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hemorrhoids. In the third trimester, the inferior vena cava due to compression of the gestational uterus reduces blood volume in the venous to return into the right ventricular in the supine position, resulting in decreased cardiac output and hypotension.

1.2.5 Urinary System

The kidneys enlarge slightly during pregnancy. Glomerular ltration rate (GFR) and renal blood volume increase from early pregnancy, and urine output also increases.

1.2.6 Digestive System

The stomach and intestinal tract are compressed by the gestational uterus. Heartburn and constipation are common pregnancy-related digestion symptoms. Constipation and compression of the veins by the gestational uterus predispose to the development of hemorrhoids.

1.2.7 Endocrine System

In early pregnancy, maternal free thyroxine (FT4) is mildly elevated and thyroid function is temporarily increased. As pregnancy progresses, Thyroxine binding globulin (TBG) increases, and although total T4 increases with TBG, hyperthyroidism does not occur because TBG causes a loss of thyroid hormone bioactivity.

1.2.8 Blood Changes

During pregnancy, the increase in circulating plasma volume exceeds the increase in red blood cells, and hemoglobin, there is a fall in hemoglobin, hematocrit, and red blood cell count. The white blood cell count increases to about 5000– 12,000/μL. The platelet count is unchanged or mildly decreased compared with nonpregnant women, averaging 213,000/μL.

1.3 Diseases inEarly Pregnancy

The most common disorders seen in early pregnancy are hyperemesis gravidarum, miscarriage, ectopic pregnancy, and congenital malformation syndrome related to maternal viral infection.

1.3.1 Hyperemesis Gravidarum

Sometimes, the pregnant woman has excessive symptoms such as vomiting almost every day, inability to eat orally, and persistent weight loss with strong positive urine ketone bodies. In addition, it may show liver dysfunction and electrolyte abnormalities due to dehydration and may develop Wernick’s encephalopathy due to vitamin B1 deciency. This is a neurological disorder with various symptoms such as ocular motility disorder, ataxia, and disturbance of consciousness. The prophylactic method is administered 10–50 mg of vitamin B1, B6, B12 with sugarcontaining electrolyte solutions [3].

1.3.2 Miscarriage

It is dened as an abortion of pregnancy of fewer than 22weeks in Japan. A spontaneous abortion is dened as an abortion that occurs spontaneously due to fetal or maternal morbidity.

1. Clinical classication.

(a) Threatened abortion: A condition in

which genital bleeding occurs but the uterine cervix is closed and the pregnancy is maintained. In early pregnancy, vaginal spotting is not an entire sign of miscarriage and possible continued pregnancy.

(b) Inevitable abortion: This is a condition in

which the cervix is open and the uterine contents (embryo, villus, a part of gestational sac) are being expelled.

the fetus remains in the uterus without obvious symptoms, but the fetus has no heartbeat.

(d) Complete abortion: Complete expulsion

of the fetus (or embryo) and fetal tissue.

(e) Recurrent abortion (miscarriage): Two

consecutive miscarriages.

2. Diagnosis

When a patient with a positive pregnancy test, there is a risk of misdiagnosis of ectopic pregnancy, miscarriage, or hydatidiform mole, if the fetal sac is not obscured due to delayed ovulation. Therefore, a careful interview and ultrasound examination should be performed (Fig.19.1).

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Fig. 19.1 Three-Dimensional Ultrasound image of a dichorionic diamniotic twins at 10weeks’ gestation

3. Treatment (a) Threatened abortion: No effective treat-

ment has been established for threatened abortion at less than 12weeks’ gestation. There is a report that the miscarriage rate was decreased by rest therapy in the case of subchorionic hematoma after the fetal heartbeat was conrmed [4].

(b) Missed abortion/Inevitable abortion.

In Japan, the use of drugs such as mifepristone and misoprostol are not approved for the treatment of miscarriages of less than 12weeks’ gestation, so either watchful waiting for a complete abortion or surgical treatment (dilation and curettage or suction evacuation) is selected.

