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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.

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Discomforts 2c lifestyle

  • 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
Nausea & Vomiting:Cochrane Intervention Review, 2010 Quinlan et al, Am Fam Phys, 2003


Background
Background

  • 70-85% of women experience nausea with pregnancy

  • ~ ½ 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
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…


Discomforts 2c lifestyle

  • 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 infant’s arrival


Etiology
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
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
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
Cochrane 2010

  • Interventions for nausea and vomiting in early pregnancy

  • 27 studies with 4041 women included

    • 22 studies excluded



Acupuncture
Acupuncture

  • Acupuncture versus placebo (sham acupuncture and no treatment)

    • two studies with 648 women

  • No sig difference or data not interpretable



  • Vitamin b6 versus placebo
    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
    Anti-emetic medication versus placebo

    • 6 studies, 803 women

    • Hydroxyzine, Debendox (Bendectin) Thiethylperazine,Fluphenazine-Pyridoxine

    • Review found substantial methodological problems with most studies and could not reach meaningful conclusion


    Adverse outcomes
    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
    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
    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
    Nausea and vomiting of pregnancy: an evidence-based review(Davis,J Perinat Neonatal Nurs. 2004)

    • First step is dietary & lifestyle changes


    Discomforts 2c lifestyle
    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
    Interventions for Heartburn in Pregnancy Position Statement on the Use of Gastrointestinal Medication 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: Position Statement on the Use of Gastrointestinal Medication in Pregnancy

    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)


    The management of heartburn in pregnancy richter 2005 alimentary pharmacology therapeutics1
    The management of heartburn in pregnancy (Richter, 2005. Alimentary Pharmacology & Therapeutics)


    Adverse effects of substance use determined by
    Adverse effects of substance use determined by: Alimentary Pharmacology & Therapeutics)

    • Timing

    • Dosage

    • Duration

    • Number of substances

    • Environment (nutrition, health status)

    • Individual susceptibility


    Effects of substance abuse include
    Effects of substance abuse include: Alimentary Pharmacology & Therapeutics)

    • 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
    Alcohol: Background Alimentary Pharmacology & Therapeutics)

    • 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


    Discomforts 2c lifestyle

    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
    Alcohol: Background, cont. alcohol use or binge drinking, by pregnancy status --- Behavioral Risk Factor Surveillance System (BRFSS) surveys, United States

    • 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
    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
    FAS, cont. Research Society on Alcoholism

    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
    FAE – Fetal Alcohol Effects or PFAE Research Society on Alcoholism

    • 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
    Fetal Alcohol Spectrum Disorders (FASD) Research Society on Alcoholism

    • Surgeon General’s 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/FAE Incidence Research Society on Alcoholism

    • 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
    Pathophysiology Research Society on Alcoholism

    • Combination of

      • Toxic effects of ethanol and its derivatives

      • Nutritional factors

      • Genetic predisposition


    Toxic effects
    Toxic effects Research Society on Alcoholism

    • 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
    Nutrition Related Effects of Alcohol Research Society on Alcoholism

    • 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 general s advisory 2005
    Surgeon General’s Advisory Research Society on Alcoholism(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 general s advisory 20051
    Surgeon General’s Advisory Research Society on Alcoholism(2005)

    Recommendations:

    • 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
    Caffeine Research Society on Alcoholism

    • 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
    The Effects of Caffeine on Pregnancy Outcome Variables Research Society on Alcoholism(Hinds et al. Nutrition Review, 1996)

    • Consumption:

      • In US 70-95% of pregnant women consume caffeine - average intake is 99-185 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 19961
    The Effects of Caffeine on Pregnancy Outcome Variables Research Society on Alcoholism(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
    Caffeine Metabolism, Genetics and Perinatal Outcomes Research Society on Alcoholism(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.”


    Discomforts 2c lifestyle
    Coffee and Health: A Review of Recent Human Research (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)


    Conception
    Conception (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

    • Many studies find > 300 mg/d associated with delay in time to conception (some do not find this effect)

    • Author’s 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
    Spontaneous Abortion (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

    • 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
    Fetal Growth (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

    • “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
    Preterm Delivery (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

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


    Birth defects
    Birth Defects (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

    • “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.”


