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The pregnant surgical trainee: Current exposures and risk factors a review

      Highlights

      • Pregnant surgical trainees are subject to both social and environmental risks due to their occupation.
      • Environmental risks to surgical trainees include exposure to radiation, chemicals, communicable diseases, anesthetic gases, and long work hours.
      • Social risks that pregnant surgeons face include lack of mentorship, negative attitudes or microaggressions from colleagues, and inadequate parental leave.
      • Training programs as well as surgical employers have the responsibility to protect the wellbeing of their female surgeons who are pregnant or planning families.

      Abstract

      More women are choosing a career in surgery, many of whom plan to have children during their residency and fellowship training. However, women still face perceived physical and psychological barriers to childbearing during training. In this article we review the risks of surgical exposures such as bloodborne disease, radiation, bone cement, physical labor and fatigue, and emotional stressors for the pregnant resident. Cultural barriers for pregnant residents persist, including biased comments or resentment from colleagues or attendings. Parental leave policies are inconsistent among programs and specialties. This article is intended to empower female residents and program faculty to make informed decisions and policies to support trainees, encourage diversity, and keep surgical programs competitive among top applicants.

      Keywords

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      References

        • 2018 ACS Governors Survey
        Gender inequality and harassment remain a challenge in surgery.
        Bulletin. 2019; (Published September 1)
        • Keene R.R.
        • Hillard-Sembell D.C.
        • Robinson B.S.
        • Novicoff W.M.
        • Saleh K.J.
        Occupational hazards to the pregnant orthopaedic surgeon.
        J Bone Joint Surg Am. 2011; 93: e1411-1415https://doi.org/10.2106/JBJS.K.00061
        • Blair J.E.
        • Mayer A.P.
        • Caubet S.L.
        • Norby S.M.
        • O'Connor M.I.
        • Hayes S.N.
        Pregnancy and parental leave during graduate medical education.
        Acad Med J Assoc Am Med Coll. 2016; 91: 972-978https://doi.org/10.1097/ACM.0000000000001006
        • Hamilton A.R.
        • Tyson M.D.
        • Braga J.A.
        • Lerner L.B.
        Childbearing and pregnancy characteristics of female orthopaedic surgeons.
        J Bone Joint Surg Am. 2012; 94: e77https://doi.org/10.2106/JBJS.K.00707
        • Mulcahey M.K.
        • Nemeth C.
        • Trojan J.D.
        • OʼConnor M.I.
        The perception of pregnancy and parenthood among female orthopaedic surgery residents.
        J Am Acad Orthop Surg. 2019; 27: 527-532https://doi.org/10.5435/JAAOS-D-18-00216
        • Rose S.H.
        • Burkle C.M.
        • Elliott B.A.
        • Koenig L.F.
        The impact of parental leave on extending training and entering the board certification examination process: a specialty-based comparison.
        Mayo Clin Proc. 2006; 81: 1449-1453https://doi.org/10.4065/81.11.1449
      1. Statistics overview | statistics center | HIV/AIDS | CDC. Published June 8, 2020. Accessed October 14, 2020. https://www.cdc.gov/hiv/statistics/overview/index.html.

        • Quebbeman E.J.
        • Telford G.L.
        • Hubbard S.
        • et al.
        Risk of blood contamination and injury to operating room personnel.
        Ann Surg. 1991; 214: 614-620https://doi.org/10.1097/00000658-199111000-00012
        • Downes J.
        • Rauk P.N.
        • Vanheest A.E.
        Occupational hazards for pregnant or lactating women in the orthopaedic operating room.
        J Am Acad Orthop Surg. 2014; 22: 326-332https://doi.org/10.5435/JAAOS-22-05-326
        • Beasley R.P.
        • Hwang L.Y.
        • Lee G.C.
        • et al.
        Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B vaccine.
        Lancet Lond Engl. 1983; 2: 1099-1102https://doi.org/10.1016/s0140-6736(83)90624-4
        • Dionne-Odom J.
        • Tita A.T.N.
        • Silverman N.S.
        • Society for Maternal-Fetal Medicine (SMFM)
        #38: hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission.
        Am J Obstet Gynecol. 2016; 214: 6-14https://doi.org/10.1016/j.ajog.2015.09.100
        • Benova L.
        • Mohamoud Y.A.
        • Calvert C.
        • Abu-Raddad L.J.
        Vertical transmission of hepatitis C virus: systematic review and meta-analysis.
        Clin Infect Dis Off Publ Infect Dis Soc Am. 2014; 59: 765-773https://doi.org/10.1093/cid/ciu447
        • Zafirova Z.
        • Sheehan C.
        • Hosseinian L.
        Update on nitrous oxide and its use in anesthesia practice.
        Best Pract Res Clin Anaesthesiol. 2018; 32: 113-123https://doi.org/10.1016/j.bpa.2018.06.003
        • Özelsel T.J.-P.
        • Kim S.
        • Buro K.
        • Tsui B.
        Elevated Waste anaesthetic gas concentration in the paediatric post-anaesthesia care unit.
        Turk J Anaesthesiol Reanim. 2018; 46: 362-366https://doi.org/10.5152/TJAR.2018.35683
      2. Maran: Infertility among female hospital doctors in the UK - google Scholar. Accessed October 22, 2019. https://scholar.google.com/scholar_lookup?title=Infertility%20among%20female%20hospital%20doctors%20in%20the%20UK&author=NJ.%20Maran&author=RP.%20Knill-Jones&author=AA.%20Spence&journal=Br%20J%20Anaesth&volume=76&pages=581P-581P&publication_year=1996.

