By Alison McCook

There are risks that accompany a career in surgery. For example, studies have shown that female surgeons have higher rates of infertility and pregnancy complications, and not just because surgeons tend to have babies later in life (JAMA Surg 2020;155[3]:243-249).

Female surgeons face various reproductive hazards present in all medical specialties, such as injuries from sharps or infections from patients, said Aleksandra SzczEsna, a sixth-year medical student at the Medical University of Warsaw, in Poland, who has studied this topic (Ginekol Pol 2019;90[8]:470-474). There’s also plain old stress, she told OR Management News: “Surgical specialties are inseparably linked to physical and emotional burden, which increases the risk of burnout and threatens mental well-being.”

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Unfortunately, the OR is home to several other potential reproductive hazards. Some, such as radiation and strenuous working conditions, are likely well known. However, others may be less familiar, like the hyperthermic intraperitoneal chemotherapy used in peritoneal carcinomatosis, and methyl methacrylate, a form of acrylic resin that’s commonly used in orthopedic surgeries.

Most of the data linking these OR exposures to pregnancy outcomes are retrospective, making it hard to draw conclusions about dose-response relationships with reproductive health, said Rose H. Goldman, MD, MPH, an associate professor of environmental health at the Harvard T.H. Chan School of Public Health, and an occupational health physician at the Cambridge Health Alliance, both in Massachusetts. Barring pregnant surgeons from the OR isn’t fair, either, she added.

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Rose H. Goldman, MD, MPH

The best way forward, Dr. Goldman said, is to limit exposures to the extent possible, and at a minimum, following guidelines from regulatory agencies, so it’s safer for women—and men—to operate during their reproductive years. “We need to not stigmatize female surgeons about it, and begin to look at the evidence and have a dialogue and some rational decision making. And look at our operating rooms and see how we can better control some exposures.”

Here is a list of some reproductive risks present in the OR, and suggestions for how to mitigate them.


Working Conditions

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What’s the risk: In some studies, working more than 40 hours per week has been linked to increased risk for preterm delivery and miscarriage; night shifts are associated with preterm delivery and miscarriage.

How to mitigate: Educate physicians about the potential risks and provide alternative conditions that aren’t unfairly restrictive.

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Radiation

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What’s the risk: Studies report a higher risk for fetal death (estimated threshold dose, 50-100 mGy), congenital abnormalities and growth restriction (estimated threshold dose, 200-250 mGy), cognitive effects with microcephaly (estimated threshold dose, 60-310 mGy), and childhood cancer (likely minimal risk at <10-20 mGy). These exposures are much higher than are found in the OR, Dr. Goldman said.

How to mitigate: Keep exposure as low as possible, mandate use of protective gear and maintain distance from the radiation source. Women who are pregnant should wear fetal dosimeters under their protective gowns near their abdomen, and have access to counseling by a qualified expert.


Surgical Smoke

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What’s the risk: Although much of the research on surgical smoke focuses on its components and does not focus on physicians, experts are getting a better picture of its potential health risks to providers. Studies of reproductive risk have associated particulate matter with low birth weight and preterm labor; toluene with congenital defects, cognitive problems and infertility; benzene with childhood leukemia; and 1,2-dichloroethane with miscarriage and infertility.

How to mitigate: Use a ventilation system, employ smoke activators with adequate capture velocity (31-46 m per minute), cut back on surgical smoke as much as possible, and use a high-filtration mask for standard procedures and an N95 mask in the presence of aerosols.

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Waste Anesthetic Gases

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What’s the risk: There is a potential for miscarriage, congenital abnormalities and infertility.

How to mitigate: Follow recommendations of the U.S. Occupational Safety and Health Administration, use ventilation and anesthetic gas–scavenging systems, maintain equipment, avoid high flow rates and other high-waste techniques, and monitor breathing zone atmospheric gas levels.


Hyperthermic Intraperitoneal Chemotherapy

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What’s the risk: Studies of occupational exposure to chemotherapy have shown increased risks for miscarriage, low birth weight, congenital abnormalities and infertility.

How to mitigate: Inform physicians who are pregnant or trying to conceive that current recommendations advise not participating in HIPEC administration, train them on proper use and handling of antineoplastic agents, and any physician in direct contact with HIPEC should use triple gloves and change them every 30 minutes.

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Methyl Methacrylate

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What’s the risk: High exposures in animals are linked to skeletal abnormalities and growth restriction.

How to mitigate: Install laminar flow ventilation, use surgical hooded helmets, and use vacuum cement mixing systems and local suction during preparation.


Female surgeons can take on less physically demanding activities during pregnancy without interrupting their career goals, said Joanna Kacperczyk-Bartnik, MD, an obstetrics and gynecology resident at the Medical University of Warsaw, in Poland. (One example, Ms. SzczEsna said, would be avoiding the night shift, either in person or on call.) “More emphasis on the scientific work, attendance at theoretical courses, training in nonsurgical wards, gaining skills essential in the diagnostic process and follow-up care are the examples of much safer options within the residency curriculum than the OR,” Dr. Kacperczyk-Bartnik said.

Although the data focus on female reproductive issues, men need to be aware of the risks and advocate for change, Dr. Goldman said. It’s very possible that some of the risks to female reproduction also affect men, so limiting exposures is “going to be good for everybody,” she said, “because there are the risks we know, and the risks we don’t know. But when we control exposures, we basically control unknown risks, as well.”


Source for all: (JAMA Surg 2020;155[3]:243-249)