OB/GYN | Mount Sinai Today

Smiling for Two—The Importance of Oral Health in Prenatal Care

Updated on Jun 30, 2022 | BFWHRI, Dental and Oral Health, OB/GYN, Women's Health

Pregnancy is a special time in the life span to secure the oral health of mothers and their young children. Pregnant women often experience changes in oral health due to increased inflammatory response to dental plaque. Uncontrolled and untreated, inflammation in the gums and bones in the mouth (periodontal disease) can induce a systematic inflammation response, affecting the health of both mom and baby. Prior research suggests a potential association between periodontal disease in pregnant women and adverse birth outcomes. Additionally, pregnant women with untreated dental caries—tooth decay—can increase the risk of dental caries for young children by transferring caries-generating germs like Streptococcus mutans, from her mouth to the baby’s mouth. In young children, dental caries may require extensive treatment involving sedation or even general anesthesia if the child cannot tolerate chair-side procedures. The costs associated with such procedures often create major financial and psychosocial burden in families.

Oral Health is Prenatal Health

Preventive, diagnostic, and restorative dental procedures are safe throughout pregnancy and effective in improving and maintaining oral health. However, more than half of mothers do not receive periodic dental cleaning during pregnancy. Education, race/ethnicity, dental insurance, and household income have all been associated with the usage of dental services and oral health outcomes. Some women are misinformed that all dental treatments should be delayed after delivery, and sometimes they worry about potential adverse effects of routine dental care to the fetus. Given the importance of oral health during pregnancy for the health and well-being of mothers and their babies, the American College of Obstetricians and Gynecologists (ACOG) in 2013 stated that ‘women should routinely be counseled about the safety and importance of oral health care during pregnancy, and should be referred for dental care as would be the practice with referrals to any medical specialists.’ ACOG made it clear that oral health is an integral part of prenatal care. Healthcare providers from both medicine and dentistry acknowledge that preventive, diagnostic, and restorative dental treatment is safe throughout pregnancy and is effective in improving and maintaining oral health.

As a mother of a young child and pediatric dentist, I believe oral health knowledge among pregnant women is the key to securing the oral health of both women at childbearing age and their young children. In 2014, I was a pediatric dental resident at The Mount Sinai Hospital ; I was also pregnant. I had begun a prenatal oral health education program with prenatal coordinators in East Harlem and the Bronx that integrated oral health education and care coordination into CenteringPregnancy, their prenatal group oral health education model. Before I joined Mount Sinai in 2014, I was involved in the publication of the national oral health guidelines for pregnant women as a dental officer at the Department of Health and Human Services. Three years after this publication, I found that the majority of clinicians, both physicians and dentists, were not aware of these guidelines. Most of my pregnant friends in prenatal groups were told to go to the dentist after delivery, unless they had a dental emergency. I was surprised by the gap between science and practice and decided to investigate the root causes. Three levels of issues generated this gap: provider training, patient education, and practice coordination.

Bridging the Gap to Improve Prenatal Dental Care

First, dental providers, primary care providers, and administrative staff need to be trained based on the most updated guidelines to advance the oral health of expecting mothers and their babies. Pregnancy should not be a reason to avoid necessary dental care, but rather it needs to be seen as a teachable moment, empowering mothers to secure their oral health as well as their baby’s healthy smile. With the current national guidelines and published best practices, we can achieve this.

Secondly, we need to acknowledge that mothers, not the pediatric dentist, are often the primary care providers. They decide what to put in the bottle, which snacks to give, and how often to brush their child’s teeth. Because of this, pregnant women and mothers should be educated on the relationship between mother’s oral health and baby’s oral health and be encouraged to receive necessary dental care, and practice home oral hygiene activities along with a low-sugar diet.

Finally, we need to build a system that is meaningful and sensible to pregnant women and connect them to oral health care. Even if care providers know the importance of oral health and are willing to provide appropriate and necessary dental services and referrals, and even if pregnant women value oral health for themselves and their babies, low-income pregnant women may not be able to access dental services without system-level support. New York is one of the states that provides comprehensive dental care for pregnant women enrolled in Medicaid. However, how many of these low-income pregnant women actually know about this coverage? How many know how to find dental facilities who accept their insurance during pregnancy? These are the questions we need to consider. Coverage is important, but patients may need help in the interpretation and utilization of such coverage.