1.3.3 Ectopic Pregnancy

It is a condition in which a fertilized ovum implants in a place other than the uterine cavity and grows to maturity. It can be divided into tubal pregnancy, ovarian pregnancy, and peritoneal pregnancy according to the implantation site of the fertilized ovum [5].

1. Diagnosis (a) No evidence of a gestational sac structure

in the uterine cavity (after 5–6 weeks gestation).

(b) A gestational sac-like structure is found

outside the uterine cavity.

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observed.

(d) A decrease in circulating blood volume

(anemia, tachycardia, hypotension) is suspected.

(e) After probe curettage in the uterine endo-

metrium, no chorionic villi are found in the extracted specimen.

(f) Indicates acute abdomen.

2. Treatment In principle, surgical treatment is per-

formed, but the indications for drug therapy (e.g., methotrexate: MTX) or conservative treatment are determined according to the patient’s general condition, implantation site, blood hCG level, presence or absence of fetal heartbeat, mass diameter, and fertility. However, MTX therapy is not covered by insurance in Japan. In case of surgery, either laparotomy or laparoscopy should be chosen.

1.3.4 Maternal Viral Infection

It indicates that a pathogen (virus) infecting the mother infects the child through pregnancy, delivery, and lactation. Currently, rubella is a social problem. In Japan, adult males aged 39 to 56 years who have not been vaccinated against rubella have a great possibility of contracting rubella and transmitting the disease to pregnant women through droplet infection. The Ministry of Health, Labour, and Welfare (MHLW) is recommending rubella vaccination for men aged 39–56years for 3years from April 2019 (free of charge in some municipalities). Figure 19.2 shows congenital fetal anomalies caused by maternal infection by pathogens [6].

1.4 Pregnancy Complications

Hypertension and diabetes mellitus are the most common complication of pregnancy.

1.4.1 Hypertensive Disorders

ofPregnancy

If hypertension develops after 20weeks of gestation, it is classied as a hypertensive disorder of

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Placenta

Transplacental transmission

• Placental disruption

• Fetal–maternal

haemorrhage

Transmission across fetal membranes

• Ascending infection

• Sexual

transmission

Fig. 19.2 Routes of transmission across the placenta and consequences of infection (reproduced with permission from [6]). (a) TORCH (Toxoplasma gondii, other, rubella virus, cytomegalovirus, herpes simplex virus) pathogens can access the intra-amniotic compartment through multiple mechanisms, including direct transplacental transmis-

Maternal impact

• Increased inflammatory response

• Sepsis

• Respiratory distress

• Obstetric haemorrhage

• Death

Placental impact

• Decreased nutrient/

oxygen transport

• Reservoir for reinfection

• Preterm labour

Fetal impact

• Growth restriction

• Birth defects

• Blindness/deafness

• Microcephaly/ neurodevelopment

• Bone marrow suppression

• Fetal demise

sion, placental damage or disruption and/or fetal–maternal hemorrhage. In addition, pathogens can be transmitted by ascending the genital tract. (b) Infections in pregnancy can affect the maternal host, fetus and/or the placenta itself. The results of infection and the inammatory response have consequences at each site

pregnancy (HDP), furthermore, if combined with proteinuria,

it may lead to preeclampsia. HDP occurs in approximately 3% to 5% of all pregnancies worldwide. It occurs in 6–8% of rst pregnancies, 14–20% of multiple pregnancies, 30% of pregnancies with uterine malformations, and 26% of pregnancies with a family history of hypertension or chronic hypertension [7].

Pathophysiology andFactors ofHDP

In HDP, the failure of trophoblastic cells to invade the spiral arteries of the decidua in the placental bed results in remodeling failure due to narrowing of the diameter of the spiral arteries, leading to fetoplacental circulatory disturbance. This is the rst stage of the two-step theory of HDP proposed by Redmann etal. [8]. In the second stage, the production of soluble fms-like tyrosine

kinase-1 (sFlt-1), a soluble receptor for a vascular endothelial growth factor (VEGF), and sEng, a soluble receptor for TGF-β1 and β3, increases in chorionic villus cells and enters the fetal placental and maternal circulatory systems due to hypoxia caused by fetoplacental circulatory failure (Fig.19.3).

