Management of medically compromised patient

Management Of Medically
Compromised Patient

Importance
1. Recognition of existing medical condition
2. Adequate preparation
- Premedication
- Prophylaxis
- Adjustment
- Preparation for any adverse effects
3. Postoperative consideration to control
- Bleeding
- Infection

Patients Classification According to their physical condition
According to the American Society of Anesthesiologists (ASA)
Type I : Normal patient
Type II : Mild to moderate systemic disease
Type III : Sever systemic disease limiting patient activity
Type IV : Sever systemic disease threatening life
Type V : Morbid patient

Treatment options
1. Office treatment
- ASA type I
- ASA type II
2. Hospitalization
- ASA type III
3. Hospitalization and emergency treatment only
- ASA type IV
4. Hospitalization and palliative treatment
- ASA type V

Stress Reduction Protocol
● Before appointment
1. Night before surgery (sleeping pills valium 5-10 mg) optional
2. Day of surgery ( short acting barbiturates secobarbital 50-100 mg optional)
3. Early appointment
4. Short appointment

Stress Reduction Protocol cont.
● During Appointment
1. Relaxing background music
2. Reassurance
3. No surprises
4. No unnecessary noise
5. Surgical instrument out of patient sight
6. Profound local anesthesia
7. IV sedation optional
8. Nitrous oxide sedation optional

Stress Reduction Protocol cont.
● After surgery
1. Further reassurance
2. Detailed information about expected postoperative sequelae
3. Effective analgesics
4. Telephone call for the patient at home

CARDIOVASCULAR DISEASES
Management of patients with systemic diseases
CARDIAC ARRHYTHMIAS
ANGINA PECTORIS
MYOCARDIAL INFARCTION
CORONARY ARTERY BYPASS GRAFTING
REHUMATIC HEART DISEASE
HYPERTENSION

Management of patient with systemic diseases
CARDIAC ARRHYTHMIAS

● Condition :
1. Abnormal pulse rate or rhythm
2. Cardiac pacemaker
● Dental Management Considerations ;
1. Consultation
2. Stress reduction protocol
3. Local anesthesia without vasoconstrictor
4. Avoid diathermy and ultrasonic scaler in case of pacemaker
5. In case of decreased heart rate
● Direct vigorous thumbing on the pericardium
6. In case of rapid heart beats
● Vagal stimulation through carotid sinus massage

Management of patient with systemic disease
ANGINA PECTORIS

● Condition :
- Temporary inability of the coronary arteries to supply the heart musculature by
oxygenated blood
- Patient suffers from
● Substernal pain radiates to the left shoulder
● Down to the fingers
● May radiate to the neck and jaws
- It always follows exercise, overeating, emotional, stress and cold weather and fear
due to increased level of epinephrine and nor epinephrine
- If lasts more than 30 minutes

● Dental Management Considerations :
1. Consultation
2. Advise the patient to eat lightly before appointment
3. Premedication with short acting barbiturate
5. Nitroglycerine tablets sublingually
● 5 min before stressful procedure
● Keep it handy
1. Monitor vital signs
2. Avoid prolonged procedures
3. Avoid painful stimuli

● Dental Management Consideration : cont.
- Injection of LA containing V.C.
IF NO V.C. -> PAIN->endogenous adrenaline
Safe suggestion 2 carpules containing max 1:100.000 adrenaline
- Injection given very slowly + aspiration is a MUST
- In case of unstable angina postpone the regular procedure, only emergency dental
care should be performed

CORONARY ANGIOPLASTY

● Condition :
Introduction of catheter containing balloon in narrowed coronary artries
- The same precautions for angina pectoris
- Anticoagulant drug management
I. Never withdrawal of anticoagulant
II. Reduce the dose of oral anticoagulant to maintain prothrombin time 1.5 to 2
times the control(e.g. 25 seconds normal 15 second)

MYOCARDIAL INFARCTION
CORONARY THROMBOSIS
(PATIENT ON ANTICOAGULANTS)

● Condition :
- Anginal attacks lasts more than 30 minutes
- Patient experiences sever substernal pain and may go into shock and cardiac
dysfunction that can lead to death
● Clinical features :
- Prolonged anginal pain last more than 30 minutes
- Tachycardia and irregular pulse
- Nausea and vomiting
- Difficulty in breathing(pulmonary edema)
- Pallor with symptoms of shock

