and mature nervous systems Impair nucleic acid synthesis Disrupts protein synthesis Cell membrane narcosis High maternal alcohol levels associated with dehydration, fetal hypoxia and acidosis, placental pathology and dysfunction, and endocrine disturbances.

Nutrition Related Effects of Alcohol

Poor nutritional status of mother Reduced placental transfer of zinc and folic acid associated in animal models Alcohol impairs absorption, utilization, and metabolism of nutrients Poor zinc status has been associated with adverse effects of alcohol in many studies

Surgeon Generals Advisory

(2005)

Science:
Alcohol consumed during pregnancy increases the risk of alcohol related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development. No amount of alcohol consumption can be considered safe during pregnancy. Alcohol can damage a fetus at any stage of pregnancy. Damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant. The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure are lifelong. Alcohol-related birth defects are completely preventable

Surgeon Generals Advisory

Recommendations:
1. 2. 3. 4.
(2005)

5.

A pregnant woman should not drink alcohol during pregnancy. A pregnant woman who has already consumed alcohol during her pregnancy should stop in order to minimize further risk. A woman who is considering becoming pregnant should abstain from alcohol. Recognizing that nearly half of all births in the United States are unplanned, women of child-bearing age should consult their physician and take steps to reduce the possibility of prenatal alcohol exposure. Health professionals should inquire routinely about alcohol consumption by women of childbearing age, inform them of the risks of alcohol consumption during pregnancy, and advise them not to drink alcoholic beverages during pregnancy.

Caffeine
History:
Rat based studies with high levels of caffeine found adverse pregnancy outcomes Early 1980s US FDA issued advisory about adverse effects of caffeine in pregnancy Further research found little association, FDA concludes that no strong evidence, urges moderation 1996 IOM review for WIC advised removing excessive caffeine intake from WIC risk criteria 1998 - USDA removed as WIC risk criteria

The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al.

Nutrition Review, 1996)

Consumption:
In US 70-95% of pregnant women consume caffeine - average intake is 99185 mg/day 5-30% of pregnant women consume >300 mg/day Heavy caffeine intake more likely in women who smoke and those with lower education levels

The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al.

Nutrition Review, 1996)

Metabolism
methylxantines cross the placenta to the fetus where an equilibrium is achieved between maternal and fetal plasma half-life of caffeine in pregnancy changes from 5.2 to 18.1 hours in T2 and T3 and returns to non-pg levels a few weeks pp

Caffeine Metabolism, Genetics and Perinatal Outcomes (Ann Epidemiol 2005)

Wide individual variation in caffeine metabolism
Due to variation in CYP1A2 enzyme activity Measuring maternal, fetal and neonatal caffeine metabolites may allow for a more precise measure of fetal caffeine exposure.

Coffee and Health: A Review of Recent Human Research (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

Conception
Many studies find > 300 mg/d associated with delay in time to conception (some do not find this effect) Authors conclusions: it may be prudent for women who are having difficulty conceiving to limit caffeine consumption to less than 300 mg/d in addition to eliminating tobacco use and decreasing alcohol consumption.

Spontaneous Abortion
Conflicting studies Women who decrease Caffeine due to N&V, more likely to have viable pregnancies. Most studies that observed significant associations between self-reported coffee or caffeine consumption and the risk of spontaneous abortion did so at intake levels of at least 300 mg/d of caffeine.

Fetal Growth
Several studies found that maternal caffeine intakes ranging from 200-400 mg/d were associated with decreases in mean birth weight of about 100 g. A meta-analysis that combined the results of eight epidemiological studies found that maternal caffeine consumption greater than 150 mg/d increased the risk of low birth weight by approximately 50%.

Preterm Delivery
Most epidemiological studies have not found coffee or caffeine consumption to be associated with the risk of preterm delivery.

Birth Defects
At present, there is no convincing evidence from epidemiological studies that maternal caffeine consumption ranging from 300-1000 mg/d increases the risk of congenital malformations in humans.

