What Would You DO?

[Noyac]

A 20yo G1 P0 at 38+ weeks is being induced by a midwife in order to deliver her baby so that she can have a root canal for a tooth abscess after delivery. She is requesting an epidural. Labs: WBC 10 Hct 40 Plt 276. VSS and afebrile at 98.3. She had a fever earilier in the week when she saw her dentist. She has not received any antibiotics and is in mild to moderate discomfort.

Whats your move?

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[nimbus]

A 20yo G1 P0 at 38+ weeks is being induced by a midwife in order to deliver her baby so that she can have a root canal for a tooth abscess after delivery. She is requesting an epidural. Labs: WBC 10 Hct 40 Plt 276. VSS and afebrile at 98.3. She had a fever earilier in the week when she saw her dentist. She has not received any antibiotics and is in mild to moderate discomfort.

Whats your move?

This is not an uncomplicated delivery which is why you posted. Does the root canal really have to wait until after delivery? Why no antibiotics? Did the dentist not want to prescribe to a pregnant woman? Any chance of getting an OB involved to help answer these questions? She really needs a good doctor to coordinate her care. I don't have any experience with midwives so I don't know their scope of practice. Do they routinely induce labor?

The risk of an epidural abscess MAY be increased but is probably still small. I haven't done a search but I doubt there is much data in this setting to support one move or another. If the complication did occur, it could be catastrophic. I would explain this to the patient and if she accepts the risks, I would proceed with an epidural after a big fluid bolus. We give epidurals all the time in the setting of chorioamnionitis.

 

[sdn1977]

I've no business answering your question on my own experience, but I did show your case to my husband who is a dentist (he doesn't read this forum generally). He couldn't figure out why the root canal wasn't started either when she was seen. He concedes at 38wks, she is may be too uncomfortable to complete the procedures, but her pregnancy at any stage would not be a contrindication for the procedure. He says he would have opened the tooth for drainage, evaluated if it was pustular or hemorraghic which would determine if it stays open or closed with a temporary filling & started on antibiotics.

He's a general dentist & says an endodontist could do it fast enough the physical discomfort of laying in a dental chair would be neglible.

He did say she may have objected to the need for a periapical x-ray which any dentist would have needed to examine the root tip, but the exposure to the fetus would have been minute since she would be covered from the neck down with a shielding apron. This concern could go along with her use of a midwife (rather than OB), but doesn't seem to match up with the fetal risk of inducing pre-term.

Again....I'm no physician - just passing on his thoughts.

So.....what did you do???

 

[jwk]

A 20yo G1 P0 at 38+ weeks is being induced by a midwife in order to deliver her baby so that she can have a root canal for a tooth abscess after delivery. She is requesting an epidural. Labs: WBC 10 Hct 40 Plt 276. VSS and afebrile at 98.3. She had a fever earilier in the week when she saw her dentist. She has not received any antibiotics and is in mild to moderate discomfort.

Whats your move?

1) Refer to an OB DOC, not a midwife, for their opinion. My guess is that an induction at 38 weeks is not indicated for this problem. I'm not a dentist either but wouldn't you expect an elevated WBC with an abscess?

2) Epidural not a big deal regardless.

3) Although root canals are never fun, I would think there are no big contraindications. Just like anything at this late stage in pregnancy, i'd give her some uterine tilt since they'll be near supine in the dentist's chair for an hour or so.

 

[sdn1977]

1) Refer to an OB DOC, not a midwife, for their opinion. My guess is that an induction at 38 weeks is not indicated for this problem. I'm not a dentist either but wouldn't you expect an elevated WBC with an abscess?

2) Epidural not a big deal regardless.

3) Although root canals are never fun, I would think there are no big contraindications. Just like anything at this late stage in pregnancy, i'd give her some uterine tilt since they'll be near supine in the dentist's chair for an hour or so.

jwk - funny you ask about the WBC - I asked my husband the same question. He just laughed & said the last time he (or his endo buddies) had blood drawn for any pt was........NEVER since getting out of school. But...he concedes you could expect it to happen particularly if her face was swollen.

He also will use an upright position for lots of folks - pregnancy, CHF, emphysema, etc...just hard on his back, but he can do it.

Noyac.....is there more to this story you haven't shared????

 

[militarymd]

send the patient back to the dentist.