● Treatment :
1. Complete physical and mental rest
2. Morphine as pain killer
3. Anticoagulant therapy to diminish thromboembolic complications
● Emergency treatment
1. Call emergency unit
2. CPR
3. Emergency oxygen
4. IM 10% lidocain
5. Nitroglcerin sublingually
6. IV thrombolytic agent injection(streptokinase)

1. Consultation and advise hospitalization
2. Postpone elective surgery till after 6 months
3. Prophylactic coronary dilators
4. Anticoagulant drug management
I. never withdraw of anticoagulants (fear of rebound thrombosis)
II. reduce the dose of oral anticoagulant to maintain prothrombin time 1.5 to
2 times the control (e.g. 25 second normal 15 second)
6. Monitor vital signs

● Dental Management considerations :
7. Decrease the amount of adrenaline
8. Local haemostatic measures
I. Constant pressure
II. Gel foam in the socket after extraction
III. Multiple sutures under tension
IV. heavy bite pressure 1 hour at least
V. Ice Packs ½ hr on ½ hr off applied externally
9. Avoid mouth rinses and hot liquids for 72 hrs

CORONARY ARTERY BYPASS GRAFTING

1. Postpone elective surgery till after 6 months
2. Same as myocardial infraction
3. For the first 6 months, patients may need preoperative antibiotic prophylaxis
against infective endocarditis

CARDIOVSCULAR DISEASES
RHEUMATIC HEART DISEASE

● Condition :
- Disease of altered immunological reaction to group A betahemolutic
streptococcsal infection
- The valves are frequently the site of subsequent bacterial endcarditis(SBE)
- The most affected valves are the mitral valve and the aortic valve subequently
● Clinical features :
1. Septicemia
2. Petecheal haemorrhage
3. Finger clubbing - nail bed haemorrhage
4. Embolic complications in kidneys, brains, eyes
5. Cardiac failure

● Mortality rate :
- 100% without antibiotics treatment
- 10-65% for trerated patients
● Treatment :
- Prohylactic antibiotic against BE utilizing
- Cardiac surgery with prosthetic valve replacement

● Dental treatement consideration :
1. Careful history
2. Medical consultation
3. Adjusting the anticoagulant therapy
4. Antiboitic coverage
5. Antiseptic mouth wash
6. Local anesthesia with vasconstrictor to minimize bacteraemia
7. Atraumatic dental procedure
8. Two weeks is the minimum interval between sessions

● Antibiotic regimen
- Standard routine
● Amoxycillin 2 grams orally 1 hourbefore procedure
● Fro children 50 mg/kg (IV/IM) 30 mintues before precedures
- Unable to take oral medications
● Ampicillin 2 grams (IV/IM) 30 mintues before procedures
● For children 50 mg/kg (IV/IM) 30 mintues before procedures

● Antibiotic regimen cont.
- Allergic to penicillin
● Clindamycin 600 mg orally 1 hour before the procedures
● For children 20 mg/kg orally 1 hour before the procedures
- Allergic to penicillin and unable to take oral medication
● Clindamycin 600 mg (IM/IV) 30 mintues before the procedures
● For childrens 20 mg/kg orally 1 hour before the procedures

HYPERTENSION

● Condition :
1. The sum of cop, blood viscosity and vessel elasticity
2. It is related to cardiovascular diseases, renal diseases and atherosclerosis
3. Early signs:
- Breathlessness
- Spontaneous nose bleeding
- Persistent headache
- Occular complains
- General malaise and dizziness
- Odontalgia with no local causes due to pulp hyperemia

● Classification of Hypertension
1. According to etiollogy
- Primary hypertention(idiopathic)
- Secondary hypertension
1. Renal disease
2. Adernal cortial hyperfunction
3. CNS lesion
2. According to its severity
- Normal blood pressure 120-140/85-90
- Mild hypertension 140-160-/90-105 mmhg
- Moderate hypertension 160-200/105-114 mmhg
- Sever hypertension >200/115 mmhg

● Complications :
- Patients with undected hypertension may account for occasional sudden death
- Due to elevation of the blood pressure that leads to
➢ Cerebral hemorhage
➢ Myocardial infraction
➢ Renal failure
➢ Heart failure

● Dental Managaement Considerations :
A. Mild to moderate hypertension :
1. Consultation
3. Monitor blood pressure
4. Decrease the amount of adrenaline ( LA +VC(1/100,000))
5. Inject anesthesia slowly and avoid intravascular injection
6. Local haemostatic measures carefully taken to avoid undue hemorrhage
7. Avoid rapid posture changes that can leads to orthostatic hypotension and
syncope