Classication by Symptom

1. Mild: Blood pressure: Any of the following cases. Systolic blood pressure of 140mmHg or more but less than 160mmHg. Diastolic blood pressure: 90 mmHg or more, less than 110mmHg. Proteinuria: 0.3g/day or more.

2. Severe: Blood pressure: Any of the following. Systolic blood pressure of 160 mmHg or higher. Diastolic blood pressure: 110mmHg or more. Proteinuria: 2g/day or more.

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CENTRAL ILLUSTRATION: Pathogenesis of Preeclampsia

341

Risk

Factors

Acquired

Genetic Immune

Impaired

trophoblast

invasion and

spiral artery

remodeling

↓Utero

placental perfusion

Placental

hypoxia

↑ Intrarenal RAAS

↑ Ang II sensitivity

↑ HIF-1α & HIF-2α

↓ Heme

oxygenase-1

↑ ER stress

↑ Mitochondrial

dysfunction

Ives, C.W. et al. J Am Coll Cardiol. 2020;76(14):1690-702.

Fig. 19.3 Pathogenesis of pregnancy-induced hypertension syndrome (reproduced with permission from [9]). Acquired, genetic, and immune risk factors contribute to early placental dysfunction (Stage 1). Placental dysfunction results in release of anti-angiogenic factors, leading to later multiorgan dysfunction (Stage 2). Solid arrows represent progression of disease. Dashed arrows represent SNS effect on respective organs. Ang II angiotensin II, ER endoplasmic reticulum, HA headache, HIF

hypoxia-

↓ NO ↓ Prostacyclin ↑ Endothelin-1

↓ Angiogenesis

Endothelial dysfunction

Pulmonary EdemaThrombocytopenia

HA Stroke PRES Eclampsia

↑ SNS outflow

Hepatic Dysfunction

Proteinuria Renal Failure

↑ sFlt-1

↑ sEng

↓ VEGF ↓ PlGF

↓ TGF-β

Hypertension Cardiomyopathy

inducible transcription factor, HIF hypoxia-inducible transcription factor, NO nitric oxide, PlGF placental growth factor, PRES posterior reversible encephalopathy syndrome, RAAS renin-angiotensin-aldosterone system, sEng soluble endoglin, sFlt soluble fms-like tyrosine kinase, SNS sympathetic nervous system, TGF transforming growth factor, VEGF vascular endothelial growth factor. Ivesetal

Maternal Management andTreatment

Inpatient management is useful because it allows a rapid response to sudden symptom exacerbation.

Caloric intake is calculated according to the individual’s age, Body Mass Index (BMI) at nonpregnancy, and physical activity level.

Oral hydralazine or methyldopa is the rstline antihypertensive agent, and if the antihypertensive effect is inadequate, continuous intravenous hydralazine or nicardipine is recommended as the second-line agent. Magnesium sulfate (MgSO4) should be administered to prevent eclampsia associated with hypertension.

Fetal Management

When fetal growth failure is observed in HDP, fetal well-being should be assessed using the following methods 1 to 4.

1. Non-stress testing (NST).

2. Fetal ultrasound measurement, amniotic uid volume.

3. Biophysical proling score (BPS).

4. Blood ow measurement (umbilical artery, middle cerebral artery, uterine artery, etc.)

Indications forCesarean Section inHDP

(a) Maternal side factor.

• When symptoms remain unchanged or worsen in response to hospitalization, bed rest, and medical therapy.

• Eclampsia, placental abruption, new ocular hemorrhage in the fundus of the eye, increased chest and abdominal uid, pulmonary edema, intracranial hemorrhage, or HELLP syndrome.