 

[jetproppilot]

A 20yo G1 P0 at 38+ weeks is being induced by a midwife in order to deliver her baby so that she can have a root canal for a tooth abscess after delivery. She is requesting an epidural. Labs: WBC 10 Hct 40 Plt 276. VSS and afebrile at 98.3. She had a fever earilier in the week when she saw her dentist. She has not received any antibiotics and is in mild to moderate discomfort.

Whats your move?

Geez, Noy. Even though you could probably put it in and everything would be fine, this is, litiginously thinking, a disaster waiting to happen.

First off, addressing the "you could put it in and everything would be fine" comment, how many medicaid women do we put epidurals in that probably have undiagnosed dental abscesses? Probably more than we think, or certainly more than we know about. Whats the chance of this lady's abscess seeding the bloodstream and subsequently the catheter? I'd say really low.

But thats not the point.

I think providing neuraxial analgesia for parturients being delivered by a midwife is increasing your litiginous exposure.

Compound that with a (potential) problem and I'd be worried about placing the epidural from a self-preservation standpoint.

An epidural is an elective procedure.

One could justify enough medical concerns to opt out of this one.

 

[Noyac]

Geez, Noy. Even though you could probably put it in and everything would be fine, this is, litiginously thinking, a disaster waiting to happen.

First off, addressing the "you could put it in and everything would be fine" comment, how many medicaid women do we put epidurals in that probably have undiagnosed dental abscesses? Probably more than we think, or certainly more than we know about. Whats the chance of this lady's abscess seeding the bloodstream and subsequently the catheter? I'd say really low.

But thats not the point.

I think providing neuraxial analgesia for parturients being delivered by a midwife is increasing your litiginous exposure.

Compound that with a (potential) problem and I'd be worried about placing the epidural from a self-preservation standpoint.

An epidural is an elective procedure.

One could justify enough medical concerns to opt out of this one.

Jet, don't you get tired of always being right?

This is exactly what I was thinking and where I was headed with this question. This is a medicaid pt that will pay nothing and be the first to sue if something goes wrong. Now I don't treat insured pts any differently than the uninsured if that is what some of you are thinking.
It would be fine to put the epidural in 99 times out of 100 but I proposed the risks to the pt who was understandibly afraid of another infection and she chose not to have the epidural ( ). I just get sick and tired of all the things that come to me mismanaged. Granted it is not always the midlevels that mismanage but it sure seems to be more frequent with these providers.
I gave her a gram of ancef IV and some stadol. I told her if the contractions get unbearable, then call me and I would place an epidural. She never called. I gave the ancef in an effort to give myself some false security if she decided to have the epidural. I don't really think she would have developed an complication but it made me feel better.

 

[militarymd]

send the patient back to the dentist.

Lots of anerobes in the mouth....if you were to start abx to prophylax against possible hematogenous seeding, then metrinidazole or a beta lactam in combo with sulbactam or clavulanic acid is mandadory.......as far as lawyers are concerned.

 

[Noyac]

Lots of anerobes in the mouth....if you were to start abx to prophylax against possible hematogenous seeding, then metrinidazole or a beta lactam in combo with sulbactam or clavulanic acid is mandadory.......as far as lawyers are concerned.

I forgot to mention that I called a real MD, the OB on call, before I did anything. She agreed that the pt need antibx but her drug of choice was ancef. Now not knowing for sure the effects of antibx on the fetus I went with her recommendation. I realize that the ancef was a poor choice. That is why I stated it was a false sense of security. If I really thought it was a high risk procedure I would have pursued the best antibx.

So now you would ask, then why give anything at all? Well it was late, I got the OB attending on board and I knew that the pt was too scared of another infection to ask for an epidural. So I figured I'd leave well enough alone. I was right by the way. She delivered without another dose of stadol or any other pain meds.

 

[jetproppilot]

I forgot to mention that I called a real MD, the OB on call, before I did anything. She agreed that the pt need antibx but her drug of choice was ancef. Now not knowing for sure the effects of antibx on the fetus I went with her recommendation. I realize that the ancef was a poor choice. That is why I stated it was a false sense of security. If I really thought it was a high risk procedure I would have pursued the best antibx.

So now you would ask, then why give anything at all? Well it was late, I got the OB attending on board and I knew that the pt was too scared of another infection to ask for an epidural. So I figured I'd leave well enough alone. I was right by the way. She delivered without another dose of stadol or any other pain meds.

Nice job, friend.

Patient did fine, and Morris Bart isnt calling your house.

Couldnt ask for a better outcome.