How COVID-19 Has Impacted Dental Care

Currently, we have a new challenge – dental care during and after the COVID-19 crisis. At the beginning of this outbreak, the New York Times published, “The Workers Who Face the Greatest Coronavirus Risk.” Dentists and dental hygienists were at the far-right corner of the graph were depicting that those in the profession have the most frequent exposure to COVID-19 and the closest proximity to others during their workdays. As dental settings have unique challenges that require specific infection control strategies, CDC published “Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response” to resume non-emergency dental care, which was on hold during the initial outbreak of COVID-19 by state order. It recommends balancing the need to provide necessary services while minimizing risk to patients and dental health care personnel.

Mount Sinai dental clinics have been serving patients with emergency dental cases during the pandemic, and we are in the process of providing routine dental care.

Although we face many challenges, this can be a time of opportunity as well. Dentistry has centered on a “drill-fill-bill” model, where definitive treatments are incentivized. However, as dentists work to minimize aerosol exposure while preventing oral health diseases, dental procedures that focus on disease management and prevention are on the spot. These procedures include silver diamine fluoride application to arrest dental caries and indirect pulp cap with Hall technique crowns—which may not require high-speed dental drills. There are also many efforts within the Mount Sinai Health System to integrate oral health into its existing primary care and prenatal care strategies.

Since 2019, the CenteringPregnancy programs at The Mount Sinai Hospital and the Mount Sinai Adolescent Health Center have embraced an interactive oral health education model where pregnant women are connected to Mount Sinai dental facilities if they do not have a dental provider. Mount Sinai OBGYN providers, pediatricians, and prenatal care nurses plan to integrate oral health education and care navigation into their existing care models. While we continue to provide our patients with excellent, up-to-date dental care, we are committed to focusing on these upstream approaches where the new norm for children’s oral health becomes no caries. Furthermore, this new norm will include the systems of care that value health as well as health care.

Hyewon Lee, DMD, MPH is a former U.S. Public Health Service officer at the Department of Health and Human Services, a member of the Blavatnik Family Women’s Health Research Institute and an Assistant Clinical Professor at the Department of Dentistry at The Mount Sinai Hospital. Her goal is to integrate oral health into primary and prenatal care to advance the oral health of mothers and young children.

COVID-19 and Cesarean Births

May 21, 2020 | COVID-19, OB/GYN, Your Health

Having a safe delivery is top of mind for all pregnant women and their partners. As hospitals and health care centers continue to address the COVID-19 pandemic, safety has become increasingly important, especially for those having a cesarean birth—a surgical delivery that generally requires a longer hospital stay than vaginal delivery. Angela Bianco, MD, Medical Director of Labor and Delivery for the Mount Sinai Health System, discusses the changes that have been implemented to ensure a safe delivery and post-operative recovery for cesarean birth patients and their newborns.

What extra precautions are taken to ensure patient safety during cesarean delivery and during their hospital stay?

Twenty four hours prior to scheduled deliveries, all women and their support persons are tested for COVID-19. Patients and visitors must wear a face covering while in the hospital. If needed, staff will provide a mask.

While all patients and staff are required to wear face coverings, knowledge of the patient’s COVID-19 status directs the use of appropriate protective equipment.

All health care workers have been trained in appropriate use of personal protective equipment to safeguard themselves and their patients. Additionally, we have separate teams that transport patients to and from the operating room if the patient is positive for COVID-19. Patients with the virus are placed on a separate floor rather than in our Post-operative Recovery Room. During the postpartum stay, they are assigned a single room to recover in to avoid spread.

All areas are continuously disinfected, including waiting rooms, patient rooms, and high-touch surfaces such as door knobs and kiosks. Patient rooms in particular receive a ceiling-to-floor cleaning between patients, which takes approximately two hours and includes several quality assurance checks.

Has the recovery stay been adjusted due to the virus?

Yes, we have recommended discharge on post-operative day two rather than post-operative day three. We made this recommendation to decrease the length of stay in order to reduce exposure to new mothers and their newborns in a hospital setting. If there is a need to be discharged later than post-operative day two, than the stay may be extended.

How are doctors keeping in touch with patients after discharge?