• If renal dysfunction appears, GFR ≤ 50 mL/min, serum Creatinine≥1.5 mg/dL, serum. Uric

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R. Oyama and T. Ikebe

acid≥6 mg/dL, serum BUN≥20 mg/dL, oliguria <300 mL/day or more than 20 mL/day should be decided comprehensively.

• Hemodynamic disorders or abnormalities in blood coagulation, such as hemoconcentration symptoms or DIC (Ht≥40%, platelet count ≤100,000, Fibrinogen≦150 mg/dL) and an increasing DIC score.

• Footnote: The values of 3 and 4 are not absolute, but are indicated when the test is performed over time and an exacerbation trend is observed.

(b) Fetal side factors (in principle, the fetus

should be able to live extrauterine).

• Fetal growth restriction: Evaluate the fetal well-being and may need to decide on termination.

• Non-Reassuring Fetal Status (NRFS): fetal heart rate monitoring shows decreased or loss of variability, a sinusoidal pattern, variable deceleration, or prolonged deceleration may be present.

1.4.2 Gestational Diabetes andDiabetes Mellitus

Pregnancy is associated with increased insulin resistance due to hormones secreted by the placenta. This tendency increases in the third trimester, and the amount of insulin increases to maintain normal blood sugar levels. There are two types of problems of glucose metabolism in pregnancy: pregnancies complicated by diabetes mellitus, in which diabetes mellitus is present before pregnancy, and the problem of glucose metabolism that is rst detected during pregnancy. There are two types of abnormalities of glucose metabolism rst detected during pregnancy: GDM, in which blood sugar levels are higher than normal but not high enough to be diagnosed as diabetes mellitus, and diabetes mellitus detected during pregnancy, in which blood sugar levels are high (apparent diabetes mellitus of pregnancy) [10].

Diagnosis

Figure 19.4 shows the problems of glucose metabolism and diagnostic criteria in gpregnancy [11].

Treatment

(a) Dietary therapy: Non-obese pregnant woman

(BMI < 25 at the time of non-pregnancy): Standard weight [height (m)2×22] × 30+200kcal.

(b) Obese pregnant woman (BMI≥ 25 at non-

pregnancy): Standard weight [height (m)2× 22] × 30kcal.

Pregnancy is characterized by a higher postprandial blood sugar level than that in nonpregnant women. Especially in pregnant women with problem glucose metabolism, the 2-h postprandial blood sugar level increases rapidly. To reduce the uctuation of blood sugar, it is important to reduce the amount of food per meal and to eat 5 to 6 divided meals to reduce the increase in postprandial blood sugar level.

even after diet therapy: Sometimes a woman with gestational diabetes must take insulin [12].

Poor Blood Glucose Control

It is known that the risk increases in pregnant women with diabetes who have poor control before and during the rst pregnancy trimester. Galindo etal. [13] reported that the incidence of major malformations was 11.7% when the maternal hemoglobin A1c (HbA1c) level was 7–8% and 15.8% when the HbA1c level was 8% or higher.

1.5 Postpartum Depression

According to the diagnostic criteria of the American Psychiatric Association, postpartum depression is dened as depressive feelings such as anxiety about baby care, dissatisfaction with

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Fig. 19.4 Screening and Diagnosis of GDM [11]. (Reproduced from Choudhury, V. Gestational diabetes mellitus A metabolic and reproductive disorder.

housework, excessive worry about the baby’s development, and loss of condence in the mother and new father within 4 weeks after the birth of the baby. The evaluation method is the “Edinburgh

Biomedicine & Pharmacotherapy. 2021; volume 143:

Postpartum Depression Scale” [14]. In Japan, if the score is 9 points or more, the possibility of postpartum depression should be considered and an interview with a psychiatrist or psychologist.

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1.6 Lactation

1.6.1 Relationship Between Sex Hormones andMammary Glands

Once pregnancy is established, the secretion of estrogen and progesterone is stimulated by hCG from the placenta and remains high. This hormonal environment is particularly pronounced after the second trimester, which stimulates lactogenic differentiation, preparing it for milk production and secretion.

