Wednesday, July 19, 2017

Pregnancy, breastfeeding, and drugs used in dentistry

Department of Pediatric Dentistry
Lutheran Medical Center
           
Resident’s Name: Brian Darling                                                                     Date:  7/19/2017
Article Title: Pregnancy, breastfeeding, and drugs used in dentistry
Author(s): Donaldson M, Goodchild JH
Journal: JADA
Date: 2012: 143: 858-71
Major Topic: Drug safety in pregnant and breastfeeding women
Type of Article: Review of topic – medications and pregnancy/breastfeeding
Main Purpose: This article aimed to describe the level of safety of drugs commonly used in dentistry for women who are pregnant or breastfeeding.
Key Points: Dentists should weight the risk to the fetus versus the benefit to the mother when choosing medications for pregnant and breastfeeding women.
·      2/3 women take prescription medications during pregnancy
·      Be mindful that women of child-bearing age may be unknowingly pregnant and that they may conceive while still receiving the medication 
·      Placental transport of substances between fetus and mother usually occurs at the 5th week of embryonic life
·      Greatest teratogenic risk to the fetus is from 3-8 weeks after conception (5-10 weeks gestation, with week 1 beginning on the 1st day of the last menstrual period)
·      Almost every drug can pass from the mother to the fetus (concept of “placental barrier” is a misnomer)
·      Generally safe to use category A and B drugs
·      Avoid prescribing drugs in the 1st trimester
·      AAP supports breastfeeding alone for the 1st 6 months
·      Infants are exposed to much higher concentrations of drugs during pregnancy than during lactation, so most drugs used during pregnancy are also safe during breastfeeding
o    Exceptions: Benziodiazepines and aspirin and some other medications
·      Chlorhexidine use decreases caries risk and bacterial transmission from mother to children
·      Prenatal fluoride supplementation is not supported by the AAPD
·      Fluoride is category C drug
·      NSAIDs (particularly ibuprofen) may cause embryonic implantation disturbances, inhibition of parturition, contraction of ductus arteriosus leading to maternal pulmonary hypertension
·      NSAIDs are also linked to gastrochisis (fetal organs develop outside the abdominal wall). Aspirin, pseudoephedrine, and phenylpropanolamine are linked to gastrochisis
·      Antibiotics may alter bowel flora and cause diarrhea in babies of breastfeeding mothers.
·      Prednisone and dexamethasone are associated with oral clefts when given during the 1st trimester
·      Acetaminophen is the safest analgesic for pregnant patietns
·      Ibuprofen is category C/D and should NOT be used during pregnancy but is safe for breast-feeding
·      Tetracyclines are not to be used during pregnancy because they can be deposited in embryo’s bones and teeth where there’s active calcification BUT they may be used during breast-feeding
·      Amoxicillin, azithromycin, cephalexin, clindamycin, erythromycin, penicillin, and metronidazole are category B and safe for pregnancy and breast-feeding EXCEPT metronidazole, which should not be used for breast-feeding patients but can be used during pregnancy
·      Nystatin is the safest antifungal agent for pregnant patients
·      Lidocaine and prilocaine are category B but prilocaine is associated with increased risk of methemoglobinemia
·      Articaine, mepivacaine, and bupivacaine are category C but mepivacaine and bupivacaine can be used in breast-feeding patients
·      Increased risk of methemoglobinemia with use of prilocaine, tetracaine, and benzocaine
·      Category C topical anesthetics are benzocaine, dyclonine, and tetracaine
·      Benzodiazepines are category D and X medications because they may cause fetal abortion, malformation, intrauterine growth retardation, functional deficits, carcinogenesis, mutagenesis
·      Zaleplon and zolpidem are preferable to benzodiazepines for sedation in pregnant women but are category C
·      Emergency medications should generally be used because of the benefit to the mother outweighs risk to fetus – especially for epinephrine, albuterol, antihistamines, flumazenil, nitroglycerin
o   Flumazenil is category C
o   Epinephrine is category C
o   Diphenhydramine is category B
o   Albuterol is category C – some research has shown increased risk of congenital malformations associated with albuterol use during pregnancy but there are also studies showing increased risk of adverse pregnancy outcomes in women with untreated asthma 


A
Results of controlled studies in women fial to demonstrate a risk to the fetus in the 1st trimester (and there’s no evidence of risk in later trimesters), and the possibility of fetal harm appears remote
B
Either the results of animal reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women
OR
Results of animal reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in 1st trimester and there is no evidence of risk in later trimesters
C
Either the results of studies in animals have revealed no adverse effects (teratogenic, embryocidal, or other) on the fetus and there are no controlled studies in women
OR
Results of studies in women and animals are not available; drug should be given only if potential benefit justifies the potential risk to the fetus
D
There is positive evidence of human fetal risk, but the benefits of use in pregnant women may be acceptable despite the risk (example, the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective)
X
Results of studies in animals or humans have demonstrated fetal abnormalities or evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit; use of drug is contraindicated in women who are or may become pregnant

Remarks:
1-
2-
https://www.betterhealth.vic.gov.au/health/healthyliving/baby-due-date à The unborn baby spends around 37 weeks in the uterus (womb), but the average length of pregnancy, or gestation, is calculated as 40 weeks. This is because pregnancy is counted from the first day of the woman’s last period, not the date of conception which generally occurs two weeks later, followed by five to seven days before it settles in the uterus. Since some women are unsure of the date of their last menstruation (perhaps due to period irregularities), a pregnancy is considered full term if birth falls between 37 to 42 weeks of the estimated due date. 

A baby born prior to week 37 is considered premature, while a baby that still hasn’t been born by week 42 is said to be overdue. In many cases, labour will be induced in the case of an overdue baby.

Assessment of Article:  Level of Evidence/Comments: III


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