B. Severe hypertension >200/115
1. Consultation
2. Postpone till blood pressure is controlled
3. On emergengy basis hospitalization
4. Premedication
5. Decrease the amount of adrenaline carefully taken to avoid undue hemorrhage

HEMATOLOGIC DISEASE
DISEASE OF RBCS
ANEMIA
DISEASES OF WBCS
LEUKEMIA
HEMORRHAGIC DISEASES
HAEMOPHILIA

BLOOD DYSCRASIAS
RBCS DISORDERS
ANEMIA

● Definitions
● Anemia
- Deficient RBCs production
- Decreased RBCs count
- Decreased hemoglobin level
● Complications
- Not withstand blood loss
● Heart failure
● Myocardial infration
- Postoperative hemorrhage
- Sore tongue

● Dental management consideration
2. Complete blood picture
3. Postpone surgery if hg concentration is less than 10g/100ml
4. Search for the signs and symptoms of anaemia
● Sore tongue
● Necrotizing ulceration of the gingiva
● Bleeding during examination
5. Consider iron and multivitamin therapy preoperatively to increase haemoglobin
synthesis
6. Local haemostatic measures and prophylactic antibiotic therapy to prevent
postoperative infection should be provided

BLOOD DYSCRASIAS
WBCS DISORDERS
LEUKEMIA

● Conditions
Progressive overproduction of immature WBCs in the world
● Features
1. Gingival bleeding
2. Ulceration of oral mucosa

2. Complete blood picture
3. Hospitalization
4. Search for the signs and aystoms of WBC disorders
5. Withdraw any systemic drug cause the condition
6. In case need prolonged antibiotics periodic check up by blood picture is must
7. Extraction is contraindicated unless under strict conditions
8. Local haemostatic measures and prophylactic antibiotic therapy to prevent
postoperative infection should be provided

BLOOD DYSCRASIAS
Management of patients withsystemic diseases
HEMATOLOGIC DISEASES
HAEMOPHILIA

Disease involving blood factors
1. Haemophilia
- Haemophilia A(factor VIII)
- Haemophilia B(christmas disease factor IX)
- Haemophilia C(plasma thromboplastin antecedent deficiency)
2. Pseudohaemophilia (factor VII)
3. Parahaemophilia (factor V)
4. Hypofibrinogenamia (factor I)
5. Hypoprothrombinaemia (prothrombin factor II)

● Dental management considerations :
1. Consultation
2. Laboratory investigations Pt, ptt, INR, platelet count and bleeding time
3. Hospitalization
4. Replacement of the deficient factor or platelet replacement (pre/post operatively)

● Dental management considerations:
5. Avoid nerve block techniques
6. Avoid major surgical procedures
7. Utilize atraumatic surgical procedures
● Obliteration of the dental soclet with absorable haemostatic materials
- Gel foam soaked with thrombin/fibrinogen
- Oxidized cellulose
● Using cryotherapy or electrocoagulation
● Suturing of the mucosa
● Application of astringents

9. Careful postoperative instruction
10. Postoperative blood transfusion
11. No NSAIDs
12. High infection control measures
13. Discharge the patient after 3 days without bleeding

PULMONARY DISEASES
BRONCHIAL ASTHMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

PULMONARY DISEASES
BRONCHIAL ASTHMA

● Condition :
- Spontaneous reversible spasmodic contraction of the smooth muscles of the
bronchioles
- Dyspnea, wheezing and cough
● Etiology :
1. Allergy
2. Viral infection
3. Familial

1. Consultation
3. Prophylaxis for adrenal insufficiency (under steriod)
4. Preoperative bronchodilators (theophiline)
5. Oxygen
6. Patients on theophylline avoid prescribing:
Aspirin, NSAIDs, barbiturates, narcotics, sulfite containing preservative anesthetics, erythromycine
antibiotics
7. In more severe attacks:
i. Aminophyline 250 mg IV very slowly
ii. Hydrocortisone 100mg IV very slowly
iii. oxygen

PULMONARY DISEASES
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

● Conditions:
- Bronchitis associated with exessive mucous secretion, cough and expectoration
● Etiology :
1. Smoking
2. Environmental pollutants