1.6.2 Hormones Involved intheStructure andFunction oftheMammary Gland

Hormones involved in the structure and function of the mammary gland include growth hormonereleasing factor (GRF), corticotropin-releasing factor (CRF), prolactin-inhibitory factor (PIF), luteinizing hormone (LH), follicle-stimulating hormone (FSH), adrenocorticotropic hormone (ACTH), thyroid stimulating hormone (TSH), and estrogen receptor (ER) and others.

1.6.3 Maternal Infections andLactation

1. Human Immunodeciency Virus (HIV)-

infected pregnancies: In Japan, where HIVinfected pregnancies are extremely rare, the proportion of conrmatory test-positive cases (i.e., infected cases) in the pregnant women screening test-positive population (positive predictive value) is extremely low, ranging from 3.8% to 7.7% [15, 16] (6.5% in the 2013 survey). Therefore, conrmatory testing is even more essential for the diagnosis of HIV infection in pregnant women. Perinatal HIV transmission occurs through three routes: placenta, labor, and breastfeeding [17]. Because articial feeding (milk) prevents mother-tobaby transmission [17–19], therefore milk is recommended immediately after birth [19].

2. Human T-cell Leukemia Virus type 1 (HTLV-

1)-infected pregnancy. Approximately 95% of mother-to-child

transmission (MTCT) of human T-cell leukemia virus type-1 (HTLV-1) is derived from prolonged breastfeeding, which is a major

cause of adult T-cell leukemia (ATL) [20]. The routes of infection are MTCT, blood transfer (blood transfusion, organ transplantation), and sexual intercourse (mainly male-tofemale). Articial nutrition, frozen breastfeeding, and short-term (3 months) breastfeeding are presented as options for the prevention of transplacental mother-to-child transmission in HTLV-1 carrier mothers [21].

1.6.4 Medication andBreastfeeding

In the drug package inserts, many drugs are described as “transfer to breast milk has been reported and breastfeeding should be avoided.” Almost all drugs are secreted into breast milk to varying degrees, and the infant ingests the drug through breast milk [22–24]. It should be noted, however, that drug exposure via breast milk is an order of magnitude less than the level of exposure in the uterine (<10% or even <1%). Drug safety has been investigated based on comparisons with usual doses (theory) and data from previous observational studies [22]. In the drug safety evaluation, “relative infant dose (RID) (%) = total amount of drug ingested via breastfeeding (mg/ kg/day)/usual dose of the drug administered to the child (mg/kg/day) × 100” is considered [22]. If the RID is much lower than 10%, depending on the type of drug, the effect on the child is estimated to be small [22]. On the other hand, when the RID is much higher than 10%, considerable caution is required. According to observational studies, many drugs have a little adverse effect on the child when taken by a lactating woman [22]. However, the current situation is insufcient to assess the effects of these drugs. Therefore, we recommend referring to FDA that has introduced the ve letter risk categories (A, B, C, D, and X) for the pregnancy and lactation labeling system since 1979, and replaced the former pregnancy risk categories on prescription and biological drugs labeling [25] (Table 19.1). In 2021, the FDA published the new Pregnancy and Lactation Labeling Rule (PLLR or nal rule). The PLLR also requires the label to be updated when information becomes outdated. The PLLR removed pregnancy letter categories-A, B, C, D, and X (Fig.19.5), therefore, physicians should need to notice drug information under the nal rule [26].

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Table 19.1

Category Drug class Drugs Category A‐drugs safe during pregnancy Category B‐drugs safe during pregnancy

Category C‐drugs likely to cause problems

Category D‐drugs that have clear health risks for the fetus

Category X‐drugs that have been shown to cause birth defects

Drug category based on safety during pregnancy (reproduced with permission from 25)

Over the counter drugs Folic acid, Vitamin B6, etc.