Coffee and Health: A Review of Recent Human Research (Higdon and Frei; crit rev food sci and nutrition, 2006) Currently available evidence suggests that it may be prudent for pregnant women to limit coffee consumption to 3 cups/d providing no more than 300 mg/d of caffeine to exclude any increased probability of spontaneous abortion of impaired fetal growth.

Smoking
25-30% of US women smoke during pregnancy; down from 40% in 1967 Cochran review found that 30 trials of intensive intervention programs in pregnant women lead to smoking cessation in 6.6-9.2% of women.

Trends in Smoking Before, During, and After Pregnancy, MMW; May 29, 2009

Trends in Smoking Before, During, and After Pregnancy, MMW; May 29, 2009

Trends in Smoking Before, During, and After Pregnancy, MMW; May 29, 2009

Trends in Smoking Before, During, and After Pregnancy, MMW; May 29, 2009

Adverse Outcomes of Maternal Smoking

Cigarette smoking is the single most important factor affecting birthweight in developed countries (DiFranza, Pediatrics, 2004) Twice the risk of LBW Lower birthweight (~200g) Perinatal: Moderately increased risk of preterm delivery, perinatal mortality, spontaneous abortion Long term: modest reduction in long term growth and intellectual development of fetus.

Nutritional Risks Associated with Smoking

No breakfast (38% of smokers vs. 18% of non-smokers) Lower dietary intakes of fruits and vegetables, protein, zinc, riboflavin, thiamin, iron

Nutritional Risks Associated with Smoking, cont.

Smoking appears to:
decrease the availability of dietary energy increase requirement for iron reduce availability of B12, amino acids, vitamin C, folate, and zinc

Lower serum vitamin C, B6, E, folate, beta carotene

Norkus et al. FASEB, 1989 and Ann NY Acad Sci 1987

Smokers Cord vit. C (mg/dl) Placental vit. C
(mg/dl)

Non-Smokers 1.68 20.9 0.3 44 20

0.61 10.1 0.2 19 7

Cord vit. E

(mg/dl)

Maternal plasma carotene (g dl Cord carotene

(g dl

Vitamin C and PROM

PROM occurs in 8-10 % of all pregnancies Vitamin C is required for collagen synthesis Maternal plasma and placental vitamin C is lower in women with PROM

Nutritional Risks Associated with Smoking, cont.

Increased carboxyhemoglobin in smokers blood leads to requires increased cutoff point for anemia in smokers. Women who smoke may have lower prepregnancy weights and may have lower pregnancy weight gains.

Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis (Oken, 2008)

Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis (Oken, 2008) The pooled estimate from unadjusted odds ratios (OR 1.52, 95% CI: 1.36, 1.69) was similar to the adjusted estimate, suggesting that sociodemographic and behavioral differences between smokers and nonsmokers did not explain the observed association.

Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis (Oken, 2008)
In parts of the world undergoing the epidemiologic transition, the continuing increase in smoking among young women could contribute to spiraling increases in rates of obesity-related health outcomes in the 21st century.

Illicit Drugs: Nutritional Implications

Estimates of 4-10% of US newborns exposed to one or more illicit drugs in utero Illicit drug use strongly associated with inadequate maternal weight gain, anemia, poor dietary habits Knight et al. (FASEB, 1992) found lower serum ferritin, folate, vitamin C and B12 levels in women when cord blood reflected illicit drugs

Illicit Drug Use & Infant Outcomes: March of Dimes fact sheet
In utero: Slowed fetal growth, reduced head circumference Perinatal: higher risk of CP, placental abruption Infancy: difficult to sooth and feed

Illicit drug use and adverse birth outcomes: is it drugs or context?

(Schempf & Stobino, J Urban Health, 2008)
In unadjusted results, marijuana, cocaine, and opiates were related to increased odds of LBW. No drug was significantly related to LBW when adjusted for Social, psychosocial, behavioral, and biomedical factors. About 70% of the unadjusted effect of cocaine use on continuous birth weight was explained by surrounding psychosocial and behavioral factors, particularly smoking and stress. Most of the unadjusted effects of opiate use were explained by smoking and lack of early prenatal care.