● Dental managemnt considerations :
1. Consultation
2. Schedule afternoon appointment to allow respiratory clearance
4. Avoid premedication with narcotics or barbiturates as they are respiratory
depressants
5. Keep bronchodilato inhaler accessible
6. Place th epatient in the dental chair in an upright positon
7. Avoid bilateral palatal or man dibular nerve blocks to avoid the sensation of
repiratory obstruction

8. Use of rubber dam is not advised
9. Patient on oxygen, should be continued during surgery
10. Prophylaxis for adernal insufficiency, if the patient is under steroid treatment
11. Avoid antiihistaminics and atropine as they lead to dry mouth and increase
mucous production

ENDOCRINAL CONDITIONS
DIABETES MELLITUS
HYPERTHYROIDISM
ADRENAL INSUFFICIENCY

DIABETES MELLITUS

● Condition:
Chronic complex disease with metabolic and vascular components
- Metabolic component:
Disorder in the metabolism of insulin, carbohydrates, proteins and fats leads to
elevation of blood glucose level
- Vascular component
● Atherosclerosis
● Microangiopathy of small vessels

● Condition :
Susceptibility to infection may be due to :
1. Hyperglycemia
2. Vascular insufficiency
3. Hetoacidosis
4. Neuropathy
Normal blood glucose level
Fasting <125 mg/dl

● Diabetes is cotrolled by:
1. Diet
2. Diet and oral hypoglycemic drug
3. Diet and insulin

1. Consultation - Uncontrolled cases should be refered for the physician and only
emergency treatment could be preformed
3. Dental procedure are best performed in the morning 90-180 min after breakfast
and insulin usual dose since it is the hours of the decending part in blood sugar
level
4. In non-insulin controlled patient all dental procedures could be performed
5. Prophylatic antibiotic administration the day before & 2-3 days after surgery (in
case of massive surgery)

6. Adjustment of the insulin dose preoperatively :
i. Normal postoperative feeding and minimal surgical intervention - do not change
the dose
ii. Moderate surgical intervention that may affect the postoperative feeding
iii. If the diet will be completely restricted postoperatively

7. Use smallest amount of epinephrine in LA ( not more than 1/ 100,00) or
preferably use CORBASIL/ octapresine since it’s effect is only 1/10 of epinephrine
in raising the blood sugar
8. If there is any doubt of insulin shock/ diabetic coma - IV dextrose
If diabetic coma - no harm
If insulin shock - dramatic correction
9. Sugar should always be available if hypoglycemic shock occur

Diabetic Coma and Insulin Shock
Item Hyperglycemia
Diabetic coma
Hypoglycemia
Insulin shock
consciousness Drowsiness and loss of
consciousness
Drowsiness and loss of
consciousness
Skin appearance Dry & flushed Moist & pale
Thrist Intense ----------------
Breath odor Acetone Normal
Vomiting Common Rare

HYPERTHYROIDISM
THYROTOXICOSIS /TOXIC GOITER /GRAVE’S DISEASE

● Conditions :
- Increase secretion of thyroid hormones (T3, T4) in the circulation that can lead to
throid crisis
● Signs and symptoms of throtoxicosis :
1. Increased apatite and loss of weight
2. Warm moist skin
3. Irritability and nervousness
4. Fine tremors and muscles weakness increased cardiac output, pulse rate and
blood pressure
5. Tachycardia
6. Dyspnea on exertion
7. exophatlmous

● Dental management considerations (prevention of throid crisis) :
2. Postpone surgery until thyroid dysfunction is well controlled (1-2 months after
controlling the case)
4. Avoid the use of vasoconstrictor
i. Use plain anesthesia
ii. Use local anesthesia with vasoconstrictor other than adrenaline / noradrenaline
5. Avoid atropine as it may lead to thyroid crisis

Thyroid Crisis
● Early symptoms of throid crisis
1. Restlessness
2. Nausea
3. Abdominal cramps
● Late symptoms of thyroid crisis
1. High fever
2. Tachycardia
3. High pulse rate with severe hypotension
4. Tachypnea due to pulmonary oedema
5. Coma and heart failure

Throid Crisis cont.
● Management of thyroid crisis:
1. Urgent call for medical aid
2. Cold packs to decrease temperature
3. Oxygen
4. Cardiopulmonary resuscitation
5. 100-300 mg hydrocortisone IV
6. Anti- throid medications e.g. potassium iodine or 200 mg propranol
7. IV fluid as a supportive measures