Antibiotics Penicillin G, Amoxicillin,

Analgesic Acetaminophen Synthetic corticosteroid Prednisone Hormones Insulin NSAID Ibuprofen H

‐receptor antagonist Famotidine

Antibiotics Streptomycin, Clindamycin,

Antidepressant Tricyclic drugs, monoamine oxidase inhibitors,

Antipsychotic agent Prochlorperazine Triazole antifungal drug Fluconazole Anticonvulsant Phenytoin, Trimethadione,

Alcohol Antineoplastics (Alkylating agents)

Antineoplastics (Taxanes) Coumarin derivatives Warfarin Antidepressant Lithium Sedative Thalidomide Retinoids Vitamin A Androgenic hormones Testosterone Statins Simvastatin

Chloramphenicol, Ciprooxacin, Doxycycline, Levooxacin, Cephalosporins, Erythromycin, Clindamycin, Metronidazole

Gentamicin, Vancomycin, Tobramycin, Ciprooxacin, etc.

Serotonergic antidepressant drugs, etc.

Valproic acid, Carbamazepine, Phenobarbital, etc.

Mechlorethamine, Procarbazine, Cyclophosphamide, Chlorambucil, Melphalan, Lomustine, etc. Paclitaxel and Docetaxel

Fig. 19.5 The new PLLR labeling requirements [26]

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1.7 Notes fromDentistry Perspective [27–32]

TetsuroIkebe

1.7.1 Timing Suitable forDental Treatment (Dental Surgery)

The most important factor in the dental treatment (surgery) of pregnant women is the interview. It is the communication with the patient through the interview. In some cases, the patient voluntarily states that she is pregnant on the questionnaire, but in other cases, she does not describe or declare her pregnancy. The rst step is to nd out whether or not the patient is pregnant. In addition, since the patient may be undergoing infertility treatment, the interview should be conducted carefully.

In the case of pregnant women, it is essential to know the pregnancy period (weeks or days after conception) to determine the timing for dental treatment (surgery). Therefore, it is necessary for dentists to have a basic knowledge about the pregnancy period. The possibility of teratogenicity, abortion, premature birth, and stillbirth should be considered.

• The gestation period is calculated as

1week=28days, 4weeks=1month.

• The start of the last menstrual period is

0weeks and 0days after conception.

• The day of ovulation (fertilization) is 2weeks

(14days) after conception.

• Delivered at 40weeks and 0days (10months)

(280days).

Based on the above, determine whether the patient’s pregnancy is in the rst pregnancy trimester, second trimester pregnancy, or third pregnancy trimester of the pregnancy period.

treatment (dental surgery) (be careful of fetal toxicity).

• Third pregnancy trimester: 28 weeks of late pregnancy (after 8 months of pregnancy): transfer of drugs to the fetus. The fetus has an immature ability to metabolize drugs.

Particular attention should be paid to the rst

trimester, from 3 to 12weeks of pregnancy. This period is the fetal organogenesis period, for example, the period of lip formation is around the rst month of pregnancy, and the period of palate formation is around the third month of pregnancy, so if the fetus is affected in any way during this period, it may cause cleft lip or cleft palate. Therefore, the most appropriate time for dental treatment (dental surgery) is between the fth and seventh months of pregnancy in the second pregnancy trimester. Unnecessary dental treatment (especially surgical treatment, treatment with drugs, and treatment that causes mental or physical stress to the pregnant woman) should wait until this time. The next period when dental treatment is possible is the third pregnancy trimester.

However, even in the rst pregnancy trimester,

if the patient has severe pain or inammation and it is decided that treatment is necessary for the health of the pregnant woman, dental treatment should be carried out after being explained about the merit and demerit of dental treatments to the patient.

1.7.2 Eects ofDental Radiation

The radiation dose that affects the fetus, including early pregnancy, is 100mSv or more.