        • Chou L.B.
        • Cox C.A.
        • Tung J.J.
        • Harris A.H.S.
        • Brooks-Terrell D.
        • Sieh W.
        Prevalence of cancer in female orthopaedic surgeons in the United States.
        J Bone Joint Surg Am. 2010; 92: 240-244https://doi.org/10.2106/JBJS.H.01691
        • Fattibene P.
        • Mazzei F.
        • Nuccetelli C.
        • Risica S.
        Prenatal exposure to ionizing radiation: sources, effects and regulatory aspects.
        Acta Paediatr Oslo Nor 1992. 1999; 88: 693-702https://doi.org/10.1080/08035259950168919
        • Hamilton L.C.
        The lesser spotted pregnant surgeon.
        Ann R Coll Surg Engl. 2017; (Published online October 19): 1-4https://doi.org/10.1308/rcsann.2017.0177
        • Uzoigwe C.E.
        • Middleton R.G.
        Occupational radiation exposure and pregnancy in orthopaedics.
        J Bone Joint Surg Br. 2012; 94: 23-27https://doi.org/10.1302/0301-620X.94B1.27689
      3. Ionising radiation: dose comparisons. GOV.UK. Accessed June 3, 2020. https://www.gov.uk/government/publications/ionising-radiation-dose-comparisons/ionising-radiation-dose-comparisons..

        • Park M.S.
        • Lee K.M.
        • Lee B.
        • et al.
        Comparison of operator radiation exposure between C-arm and O-arm fluoroscopy for orthopaedic surgery.
        Radiat Protect Dosim. 2012; 148: 431-438https://doi.org/10.1093/rpd/ncr149
        • Farah K.
        • Coudert P.
        • Graillon T.
        • et al.
        Prospective comparative study in spine surgery between O-arm and airo systems: efficacy and radiation exposure.
        World Neurosurg. 2018; 118: e175-e184https://doi.org/10.1016/j.wneu.2018.06.148
        • Blattert T.R.
        • Fill U.A.
        • Kunz E.
        • Panzer W.
        • Weckbach A.
        • Regulla D.F.
        Skill dependence of radiation exposure for the orthopaedic surgeon during interlocking nailing of long-bone shaft fractures: a clinical study.
        Arch Orthop Trauma Surg. 2004; 124: 659-664https://doi.org/10.1007/s00402-004-0743-9
        • Malik A.T.
        • Rai H.H.
        • Lakdawala R.H.
        • Noordin S.
        Does surgeon experience influence the amount of radiation exposure during orthopedic procedures? A systematic review.
        Orthop Rev. 2019; 11https://doi.org/10.4081/or.2019.7667
        • Jones D.P.
        • Robertson P.A.
        • Lunt B.
        • Jackson S.A.
        Radiation exposure during fluoroscopically assisted pedicle screw insertion in the lumbar spine.
        Spine. 2000; 25: 1538-1541https://doi.org/10.1097/00007632-200006150-00013
        • Kirousis G.
        • Delis H.
        • Megas P.
        • Lambiris E.
        • Panayiotakis G.
        Dosimetry during intramedullary nailing of the tibia.
        Acta Orthop. 2009; 80: 568-572https://doi.org/10.3109/17453670903350057
        • Han B.
        • Shi Z.
        • Fu Y.
        • Ye Y.
        • Jing J.
        • Li J.
        Comparison of free-hand fluoroscopic guidance and electromagnetic navigation in distal locking of femoral intramedullary nails.
        Medicine (Baltim). 2017; 96e7450https://doi.org/10.1097/MD.0000000000007450
        • Cantlon M.B.
        • Ilyas A.M.
        Assessment of radiation protection in hand-shielding products with mini C-arm fluoroscopy.
        Handb Neuropsychol N. 2019; (Published online August 12,)1558944719865937https://doi.org/10.1177/1558944719865937
        • Britain Great
        • Health
        • Executive Safety
        Work with Ionising Radiation: Ionising Radiations Regulations 2017.
        2018
        • Linehan C.M.
        • Gioe T.J.
        Serum and breast milk levels of methylmethacrylate following surgeon exposure during arthroplasty.
        J Bone Joint Surg Am. 2006; 88: 1957-1961https://doi.org/10.2106/JBJS.F.00089
      4. Document display | NEPIS | US EPA. Accessed May 5, 2020. https://nepis.epa.gov/Exe/ZyNET.exe/P1006D1N.TXT?ZyActionD=ZyDocument&Client=EPA&Index=1995+Thru+1999&Docs=&Query=&Time=&EndTime=&SearchMethod=1&TocRestrict=n&Toc=&TocEntry=&QField=&QFieldYear=&QFieldMonth=&QFieldDay=&IntQFieldOp=0&ExtQFieldOp=0&XmlQuery=&File=D%3A%5Czyfiles%5CIndex%20Data%5C95thru99%5CTxt%5C00000025%5CP1006D1N.txt&User=ANONYMOUS&Password=anonymous&SortMethod=h%7C-&MaximumDocuments=1&FuzzyDegree=0&ImageQuality=r75g8/r75g8/x150y150g16/i425&Display=hpfr&DefSeekPage=x&SearchBack=ZyActionL&Back=ZyActionS&BackDesc=Results%20page&MaximumPages=1&ZyEntry=1&SeekPage=x&ZyPURL.