Post-discharge patients are called within the first week, typically three days following their release. Patients have a telehealth visit at two weeks, but this can also be an in- person appointment for those who require a site visit or who are unable to communicate with their physician via telehealth.

Since women are being discharged a day early, are there additional precautions that need to be taken once they go home?

Generally, no. When released, pregnant women and their partners are given the same discharge instructions for post-operative day two release as they would have been given for a day three release. Instructions include when to call for issues such as high blood pressure and headache or if patients have questions about wound care or breastfeeding.

How Mount Sinai is Keeping Patients Safe

COVID-19 and Pregnancy: Answers to Your Questions

May 12, 2020 | COVID-19, OB/GYN, Your Health

As the COVID-19 pandemic continues to impact all facets of life, many have raised questions about the virus’ effect on pregnancy and delivery. Brian Wagner, MD, Medical Director of Labor and Delivery at Mount Sinai West, gives advice to expectant parents and those trying to conceive, and explains how Mount Sinai is creating a safe birthing place for mother, baby, and the extended care team.

Is it safe to get pregnant during the COVID-19 pandemic?

It is unclear whether couples should delay attempts to get pregnant. If you become pregnant now and become sick with the coronavirus, infection would most likely happen during the early part of your pregnancy. Unfortunately, we have limited research on what this could mean, and important questions about an increase in miscarriages or birth defects remain unanswered. Current data suggests that pregnant women are not at any increased risk when compared to non-pregnant individuals. We would recommend you have a conversation with your OB/GYN about your personal medical and obstetric history to help decide if this is the best time to conceive.

How does having COVID-19 complicate pregnancy?

As this viral infection is new, data is limited and just emerging. However, the limited data that exists is reassuring as it indicates that there is no increase in miscarriage or birth defects. With severe disease, there appears to be an increased risk of preterm birth; however, many of these babies were delivered to improve maternal outcomes and were not the result of preterm labor. Additionally, there is no strong evidence that the virus can pass from mom to baby. More information on how COVID-19 may affect pregnancy will emerge as more women deliver.

Are COVID-19 symptoms more severe in pregnant women? Are the symptoms different? Are pregnant women more at risk of contracting COVID-19?

In general, respiratory infections, like the flu, have been thought to be more severe in pregnant women. However, current data suggests the symptoms of COVID-19 appear to be the same as in the non-pregnant population. Symptoms tend to appear between 2 to 14 days from exposure and the most common symptoms appear to be cough, shortness of breath, and fever. In addition, pregnant women also appear to have the same risk for disease severity as non-pregnant individuals. The majority of pregnant women have mild symptoms and recover completely.

Pregnancy itself does not seem to increase the risk of infection or severe reaction to the virus. Pregnant women who have conditions such as diabetes and hypertension may be at increased risk for severe illness, but at the same level as the general population with those conditions.

Are obstetrics appointments being spaced further apart and/or being done via telemedicine appointments?

COVID-19 has necessitated a number of changes in the practice of medicine, in obstetrics and prenatal care. This has included spacing out appointments and grouping components of prenatal care together, including vaccinations and diabetes screening, and utilizing telehealth. As a result, a number of visits are being performed through videoconferencing and telephone. Patients are being asked to self-monitor with blood pressure cuffs and fetal heart rate monitors. This ensures that prenatal care continues to offer all the benefits while reducing the risk of exposure that comes with being out in the community. Of course, some elements of care will continue to require a face-to-face visit, including ultrasound examinations of the fetus.

How do pregnant women stay healthy during this time?

It is recommended that pregnant women take the same precautions as the general public to reduce their risk of COVID-19 infection. We know that the virus spreads from person to person through a number of methods, including droplets created when someone sneezes or coughs, close personal contact, and touching one’s eyes, nose, or mouth before washing one’s hands.

Steps that can help reduce your risk of infection include:

Wash your hands with soap and water for at least 20 seconds or clean your hands with hand sanitizer that contains at least 60 percent alcohol
Avoid touching your face, eyes, nose, and mouth
Avoid people who are sick, and maintain a safe distance of six feet from other people
Wear a face cover when leaving your house or apartment

In addition, general tips to stay healthy in pregnancy include eating a healthy diet, and getting regular exercise and plenty of rest.