Typical radiation doses during radiography

are shown in Table19.2. There may be no problem in terms of radiation dose when ordinary dental radiography is performed on pregnant

• Two weeks from fertilization to implantation: no connection between mother and fetus.

• First pregnancy trimester: 3weeks to 12weeks (up to 4months of pregnancy): organogenesis period (a period to watch out for teratogenesis).

• Second pregnancy trimester: 5 to 7 months: stable period: appropriate timing for dental

Table 19.2 Radiation dose during radiography

The oral radiograpy 0.01~0.03mSv Panoramic radiography 0.02~0.03mSv Dental CT 0.1mSv Medical head CT 0.5mSv Chest X-ray 0.06~0.15mSv

Natural dose of 0.2mSv when ying between Tokyo and NewYork and back

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women, but its dose should be kept to a minimum and the abdomen where the fetus exists should be protected with a lead apron.

The use of contrast media for CT and MRI

should be avoided in pregnant women. If contrast media must be used for lactating women, then, it is better not to breastfeed for 48h after the use of contrast media.

1.7.3 Inuence ofDental Medication:

Antibiotics andAnalgesics (NSAIDs)

When oral or injectable drugs are administered to a pregnant woman, it must be recognized that the drugs are transferred to the fetus through the placenta. Depending on the type and dose of the drug, the fetus may be affected during organogenesis.

Therefore, medication should be avoided, if

possible, until 12weeks (3months) of pregnancy. The second trimester pregnancy (5 to 7months) is a safe time for medication and treatment.

In addition, after birth, drugs administered to

the mother may be transferred to the infant through breast milk. If the drug is taken immediately after breastfeeding, the concentration of the drug in breast milk can be reduced. Of course, the drug should be administered as little as necessary.

Antibiotics and nonsteroidal anti-

inammatory drugs (NSAIDs) are the most commonly prescribed drugs in dentistry. Attention should be paid to the transplacental passage and breast milk transit of these drugs.

Antibiotics

Penicillins or cephem antibiotics (cephalosporin) should be the rst choice of antimicrobial agents for pregnant and lactating women. To prevent the emergence of antimicrobial resistance (AMR) bacteria, which has become an international issue, third-generation cephems should be avoided, and penicillins such as amoxicillin are recommended. Amoxicillin is safe throughout pregnancy and is rapidly absorbed and excreted. Its transfer to breast milk is low, and there is little effect on the infant.

If the patient is allergic to penicillins or cephems, macrolide antibiotic should be used. Macrolides are more likely to be transferred to breast milk than penicillins or cephems.

In addition, penicillins, cephems, and macrolides can be used in pediatric patients. However, new quinolones should not be administered to pregnant women or lactating women because their safety for fetuses and infants has not been established.

Analgesics

As an analgesic, acetaminophen is safe for pregnant women and nursing mothers. The transfer of acetaminophen (Caronal®) to breast milk is low even when taken during lactation, and there is no problem in administering it in regular doses.

However, NSAIDs should be avoided. NSAIDs are placental transmissible, and when administered to the mother, they are almost always transferred to the fetus and may constrict the fetal ductus arteriosus. This may lead to decreased amniotic uid and premature birth. It is also transferred to breast milk. Therefore, it should not be used after 28weeks (7months) of pregnancy. Diclofenac sodium (Voltaren®), one of NSAIDs, should not be administered to women of childbearing potential.

1.7.4 Local Anesthesia

Local anesthetics for dental treatment should be avoided in the rst pregnancy trimester and waited until the second pregnancy trimester. However, for emergency treatment such as pulp extirpation or abscess incision, local anesthesia should be administered with the following precautions in mind.

Lidocaine: lidocaine crosses the placenta easily. Fifty percent of the maternal blood concentration becomes the fetal blood concentration.

Adrenaline (vasoconstrictors): easily destroyed and not readily transferred to the fetus.

Propitocaine (Citanest

) and felypressin (Octapressin®): the use of felypressin, a vasoconstrictor, is prohibited because of its delivery (childbirth) accelerating effect.

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