Illicit Drugs: Nutritional Implications

Cocaine:
associated with fewer meals, increased alcohol and caffeine and fat intake 32% also classified as eating disordered

Methadone
Higher birthweights than women who continue to use heroine diarrhea, constipation, nausea, anorexia, and dry mouth

Heroin
altered glucose tolerance - delayed glucose response

Position of the American Dietetic Association: Use of nutritive and nonnutritive sweeteners (2004)

Toxicity testing during reproduction is required for FDA approval. The consumption of acesulfame potassium,aspartame, saccharin, sucralose,and neotame within acceptable daily intakes is safe during pregnancy.

Exercise
Benefits:
improved or maintained fitness reduces anxiety and depression eases pregnancy discomforts such as constipation, backache, fatigue and varicose veins

Exercise
Contraindications
previous experience of preterm labor ob complications including vaginal bleeding, incompetent cervix, ruptured membranes, compromised fetal growth Hx of medical problems (hypertension, heart disease, etc.) requires health care provider approval

Exercise
Changes with pregnancy
tolerance for strenuous exercise decreases as pregnancy progresses
work of breathing increases as enlarging uterus crowds the diaphragm oxygen needs increase

if lying flat on back after the 4th month, risk of compression of vena cava with dizziness and interference with blood flow to the uterus

Exercise
Changes with pregnancy, cont.
may have increased efficiency of heat dissipation altered sense of balance with shift in center of gravity high hormonal levels associated with lax connective tissue and increased joint susceptibility

Postpartum
Physiological changes persist 4 to 6 weeks postpartum Return to vigorous exercise should be gradual Return to physical activity may be protective against postpartum depression if exercise is stress relieving- not inducing

Cochrane: Aerobic Exercise for Women During Pregnancy (2006)

11 trials involving 472 women The trials were not of high methodologic quality. Results:
Regular aerobic exercise during pregnancy appears to improve (or maintain) maternal physical fitness Non significant, but concerning increased risk of preterm birth in exercise groups. From 7 trials: Pooled RR 1.82 (95% CI 0.35-9.57). Data insufficient to infer important risk or benefits for mother or infant

Continuous, Strenuous, Vigorous Activity Throughout Pregnancy

(Gunderson, Clin Obstet gynecology, 2003)

Can reduce birth weight & length of gestation Additional carbohydrate recommended before activity Increased need for B vitamins Careful screening for nutritional & herbal supplements Athletes at higher risk for Fe depletion.

Oral Health & Pregnancy: Major Concepts (Academy of General Dentistry)

Increased risk for gingivitis (red,swollen, tender gums that are more likely to bleed) associated with increased estrogen and progesterone Frequent consumption of high cho foods may be used to combat nausea Cariogenic bacteria may be passed from mother to infant Periodontal disease is associated with preterm birth

Position of the American Dietetic Association: Oral Health and Nutrition, 2009
Periodontal Disease: nutrient deficiencies increase susceptibility & compromise systemic response to inflammation & infection Primary determinants of cariogenic, cariostatic, and anticariogenic properties of the diet:
food form (liquid, solid or sticky, slowly dissolving) frequency of consumption of sugar and other fermentable Carbohydrates nutrient composition, potential to stimulate saliva, sequence of food intake, and combinations of foods

Pregnancy Gingivitis
30-75% of women experience gingival changes such as edema, hyperplasia, redness, and bleeding Hormonal changes cause greater reaction to dental plaque Women who are plaque and inflammation-free at beginning of pregnancy have only 0.03 chance of gingivitis

Periodontitis
Definition: an infection caused by specific bacterial plaque that involves loss of bone, fiber, and gum tissue attachment for the tooth. Smoking associated with increased prevalence and severity of periodontitis Periodontal infections caused by gramnegative pathogens are associated with increase in preterm delivery and/or PROM one mediating factor is prostaglandin production triggered by bacterial products. Women with diabetes are at higher risk

Periodontitis (cont.)
Pathogens and bacterial products may translocate and inhibit normal clearance of enteric organisms from genitourinary tract. Overgrowth of gram negative bacteria and infection can be associated with preterm birth.