ADERNAL INSUFFICIENCY
ADDISON’S DISEASE

● Adrenal suppression can be caused by :
1. Addison’s disease (1 ry)
2. 2 ry deficiency
i. Pituitary or hypothalamic disease
ii. Prolonged corticosteroid therapy
● Adrenal xortical suppression should be suspected if patient take
1. 20 mg or more of cortisone daily
2. 2 weeks or more
3. Within last 2 years

2. Adjust the corticosteroid dose
Patient who has
taken
corticosteroids in
the last 2 years
Patient who are
under
corticosteroid
therapy
emergrncy
Management 1. Reinstitute the
previous dose
of
corticosteroid
2 days before
the day of
surgery
2. Continue the
steroid
therapy for
one week
postoperativel
y
1. Double or
triple the dose
day before
surgery
2. Day of surgery
3. 2 days
postoperativel
y
4. Reinstitue
normal dose
after that
125 mg of solu-
medrol(
hydrocortisone ) is
given IV at the time
of surgery normal
dose is doubled for
2 days following

4. Antibiotic therapy if extensive surgical procedures are anticipitated or if one is
operating in an infected surgical field
5. GA is preferable for major surgries
6. Preparation of the patient for general anesthesia:
1. IM 100 mg hydrocortisone night before operation
2. Repeat the dose immediately before operation
3. Sometimes anesthetist give IV drip ( cortisone) drug operation time
4. Post operatively (tapering)
5. 50 mg hydrocortisone after recovery
6. 1.5 -2 times the normal oral dose on the 2nd day
7. Normal dose on the 3rd day

Adernal crisis
● Clinical features of adernal crisis:
1. Sever hyotension
2. Dehyration
3. Circulatory collapse
4. Shock
5. Respiratory collapse
● Treatment of ADERNAL CRISIS:-
1. Pt in shock position
2. Oxygen
3. Administration of glucocorticoids:
4. Prednisolone IV or IM (4 times > cortisone)
5. Dexanethasone (25 times > cortisone)
4. Vasopressor drug such as wyamine sulphate
5. Fluid and electrolytes replacement
6. Hospitalization

LIVER DISEASES
LIVER CIRRHOSIS
HEPATITIS

Function of the liver
1. Exocrine function by production of bile salts
2. Carbohydrates and lipids metabolism (glycogen storage)
3. Detoxification properties
4. Production of bilirubin from the break down of haemoglobin
5. Production of :
i. Albumin
ii. Clotting factors (prothrombin and fibrogen)
iii. Plasma proteins
iv. Urea
v. Amino acids

Impaired liver function leads to:
1. Abnormalities in metabolic processes
2. Abnormalities in coagulation
3. Abnormalities in drug metabolism

Laboratory investigation used to evaluate hepatic functions:
1. Serum bilrubin when elevated -> intraheptic or obstructivr liver disease
2. Serum alkaline phosphatase when elevated -> obstructive liver disease rather than
cellular liver disease
3. Serum transaminase levels when elevated -> hepatocellular necrosis
(NONSPECIFIC)
4. Serum albumin decreased late during liver diseases
5. Bromsulphalim (BSP) retention (MOST SPECIFIC)
6. Prothrombin time elevated in heptic disease
7. Antigen antibody markers to differentiate different type of viral hepatitis

LIVER DISEASES
LIVER CIRRHOSIS

● Condition:
- Heptic parechymal damage with fibrosis and damage of the normal lobular
pattern of liver
● Etiology :
1. Idiopathic
2. Alcoholism
3. Hepatits
4. Liver automimmune disease
5. hepatotoxins

● Clinically:
1. Jaundice
2. Bleeding tendaency
3. Portal hypertension
4. Ascites
5. Hypoglycemia
6. hepataosplenomegaly

LIVER DISEASES
HEPATITIS

● Condition:
- Inflammation of the liver cells
● Etiology and types:
1. Primary hepatits:
i. Viral hepatits
ii. Toxic hepatits
iii. Drug induced hepatits
2. Secondary hepatits:
i. Syphilis
ii. TB
iii. Infective mononucleosis

● Clinically :
1. Anorexia or nausea
2. Fever which gradually subside
3. Enlargement and tenderness of liver
4. Splenomaegaly
5. Jaundice
6. Lymphadenopathy
● Complications of hepatits:
1. Degenerative necrosis of liver cells
2. Biochemical abnormalities
3. Liver cirrhosis
4. Hepatocellular carcinoma