    Discomforts 2c lifestyle
    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
    Smoking (Higdon and Frei; crit rev food sci and nutrition, 2006)

    • 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 (Higdon and Frei; crit rev food sci and nutrition, 2006), MMW; May 29, 2009


    Trends in smoking before during and after pregnancy mmw may 29 20091
    Trends in Smoking Before, During, and After Pregnancy (Higdon and Frei; crit rev food sci and nutrition, 2006), MMW; May 29, 2009


    Trends in smoking before during and after pregnancy mmw may 29 20092
    Trends in Smoking Before, During, and After Pregnancy (Higdon and Frei; crit rev food sci and nutrition, 2006), MMW; May 29, 2009


    Trends in smoking before during and after pregnancy mmw may 29 20093
    Trends in Smoking Before, During, and After Pregnancy (Higdon and Frei; crit rev food sci and nutrition, 2006), MMW; May 29, 2009


    Adverse outcomes of maternal smoking
    Adverse Outcomes of Maternal Smoking (Higdon and Frei; crit rev food sci and nutrition, 2006)

    • 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
    Nutritional Risks Associated with Smoking (Higdon and Frei; crit rev food sci and nutrition, 2006)

    • 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
    Nutritional Risks Associated with Smoking, cont. (Higdon and Frei; crit rev food sci and nutrition, 2006)

    • 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
    Norkus et al. FASEB, 1989 and Ann NY Acad Sci 1987 (Higdon and Frei; crit rev food sci and nutrition, 2006)


    Vitamin c and prom
    Vitamin C and PROM (Higdon and Frei; crit rev food sci and nutrition, 2006)

    • 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 cont1
    Nutritional Risks Associated with Smoking, cont. (Higdon and Frei; crit rev food sci and nutrition, 2006)

    • 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.


    Discomforts 2c lifestyle
    Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis(Oken, 2008)


    Discomforts 2c lifestyle
    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.”


    Discomforts 2c lifestyle
    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
    Illicit Drugs: Nutritional Implications systematic review and meta-analysis

    • 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
    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


    Discomforts 2c lifestyle
    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 implications1
    Illicit Drugs: Nutritional Implications context?

    • 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
    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
    Exercise nutritive and nonnutritive sweeteners (2004)

    • Benefits:

      • improved or maintained fitness

      • reduces anxiety and depression

      • eases pregnancy discomforts such as constipation, backache, fatigue and varicose veins


    Exercise1
    Exercise nutritive and nonnutritive sweeteners (2004)

    • 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


    Exercise2
    Exercise nutritive and nonnutritive sweeteners (2004)

    • 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


    Exercise3
    Exercise nutritive and nonnutritive sweeteners (2004)

    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
    Postpartum nutritive and nonnutritive sweeteners (2004)

    • 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
    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
    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
    Oral Health & Pregnancy: Major Concepts Pregnancy (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
    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
    Pregnancy Gingivitis and Nutrition, 2009

    • 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
    Periodontitis and Nutrition, 2009

    • 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 gram-negative 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
    Periodontitis (cont.) and Nutrition, 2009

    • 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
    Can preterm birth be prevented by periodontal treatment? and Nutrition, 2009

    • 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
    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


    Discomforts 2c lifestyle
    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
    2 Recent Trial Reports delivery: a randomized controlled trial (Offenbacker et al, Obstet Gynecol, 2009)

    • 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
    All Periodontal Treatment Impacts are not the Same: delivery: a randomized controlled trial (Offenbacker et al, Obstet Gynecol, 2009)

    • 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 2.57-14.03)


    Discomforts 2c lifestyle
    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
    Oral Health: Recommendations Periodontal Management of the Pregnant Patient

    • 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


    Discomforts 2c lifestyle
    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


    Discomforts 2c lifestyle

    “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.”


    Discomforts 2c lifestyle

    “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 caregiver’s mouth to a

    child’s. The healthier the mother’s 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.”