Is it safe to give birth in a hospital during the pandemic? What is Mount Sinai doing to keep it safe for women to give birth during this time?

A hospital or certified birth center is the safest place to have your baby. Even the most uncomplicated pregnancies can develop problems or complications with little warning during labor and delivery. Being in a hospital allows you and your baby to have access to all the necessary medical care if these problems arise.

Due to COVID-19, at Mount Sinai we are taking extra precautions to ensure that you, your newborn, and your care team are safe and well. This includes extra cleaning and disinfection protocols, and wearing masks at all times and personal protective equipment as necessary. To enhance safety, you and your support person will be required to wear personal protective equipment—including a mask, gloves, and gown. The Mount Sinai Health System is screening all pregnant patients and their support partners for fever and symptoms of COVID-19 prior to admission since we know some people can have the virus yet be asymptomatic. All admitted patients and their support partners also will be tested for COVID-19. This ensures all the correct protective measures can be in place as needed to protect yourself and your newborn.

How Mount Sinai is Keeping Patients Safe

How Should Pregnant People Protect Themselves From COVID-19?

Mar 26, 2020 | COVID-19, OB/GYN, Your Health

The rapidly changing health advisories surrounding COVID-19, the novel coronavirus causing a pandemic, can be confusing. While the elderly and those with severe respiratory illness have been highlighted as high risk populations, the question remains as to whether pregnant people are also at risk.

Frederick Friedman, Jr., MD, Associate Professor of Obstetrics, Gynecology and Reproductive Science, at the Icahn School of Medicine at Mount Sinai, explains what we know about COVID-19 and pregnancy and how pregnant people can protect themselves.

I am pregnant. Am I high risk for COVID-19?

We don’t have a lot of data about coronavirus and pregnancy. There were two studies released about 18 pregnant individuals from China. Sixteen delivered by caesarean section, all delivered at term, and none of the children was affected. As a result of that very small study, it appears that as long as mom is healthy, the baby is likely to be healthy.

As far as we know the coronavirus does not cause problems for the fetus in cases of pregnant women who are exposed in the first trimester. However, it’s important to remember that we do not have much data that will confirm this. That being said, the general philosophy is that once the baby is formed, any virus that might cause birth defects would not have that effect. Whether or not COVID-19 causes developmental problems similarly is not yet known. But, as is the case with prior coronavirus infections, it does not seem to have any damaging effect on the baby.

Unfortunately, there are not enough data to say with certainty what effect the virus has on pregnancy and similarly what effect pregnancy has on progression of the disease. Due to the immune system changes in pregnancy and based on historic data from other viral infections, pregnancy might make women more susceptible to infection. In addition, they might have a more serious response to the virus. However, I emphasize that this is conjecture at present.

Should I put off trying to conceive?

At present, there are no recommendations to delay conception efforts. However, it is important to understand that our knowledge base will continue to expand. Also, it is critical that if one’s partner is ill, safe distances be maintained to prevent spread of the virus; that might delay conception efforts.

What if I have a pre-existing condition? Should I be particularly worried?

Anything that poses a severe risk to the mother—that is if the mom has a severe response to the virus that—could have harmful effects on the entire pregnancy, not just the baby. Such illness would place the mother at risk for preterm labor.

COVID-19 seems to affect most severely those individuals who are over 60, especially those over 80, which would not involve most of our pregnant patients. However, anyone with underlying respiratory ailments or chronic cardiovascular disease, as well as those who are immunocompromised have been affected more severely.

Are there particular precautions I should take after delivery? What about when I return home?

As much as birth is a social event, it’s also one that involves a baby who has a very poorly developed immune system and is highly susceptible to any types of infections. Any individual that handles the newborn should be free of any evidence of upper respiratory tract infection. No coughing, no runny nose, no sneezing, no fever.

Presently, most hospitals have visitation limits to the labor and postpartum floors. Due to the changing nature of the virus, each hospital’s visitation policy is in flux. Be sure to confirm the policy at your birthing location beforehand.

Additionally, while breastfeeding is generally encouraged, mothers who are suspected of having COVID-19 should keep distance from the baby when not feeding. Allow other caregivers to care for the baby and wear a mask while breastfeeding. The good news is that there have been no severe cases of coronavirus in individuals under nine years of age. But, discretion is the better part of valor.

