22. Pregnancy

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© Springer Nature Switzerland AG 2021

R. Reti, D. Findlay (eds.)Oral Board Review for Oral and Maxillofacial Surgerydoi.org/10.1007/978-3-030-48880-2_22

22. Pregnancy

Zain Manji1   and Aaron D. Figueroa2
(1)

Bramalea Oral Surgery, William Osler Health System, Department of Surgery, Division of Oral & Maxillofacial Surgery, Brampton, ON, Canada
(2)

University of Iowa Hospitals and Clinics, Hospital Dentistry Institute, Oral and Maxillofacial Surgery, Iowa City, IA, USA
 
Keywords

PregnancyPreeclampsiaHELLP (hemolysis elevated liver enzymeslow platelet) syndromeGestational hypertensionGestational diabetesEclampsia

Physiologic Changes During Pregnancy

Cardiovascular

  • Decrease in systemic vascular resistance.

  • Increase in cardiac output.

  • Increase in heart rate.

  • Increased cardiac workload can result in ventricular hypertrophy.

  • Benign systolic ejection murmur is common due to increased HR and blood volume; resolves after delivery.

  • Uterine compression of the inferior vena cava, leading to venous stasis and deep venous thrombosis.

  • Decrease in oncotic pressure leads to pedal edema.

Hematological

  • Increase in plasma exceeds that of erythrocytes, leading to physiologic anemia aka “hemodilution” [1, 2].

  • Hypercoagulable state increases the risk for deep venous thrombosis and pulmonary embolism:

    • Reduction in protein S activity.

    • Activated protein C resistance.

    • Increase in coagulation factors except XI and XIII [2].

    • Pressure from gravid uterus causes endothelial damage.

    • Leukocytosis due to hormonal changes.

    • Suppression of the immune system. Decreased chemotaxis and cell-mediated immunity [2] .

Respiratory

  • There is relaxation of the rib cage allowing for a more horizontal position and upward displacement of the diaphragm.

  • Pulmonary Function:

    • Tidal volume – Increases

    • Respiratory rate – Increases

    • Minute ventilation – Increases

    • Expiratory reserve volume – Decreases

    • Residual volume – Decreases

    • Functional residual capacity – Decreases

  • Respiratory changes result in respiratory alkalosis, due to increase in minute ventilation.

  • Increase in oxygen consumption.

  • Rapid desaturation during periods of apnea.

Genitourinary

  • Increase in glomerular filtration rate [1].

  • Increase in renal blood flow.

  • Increase in creatinine clearance.

  • Third trimester, bladder capacity reduction due to pressure from enlarged uterus. Hydroureter found in 90% of pregnancies [2]. See increased rate of UTI due to urinary stasis.

Gastrointestinal System

  • Decrease in lower esophageal sphincter tone.

  • Increase in gastric emptying time.

  • Increase in gastric pressure, can cause pyrosis (gastroesophageal reflux) complaint in 70% of pregnancies [1, 2].

  • Increase in bile secretion.

  • Increase in gallstone formation.

Endocrine

  • Insulin resistance.

    • Fasting glucose levels are lower due to glucose utilization by the fetus.

  • Hypoglycemia can result from insulin resistance and glucose utilization by the fetus, especially in times of fasting.

  • Estrogen increases thyroxine-binding protein, which increases total levels of T3 and T4.

    • Circulating free T3 and T4 remain unchanged.

Oral Manifestations in the Pregnant Patient

Due to physiological and hormonal changes common oral manifestations are seen:

  • Chronic gingivitis.

  • 1–5% patients develop pregnancy tumors (pyogenic granulomas) due to increased angiogenesis and local irritating factors such a plaque buildup. Normally self resolves [1, 3].

  • Decrease in salivary pH can lead to decreased mucosal desquamation and dental decay.

  • Melanosis of the skin and mucosa due to increase in estrogen and progesterone [1].

Diseases of Pregnancy

Preeclampsia

  • Preeclampsia is a pregnancy-induced condition due to abnormal placental implantation. It results in hypertension that occurs after 20 weeks of gestation or postpartum, accompanied by either proteinuria or other maternal organ dysfunction.

Treatment

  • Term

    • Delivery of the fetus.

  • Pre-term

    • Mild preeclampsia.

      • Conservative management – control of blood pressure, fluid management, and frequent observation/fetal monitoring.

      • Bed rest.

      • Delivery at 37 weeks.

    • Severe preeclampsia.

      • Delivery of the fetus regardless and management of sequelae.

      • Antihypertensive therapies are aimed at prevention of abruptio placentae and stroke; indications include chronic hypertension and severe hypertension during labor or delivery.

      • Agents of choice: labetalol, hydralazine, and nifedipine.

      • Seizures prophylaxis is managed by administration of magnesium sulfate.

Eclampsia

  • Form of severe preeclampsia characterized by seizures or coma without any other brain pathology.

  • Can be associated with respiratory failure, kidney failure, coagulopathy, stroke, and cardiac arrest.

Treatment

  • Patient positioning into lateral decubitus position (reduce pressure vena cava), suctioning of secretions, and supplemental oxygen.

  • Administration of magnesium sulfate for seizure management.

  • Use antihypertensive medications to control blood pressure.

  • Emergent delivery of the fetus irrespective of gestational age.

  • Management as needed for other sequelae.

HELLP Syndrome

  • Syndrome characterized by hemolysis, elevated liver transaminases, and low platelet counts.

  • Occurs in conjunction with eclampsia or preeclampsia.

  • Patients may develop a subcapsular hepatic hematoma, which can rupture and lead to severe intra-abdominal bleeding and disseminated intravascular coagulation.

  • High maternal and perinatal morbidity/mortality rate.

  • Immediate delivery for pregnancies regardless of gestational age if mother is unstable.

  • If gestational age is less than 33 weeks and mother is stable, consider corticosteroids administration to allow for fetal maturation and improve platelet count. Delivery within 48 hours if maternal condition stabilized after steroid administration.

Gestational Hypertension

  • Elevated blood pressure during pregnancy not associated with proteinuria or any preexisting chronic hypertension. SBP ≥140 mm Hg and/or DBP ≥90 mm Hg (average of at least 2 measurements taken at least 15 minutes apart) [4].

  • May develop into preeclampsia if proteinuria develops.

  • May develop into chronic hypertension if it remains 3 months after delivery.

  • Treated with antihypertensive medication, concern for HELLP, preeclampsia, end organ damage, and risk of maternal stroke.

  • Women with severe hypertension with SBP 160 or DBP 110 mm Hg in pregnancy require urgent antihypertensive therapy because it is considered an obstetrical emergency [4].

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Jul 23, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 22. Pregnancy
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