● Dental management consideration:
2. Liver function tests
3. Coagulation screening profile
4. Regulation of the bleeding tendency:
i. Blood transfusion prior to surgery if needed
ii. Vitamin K injection (10 mg synkavit 1 hour before and after surgery)
6. Prophylactic antibiotics

8. Avoid hepatotoxic drugs
9. Minimize the use of drugs metabolized in liver
10. LA is safe with small doses and least concentrations
11. Least amount of surgical intervention

Drug therapy in liver diseases
Item To be avoided Preferable
Analgesics Morphine
Valium
Aspirn
Paracetamol
Antibiotics Penicillin
Sulphonamides
Clindamycin
Metranidazole
Anesthesia Amide types :
Mepivicain
Xylocaine
Ester types :
Procaine

RENAL DISEASES
RENAL FAILURE
KIDNEY TRANSPLANTATION

RENAL FAILURE
RENAL FAILURE

● Clinically :
1. Nausea and vomiting
2. Loss if weight
3. Pallor
4. Anemia hypertension
5. Acidosis
6. Congestive heart failure
7. Plmonary edema
8. Renal osteodystrophy
9. Elevated serum creatinine (0.6 -> 1.2 mg /100ml blood)
10. Elevated BUN (blood urea nitrogen ) (8->23mg)
● Treatment :
1. Artificial blood diltration (dialysis)
2. Kidney transplantation

Renal haemodialysis
3. Avoid drugs that are excreted through the kidneys
4. Avoid nephrotoxic drugs
5. Postpone till the same day (not before 4 hours) or better day after dialysis
6. Prophylactic antibiotics to guard against SBE (SHUNT)
7. Least traumatic surgery
8. Least amount of LA

Renal transplant
2. Stress reduction protcol
3. Regulation of the corticosteroids
4. Minimal stress-> no change
5. Moderate stress-> double the dose
6. Severe stress-> 100mg hydrocortisone IV
7. Avoid nephrotoxic drugs
8. Prophylactic antibiotics to minimize bacteremia specially because the patient is
under the action of cytotoxic drugs

Drug therapy in renal diseases
Analgesics Aspirin
NSAIDs
Paracetamol
ibubrufen
Antibiotics cephalosporens Erythromycin
Clindamycin
Metronidazole
Anesthesia Procaine Xylocaine

MISCELLANEOUS
PREGNANCY AND LACTATION
EPILEPSY
HIV
OSTEORADIONECROSIS

MISCELLANEOUS
EPILEPSY

2. Postpone surgery until seizures are well controlled
3. Anticonvulsant premedication
5. Avoid hypoglycemia
6. Avoid lengthy
● In case of seizures
1. Stop the procedure
2. Put patient in supine position
3. Place bite block or tongue blade between teeth

MISCELLANEOUS
HIV

● Condition:
1. Generalized lymphadinopathy
2. Opportunistic indections
3. Maliganacies preiodontal disease without local factor
4. Hairy leukoplakia
5. Xerostomia
● Dental management consideration :
1. Consultation
2. Strict infection control measures

MISCELLANIOUS
PREGNANCY AND LACTATION

● Best time for dental procedure is the middle or the 2nd trimster due to:
1. Minimal mausea and vomiting
2. Stable fetus
3. Low incidence of obstetrical complications
Emercgency treatment can be done at any time
Dental procedures involves potenially harmful elements for pregnant female
including:
1. Radiographs
2. Drug administration
3. Pain and stress
4. Supine hypotension in late pregnancy

1. Consult the patient’s obstetrician
2. Short appointments
3. Avoid painful stimuli
4. Avoid placing the patient in supine position
5. Avoid radiographs
It should be limited and used only after 1st trimster
6. LA is more suitable than GA
7. Avoid drugs with teratogenic potential

Drug contraindicated and alternatives in pregnancy
Analgeseics Aspirin
NSAIDs
Paracetamol
Antibiotics Tetracyline
Aminoglycosides
Streptomycin
Metronidazole
Penicilin
Erythromycin
Cephalsoporin
Others Corticosteroids

All preferable medications has to be approved by the
patients gynecologist

● Medications to avoid during lactation:
1. Ampicillin
2. Tetracycline
3. Aspirin
4. Steroids
5. Valium
6. Barbiturates
● Premissible drug during lactation :
1. Keflex
2. Erythromycin
3. Xylocaine

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