Urology has traditionally been a male-dominated occupation; however, in recent years there has been a gradual increase in the number of women entering the specialty. This change in the surgical demographic has resulted in an increased prevalence of pregnant urologists. A growing body of evidence from the US and UK suggests that surgeons are at increased risk of miscarriage and pregnancy-associated complications when compared to the general population. Despite this, there is a lack of clear and concise advice for pregnant urologists, and it can be difficult to access information regarding potential occupational risks during pregnancy. Navigating work-related issues during pregnancy is challenging and may be particularly so in the early stages when pregnancy is not yet common knowledge. In this article, we aim to highlight potential work-related risk factors for pregnancy-associated complications and suggest strategies to mitigate these risks.

General Working Conditions

Surgeons typically work long hours, experience high levels of fatigue, and operate sitting or standing for long periods. Working for more than 32 hours a week has been shown to be associated with an increased risk of intrauterine growth restriction and fetal death, and working with high activity for more than 40 hours a week has been associated with a reduction in birth weight of up to 350 g.¹ Fatigue and night shifts have been shown to be associated with an increased risk of miscarriage,² and night shifts have been linked to intrauterine growth restriction and preterm labor.^3,4 Avoiding fatigue and antisocial working can be difficult whilst working as a surgeon; each pregnant surgeon will need to weigh up the risks they are willing to take and the impact that avoiding these risks will have on their career and income. It may be worthwhile to discuss with employers the possibility of stopping nighttime working and reducing physical exertion in pregnancy. Large studies have demonstrated an increased risk of miscarriage with heavy lifting including transferring patients; therefore, manual handling should be avoided.⁵

Standing to operate for long periods results in venous stasis and pooling, which can lead to light-headedness and fainting. Pregnant surgeons are at greater risk of fainting due to hormonal changes, and, later in pregnancy, these problems can be exacerbated by mechanical compression of the vena cava by the uterus. Furthermore, standing for long periods can result in worsening of musculoskeletal issues caused by raised levels of progesterone and relaxin. Wearing supportive thromboembolic stockings and pelvic binders can help minimize these problems.

Radiation

The use of X-rays is a common concern among pregnant urologists—in particular, intraoperative fluoroscopic screening. The International Commission for Radiological Protection has recommended that in pregnancy, individuals should not be exposed to more than 1 mSv of radiation whilst at work. The US National Council on Radiation Protection and Measurements has recommended a less stringent limit of <5 mSv exposure throughout pregnancy and <0.5 mSv/mo. Exposure to 1 mSv or 5 mSv above background dose is estimated to increase the probability of a child being born with a congenital malformation or developing cancer from 4.07% to 4.078% and 4.12%, respectively.⁶ Some small studies suggest that radiation exposure levels during pregnancy are likely to be <1 mSv for urologists undertaking fluoroscopic screening procedures when measuring doses beneath lead aprons.^7,8 Furthermore, a review of 534 pregnant interventional radiologists, most of whom continued to practice whilst pregnant, demonstrated no difference in fetal outcomes from those of the general population.⁹ Thus, it is likely that, provided suitable radiation protection is worn, pregnant urologists are at low risk for adverse pregnancy-related outcomes due to radiation exposure. A standard 0.5 mm lead apron will block 99% of radiation, and maternal tissues will block a further 70%; lighter, nonlead gowns are available for those suffering from musculoskeletal pain. In addition, standing 2 m away from an image intensifier will reduce radiation exposure by a factor of 4. For reassurance and monitoring, radiology departments may be able to provide radiation dose monitors to wear under radiation protection gowns.

Teratogenic and Mutagenic Substances

Many medical substances have the potential to be teratogenic; this is of particular concern during the first trimester when rapid cell division and organogenesis occurs.¹⁰ It is prudent for pregnant urologists to research any substances that they come into frequent contact with. There is strong advice to avoid contact with crushed or broken 5α-reductase inhibitor tablets (finasteride, dutasteride), as these drugs can cause birth defects and abnormal development of external genitalia in male fetuses. Cytotoxic drugs, such a mitomycin, pose a potential risk,¹¹ and pregnant women are advised to avoid contact with these substances.¹²

Regular use of a povidone-iodine surgical scrub has been shown to raise maternal urine iodine secretions and alter thyroid hormone levels, and there is concern that iodine may be absorbed and affect the fetal thyroid^13,14; thus, scrubbing with chlorhexidine is advised during pregnancy and breastfeeding.

Anesthetic gases may be teratogenic; however, modern closed anesthetic systems have dramatically reduced the risk of inhalation of these gases in operating theaters. There is a potential risk of expired gas inhalation in recovery areas; minimizing time spent working in these settings should be considered.

Infectious Diseases

Infections of concern during pregnancy include varicella zoster, cytomegalovirus, viral hepatitis, HIV, parvovirus, toxoplasmosis, and listeria. Maternal infection with hepatitis B carries a 90% risk of transmission to the fetus, and therefore operations on those with hepatitis B should be avoided in pregnancy. Protection from bloodborne viruses should be part of standard practice for all surgeons; appropriate personal protective equipment should be used and recommended immunization schedules and hand hygiene protocols followed. Prophylactic treatment can be administered following HIV exposure; however, these drugs pose a potential risk to a developing fetus.

In summary, occupational risks related to pregnancy and surgery exist; however, many of these risks can be mitigated. Pregnant surgeons should feel empowered to advocate for changes in working arrangements and schedules to prioritize their own health and that of their unborn child. Providing a comfortable and safe working environment for pregnant urologists will facilitate optimal patient care and protect the health of the urology workforce.