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Exposure in Health Care: Pregnancy Outcome and Fertility. Marja-Liisa Lindbohm Finnish Institute of Occupational Health. Health care work: exposures. Chemicals: anesthetic gases, antineoplastic agents, sterilizing agents, solvents, mercury Radiation Biological agents Physical strain

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exposure in health care pregnancy outcome and fertility

Exposure in Health Care: Pregnancy Outcome and Fertility

Marja-Liisa Lindbohm

Finnish Institute of Occupational Health

health care work exposures
Health care work: exposures
  • Chemicals: anesthetic gases, antineoplastic agents, sterilizing agents, solvents, mercury
  • Radiation
  • Biological agents
  • Physical strain
  • Irregular working hours
reproductive effects of anesthetic gases
Reproductive effects of anesthetic gases
  • in several human studies exposure related to
    • spontaneous abortions
    • congenital malformations
    • reduced fertility in women
  • in some studies exposure related to
    • reduced birth weight
    • increased risk of small for gestational age
    • spontaneous abortion among the wives of exposed men and malformations in their offspring
anesthetic gases and spontaneous abortions a meta analysis boivin 1997
Anesthetic gases and spontaneous abortions: a meta-analysis (Boivin 1997)
  • 19 studies published in 1971 – 95
  • Relative risk 1.48 (95% CI 1.4 – 1.58)
  • Analysis limited to 6 most valid studies:

relative risk 1.9 (95% CI 1.72 – 2.09)

  • Conclusion: the available data suggest that a real risk may be present
a study of dental assistants exposed to nitrous oxide rowland et al 1992 1995
A study of dental assistants exposed to nitrous oxide (Rowland et al 1992, 1995)
  • 7000 dental assistants
  • Telephone interview, 69% responded
  • Reduced fertility in women exposed to 5 hours per week to unscavenged nitrous oxide
  • Increased risk of spontaneous abortion among women exposed  3 hours per week to unscavenged nitrous oxide
a study of midwives exposed to nitrous oxide ahlborg et al 1996 bodin et al 1999
A study of midwives exposed to nitrous oxide (Ahlborg et al 1996, Bodin et al 1999)
  • 3985 midwives
  • A mailed questionnaire, 84% responded
  • Reduced fertility in women assisting >30 deliveries/month (FR 0.63, 95%CI 0.43 – 0.94)
  • No increased risk of spontaneous abortion
  • Reduced birth weight (-77 gm, 95%CI –129, -24) and increased risk of infants being small for gestational age (OR 1.8, 95%CI 1.1 – 2.8)
enflurane etomidate fentanyl halothane isoflurane propofol sevoflurane thiopental
Enflurane, etomidate, fentanyl, halothane, isoflurane, propofol, sevoflurane, thiopental
  • Data limited and no human studies on the effects of occupational exposure to these agents
  • Halothane: increased frequency of developmental delay in some experimental studies, but not all, and behavioral abnormalities among the offspring
  • Enflurane and isoflurane evaluated: animal data show that no classification for toxic to reproduction is indicated
  • Thiopental: no increased risk of malformations in women treated during pregnancy
suggested new guidelines for concentrations of anesthetic gases during pregnancy in finland
Suggested new guidelines for concentrations of anesthetic gases during pregnancy in Finland
  • Nitrous oxide 10 ppm (TLV for all:100 ppm)
  • Halothane 0,1 ppm (TLV for all: 1 ppm)
  • Desflurane 10 ppm
  • Enflurane 10 ppm
  • Isoflurane 10 ppm
  • Sevoflurane 10 ppm
anesthetic gases exposure assessment
Anesthetic gases: exposure assessment

Exposure may be high in:

  • operating rooms with poor ventilation or no efficient scavenging equipment
  • delivery rooms
  • administration of anesthesia to small children in arms
  • veterinary operating rooms
  • dental offices
antineoplastic agents and reproductive health
Antineoplastic agents and reproductive health
  • increased risk of malformations and reduced probability of live births in treated patients
  • teratogenic in animal experiments
  • occupational exposure related to:
    • menstrual dysfunction
    • infertility
    • spontaneous abortions
    • congenital malformations
antineoplastic agents hazard assessment
Antineoplastic agents: hazard assessment
  • Exposure may be high in:
    • dilution and preparation of the solutions
    • cleaning of the preparation room
    • injection/infusion of the drugs
    • handling of the excreta of patients
  • Guideline: a pregnant worker should not do these jobs
ethylene oxide and adverse pregnancy outcome
Ethylene oxide and adverse pregnancy outcome
  • Used as a sterilant in hospitals, and in medical and dental offices
  • Mutagenic, teratogenic and carcinogenic agent
  • Increased risk of spontaneous abortion in exposed hospital sterilising staff and dental assistants
  • Increased risk of preterm and postterm birth
  • Exposure should be avoided
ionizing radiation and pregnancy outcome
Ionizing radiation and pregnancy outcome
  • High doses known to be harmful to reproductive health
  • Findings on the reproductive effects of occupational exposure are contradictory
    • increased risk of spontaneous abortion reported among veterinarians and radiology technicians
    • no excess of malformations or cancer in children of radiographers, but a slight increase of chromosomal anomalies other than Down
ionizing radiation exposure assessment
Ionizing radiation: exposure assessment
  • The protection of the fetus must be comparable with that provided to the members of the public
  • The equivalent dose of radiation should not exceed 1 mSv during the remainder of the pregnancy
  • Recommendation: a pregnant worker should not hold patients during x-ray or give regularly isotope treatment
non ionizing radiation and adverse pregnancy outcome
Non-ionizing radiation and adverse pregnancy outcome
  • Physiotherapists may be exposed to short-waves, microwaves and ultrasound
  • MRI technologists may be exposed to strong static magnetic fields
  • Evidence on their adverse reproductive effects is inconclusive
    • Increased risk of spontaneous abortion and low birth weight related to use of short-wave equipment
  • EU guideline: exposure to short waves should be minimised
references on exposures in health care and reproductive health
References on exposures in health care and reproductive health
  • Figà-Talamanca I. Reproductive problems among women health care workers: epidemiologic evidence and preventive strategies. Epidemiologic Reviews 2000;22:249-260.
  • Boivin J-F. Risk of spontaneous abortion in women occupationally exposed to anesthetic gases: a meta-analysis. Occup Environ Med 1997;54:541-548.
  • Ahlborg G, Hemminki K. Reproductive effects of chemical exposures in health professions. J Occup Environ Med 1995;37:957- 961.