Can preterm birth be prevented by periodontal treatment?

NIDCR funded two large RCT women assigned to treatment or no treatment
Oral Therapy to Reduce Obstetric Risk (OPT) results published in 2006 Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) results published in 2009

Other large trial results published in 2010

OPT: Treatment of Periodontal Disease and the Risk of Preterm Birth

(Michalowicz et al. NEJM, Nov. 2006)

823 women with periodontal disease, enrolled between 13-17 weeks gestation, randomized to:
Scaling and root planing before 21 weeks; monthly polishings Scaling and root planing after delivery

Major Outcomes:
no difference in rates of preterm birth or low birthweight no adverse outcomes associated with treatment

MOTOR: Effects of periodontal therapy on rate of preterm delivery: a randomized controlled trial (Offenbacker et al, Obstet Gynecol, 2009)

3 site RCT, 1,760 women with periodontal disease, assigned to:

Scaling, root planing early in T2 Treatment after delivery

No significant differences with regard to adverse events or major obstetric and neonatal outcomes

2 Recent Trial Reports

Australia RCT, 1,000 women (Newnham et al, Evid Based
Dent. 2001): No differences in preterm birth, fetal growth restriction, preeclampsia Periodontal tx not hazardous to women or pregnancies

US Periodontal Infections and Prematurity Study (PIPS), 750 women (Macones et al, Am J Obstet Gynecol, 2010)
TX did not reduce risk of spontaneous preterm delivery (SPTD) Suggestion of increased risk in SPTD < 35 weeks with active tx (RR 3.01, 95% CI, 0.95-4.42)

All Periodontal Treatment Impacts are not the Same:

Periodontal infection and preterm birth: successful periodontal therapy reduces preterm birth (Parry et al, BJOG, 2010)
At 20 week FU treated women categorized as successful (no periodontal disease) or not successful (ongoing disease) Successful treatment protected against preterm birth (OR 6.02, 95% CI 2.5714.03)

American Academy of Periodontology Statement Regarding Periodontal Management of the Pregnant Patient (2004)
Achieve a high level of oral hygiene prior to becoming pregnant and throughout pregnancy Periodonal treatment (eg; scaling and root planing) is usually scheduled in second trimester Emergencies such as acute infection and abcess may require immediate treatment regardless of stage of pregnancy) Consultation with prenatal care provider

Oral Health: Recommendations

Frequent dental cleanings (3 to 6 months) Daily oral care routines including brushing and flossing at least twice daily and after eating Use of toothpastes and rinses with fluoride Consider cariogensis in food choices and patterns. Offer smoking cessation programs

Improving Access to Perinatal Oral Health Care: Strategies & Considerations for Health Plans (Issue Brief July 2010)

National Institute for Health Care Management Foundation

http://nihcm.org/pdf/NIHCM-OralHealth-Final.pdf

Research has exhibited an association between periodontal disease in pregnant women and adverse birth outcomes, such as low birth weight, preterm birth, preeclampsia and gestational diabetes. Because studies have shown conflicting results on the relationship between periodontal disease and birth outcomes, and there is no general consensus on this association, further research is needed to explore and confirm this possible correlation. However, research does universally support the safety of dental treatment during pregnancy and confirms that maintaining good oral health prior Improving Access to Perinatal Oral Health Care: Strategies & Considerations for Health Plans to and during pregnancy remains a key factor in achieving overall health and well-being for women and their infants.

Mother-to-child transmission of bacteria is the primary vehicle through which children first acquire dental caries, the disease process that causes cavities. These bacteria are transmitted through saliva that is passed from a caregivers mouth to a childs. The healthier the mothers mouth, and the longer the initial transmission of caries-causing bacteria is delayed, the more likely children are to establish and maintain good oral health.