Ultimately, we don’t know with certainty that pregnant or postpartum women are at greater risk for contracting the virus or having a more severe infection. Should they contract it, as is the case with influenza, these women tend to have a much higher risk of serious disorders. I would recommend the same universal precautions: avoidance of individuals with evidence of respiratory ailments like coughing, sneezing, and a runny nose; careful hand washing with soap and water or hand sanitizer; and avoidance of large crowds. Social distancing is difficult for some individuals, but prudent given our current situation.

Is Asthma Worse When You’re Pregnant?

Updated on Jun 30, 2022 | Asthma, OB/GYN, Your Health

Pregnancy can be a difficult time for many women, but especially for those with the added burden of asthma.

Asthma, a chronic disease of the airways of the lungs, is one of the most common medical problems that occurs during pregnancy. Sonali Bose, MD, a pulmonologist at the Mount Sinai – National Jewish Health Respiratory Institute, explains how asthma can affect both the mother and child, and what you can do about it.

Why is my asthma worse when I am pregnant?
Asthma control during pregnancy can be unpredictable. Asthma may get worse during pregnancy because of the effects of hormonal changes associated with pregnancy. Some experts have proposed that changes in the hormone progesterone can have effects on the mother’s airways, such as influencing airway inflammation or its sensitivity, but the exact mechanisms are still unclear.

Another major reason that asthma may get worse during pregnancy is that many pregnant women tend to stop or decrease their asthma medications because they are worried about how these medications may affect their unborn child, which in turn may cause the mothers to have worse control of their asthma.

What are the symptoms of asthma during pregnancy?
Women with asthma may have variable symptoms over the course of their pregnancy. Women with poorly controlled asthma may have more severe respiratory symptoms, such as wheeze, chest tightness, or cough. Some women may be more likely to have an asthma attack, either during the pregnancy or even after delivery.

Is asthma dangerous during pregnancy?
Asthma is a serious disease for all patients, not just pregnant women. However, asthma control can get worse with pregnancy. The detrimental effects of asthma not only affect the mother, but we are increasingly discovering their serious effects on the health and development of the unborn child.

Women with uncontrolled asthma during pregnancy have been reported to have more complications, such as preeclampsia, pregnancy-induced hypertension, and preterm labor. Uncontrolled asthma during pregnancy may lead to poor growth of the fetus and low birth weight. But we need better research studies to improve our understanding of exactly how asthma during pregnancy affects both the mother and child.

Can asthma be transferred from mother to child?
Asthma does run in families. Children of mothers with uncontrolled asthma (for example, those who have had an asthma attack during pregnancy) may have a higher risk of developing asthma and other allergic diseases and chest infections, or have lower lung function during childhood.

How is asthma treated during pregnancy?
The goal for treating asthma during pregnancy is similar to that for patients who are not pregnant: focus on improving asthma control. Inhaled corticosteroids are still the main way of helping control asthma during pregnancy and are effective in treating airway inflammation and preventing an exacerbation. These inhalers appear to be safe in pregnancy, and any risks are thought to be outweighed by the benefits of achieving good asthma control.

However, if an exacerbation occurs, oral steroids may be needed to treat it. In addition, we advise that pregnant mothers try to avoid their known environmental triggers and follow universal precautions to avoid contracting a respiratory infection. It is important to optimize asthma control even before becoming pregnant, because it seems that women who have more severe asthma before getting pregnant may be more vulnerable to having problems during their pregnancy.

Make an appointment with Sonali Bose, MD

A Modern Approach to Reproduction and Fertility

Sep 28, 2015 | OB/GYN, Women's Health

By Alan B. Copperman, MD, Clinical Professor, Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Director, Division of Reproductive Endocrinology and Infertility, the Mount Sinai Hospital.

Many of us are surprised to hear how difficult it is for humans to conceive. In fact, the chance of getting pregnant during any given cycle is only one in five. As women age, however, the likelihood of conceiving a healthy pregnancy decreases. This is largely due to the age-related decline in ovarian function. When a woman is in her twenties nearly 90% of her eggs are normal, while by the time she is in her forties, nearly 90% of her eggs are chromosomally abnormal. Increased awareness of these data and new emerging treatment modalities are combining to combat the basic biological realities. (more…)

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