        • Singh A.R.
        • Lawrence W.H.
        • Autian J.
        Embryonic-fetal toxicity and teratogenic effects of a group of methacrylate esters in rats.
        J Dent Res. 1972; 51: 1632-1638https://doi.org/10.1177/00220345720510062201
        • Solomon H.M.
        • McLaughlin J.E.
        • Swenson R.E.
        • et al.
        Methyl methacrylate: inhalation developmental toxicity study in rats.
        Teratology. 1993; 48: 115-125https://doi.org/10.1002/tera.1420480205
        • McLaughlin R.E.
        • Reger S.I.
        • Barkalow J.A.
        • Allen M.S.
        • Dafazio C.A.
        Methylmethacrylate: a study of teratogenicity and fetal toxocity of the vapor in the mouse.
        J Bone Joint Surg Am. 1978; 60: 355-358
        • Schlegel U.J.
        • Sturm M.
        • Ewerbeck V.
        • Breusch S.J.
        Efficacy of vacuum bone cement mixing systems in reducing methylmethacrylate fume exposure: comparison of 7 different mixing devices and handmixing.
        Acta Orthop Scand. 2004; 75: 559-566https://doi.org/10.1080/00016470410001420
        • Darre E.
        • Hölmich P.
        • Jensen J.S.
        The use and handling of acrylic bone cement in Danish orthopaedic departments.
        Pharmacol Toxicol. 1993; 72: 332-335https://doi.org/10.1111/j.1600-0773.1993.tb01659.x
        • Cloft H.J.
        • Easton D.N.
        • Jensen M.E.
        • Kallmes D.F.
        • Dion J.E.
        Exposure of medical personnel to methylmethacrylate vapor during percutaneous vertebroplasty.
        AJNR Am J Neuroradiol. 1999; 20: 352-353
        • Waters T.R.
        • Dick R.B.
        Evidence of health risks associated with prolonged standing at work and intervention effectiveness.
        Rehabil Nurs Off J Assoc Rehabil Nurses. 2015; 40: 148-165https://doi.org/10.1002/rnj.166
        • Snijder C.A.
        • Brand T.
        • Jaddoe V.
        • et al.
        Physically demanding work, fetal growth and the risk of adverse birth outcomes. The Generation R Study.
        Occup Environ Med. 2012; 69: 543-550https://doi.org/10.1136/oemed-2011-100615
        • Hatch M.
        • Ji B.T.
        • Shu X.O.
        • Susser M.
        Do standing, lifting, climbing, or long hours of work during pregnancy have an effect on fetal growth?.
        Epidemiol Camb Mass. 1997; 8: 530-536https://doi.org/10.1097/00001648-199709000-00010
        • Croteau A.
        • Marcoux S.
        • Brisson C.
        Work activity in pregnancy, preventive measures, and the risk of preterm delivery.
        Am J Epidemiol. 2007; 166: 951-965https://doi.org/10.1093/aje/kwm171
        • Lee L.J.
        • Symanski E.
        • Lupo P.J.
        • et al.
        Role of maternal occupational physical activity and psychosocial stressors on adverse birth outcomes.
        Occup Environ Med. 2017; 74: 192-199https://doi.org/10.1136/oemed-2016-103715
        • Lereim P.
        • Rö J.
        Physical work performed by surgeons during orthopaedic operations.
        Acta Orthop Scand. 1975; 46: 31-37https://doi.org/10.3109/17453677508989189
        • Robinson G.E.
        Stresses on women physicians: consequences and coping techniques.
        Depress Anxiety. 2003; 17: 180-189https://doi.org/10.1002/da.10069
        • Phelan S.T.
        Sources of stress and support for the pregnant resident.
        Acad Med J Assoc Am Med Coll. 1992; 67: 408-410https://doi.org/10.1097/00001888-199206000-00014
        • Stack S.W.
        • Jagsi R.
        • Biermann J.S.
        • et al.
        Maternity leave in residency: a multicenter study of determinants and wellness outcomes.
        Acad Med J Assoc Am Med Coll. 2019; 94: 1738-1745https://doi.org/10.1097/ACM.0000000000002780
        • Chen M.M.
        • Yeo H.L.
        • Roman S.A.
        • Bell R.H.
        • Sosa J.A.
        Life events during surgical residency have different effects on women and men over time.
        Surgery. 2013; 154: 162-170https://doi.org/10.1016/j.surg.2013.03.014
      5. Finch SJ. Pregnancy during residency: a literature review. Acad Med J Assoc Am Med Coll. 2003;78(4):418-428. doi:10.1097/00001888-200304000-00021.

        • Mayer K.L.
        • Ho H.S.
        • Goodnight J.E.
        Childbearing and child care in surgery.
        Arch Surg Chic Ill 1960. 2001; 136: 649-655https://doi.org/10.1001/archsurg.136.6.649
        • Mohan H.
        • Ali O.
        • Gokani V.
        • et al.
        Surgical trainees' experience of pregnancy, maternity and paternity leave: a cross-sectional study.
        Postgrad Med. 2019; 95: 552-557https://doi.org/10.1136/postgradmedj-2018-135952
        • Walsh A.
        • Gold M.
        • Jensen P.
        • Jedrzkiewicz M.
        Motherhood during residency training: challenges and strategies.
        Can Fam Physician Med Fam Can. 2005; 51: 990-991
        • McMurray J.E.
        • Linzer M.
        • Konrad T.R.
        • Douglas J.
        • Shugerman R.
        • Nelson K.
        The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group.
        J Gen Intern Med. 2000; 15: 372-380
        • Wang H.
        • et al.
        The association between pregnancy and COVID-19: a systematic review and meta-analysis.
        Am J Emerg Med. 2022; 56: 188-195
        • Kingston E.V.
        High rates of stillbirth and preterm delivery in women with covid-19 and the efficacy of ECMO in pregnancy.
        BMJ. 2020; 370m2921
        • Schwartz D.A.
        Stillbirth after COVID-19 in unvaccinated mothers can result from SARS-CoV-placentitis, placental insufficiency, and hypoxic ischemic fetal demise, not direct fetal infection: potential role of maternal vaccination in pregnancy.
        Viruses. 2022; 14https://doi.org/10.3390/v14030458
        • Halasa N.
        • et al.
        Effectiveness of maternal vaccination with mRNA COVID-19 vaccine during pregnancy against COVID-19-associated hospitalization in infants aged <6 Months - 17 States, july 2021-january 2022.
        MMWR Morb Mortal Wkly Rep. 2022; 71 (Overcoming, C.-N.): 264-270https://doi.org/10.15585/mmwr.mm7107e3
        • Kugelman N.
        • et al.
        Maternal and neonatal SARS-CoV-2 immunoglobulin G antibody levels at delivery after receipt of the BNT162b2 messenger RNA COVID-19 vaccine during the second trimester of pregnancy.
        JAMA Pediatr. 2022; 176: 290-295https://doi.org/10.1001/jamapediatrics.2021.5683
        • Kassis
        • et al.
        COVID-19 mRNA vaccine in pregnancy and newborn passive immunization: a case report.
        Future Sci OA. 2022; 8FSO761https://doi.org/10.2144/fsoa-2021-0043