Wednesday, May 11, 2011

Pregnant in the cath lab

There is no harm in being protective of your unborn child. There is no harm in speaking up for yourself when you have strong feelings about any subject. For heaven sakes we are in a healing profession- we should take care of one another too. We should make a pact- all MiM and MiM followers to steadfastly protect and promote the (physical and mental) well being of our gravid counterparts.

There is potential harm in overstating the risk of x-ray in pregnancy. At least from my perspective. Sorry for additional post Fizzy, I have too much to say for comment section. I really think you are on to something here, and I appreciate this discussion.

First to get this out of the way, there is a major difference between therapeutic (or diagnostic) radiation exposure vs. occupational radiation exposure. All physicians would consider using x-rays to examine or treat a pregnant woman. As long as the benefit outweighs the risk. Do you need dental xrays while pregnant- probably not. You have a serious condition during pregnancy, attempts will be made to use alternative imaging or minimize fetal exposure. The risk to the fetus is based on amount of exposure (may vary based on type of exam) and week of pregnancy. It would be a mistake to x-ray a pregnant woman without considering the fetus (therefore the questions and signs in radiology). Just because there are signs and attempts made to avoid exposure in no way means that it is absolutely contraindicated.

Here as Mothers in Medicine we are discussing occupational exposure. A classic intersection of personal responsibility and professional obligation with undercurrents of gender discrimination. We would all take a bullet (literally) for our children, our own safety/sanity is only a secondary concern. What are we willing to expose our children to- now that is a hot topic.

Fifty percent of Internal Medicine residents are women, yet only 14% of all cardiology fellows and a mere 7% of practicing cardiologists are women. We may be few, but as women in cardiology we are a serious bunch- and are concerned about why more women do not consider careers in cardiology. It is likely women are deciding not to pursue cardiology early- as med students or interns. Concern over lifestyle and radiation exposure during mothering years is likely a key issue.

Tackling the subject head on, two important papers are published in cardiology journals. The first published in JACC in 1998 (http://www.ncbi.nlm.nih.gov/pubmed/9525565) is a consensus statement for radiation safety in the cath lab. This year another consensus statement (http://www.ncbi.nlm.nih.gov/pubmed/21061249 ) was published by a group of women interventional cardiologists (now these are women who I seriously admire). I recommend that you read both if this issue affects you directly.

Here are important points I would like to make:
1. Fizzy's initial post upset me a great deal, it felt like a personal attack (unreasonable I know). I think this points to how intimate and heart wrenching pregnancy related issues can be.

2. Fundamental radiation science: exposure is proportional to energy emitted, inverse to distance from source, and subtracted by protective equipment. When pregnant I wore two layers of lead (my usual apron) in my first trimester then special pregnancy apron (even though it weighed 12 lbs-or maybe a TON) the rest of the time. I never let the fellows control the fluoro pedal and when able always took an extra step away from the camera. On occasion I took it as an excuse to stay far far away from the table, on a stool in the corner where I could rest my feet too, a bonus.

3. When I was a fellow one of my female attendings was pregnant. It really helped me to see her in this role. She gave me the best advice. Meet with the University Radiation Officer- this really helped to balance my fears with what is known about the risk.

4. The female fellows in my current program are not allowed to work in the cath lab during pregnancy. This takes the decision making away from them. I am not 100% behind this, only because it is really hard for them to find coverage for maternity leave already.

5. X ray is not the only source of radiation exposure. I learned from the Radiation Officer that my greatest risk would be during my nuclear cardiology rotation. Patients dosed with isotope emit radiation, and despite high standards areas of radiation can be present in the department. Always wear your badge when reading nucs, do not leave your lunch in the reading room and for heaven sakes do not do injections for stress tests or PETs.

6. The total amount of radiation allowed in pregnancy is 0.5 mSv per month and 5 mSv for entire pregnancy. This is 10% of the amount of radiation defined as negligible by ACOG guidelines (Obstet Gynecol 2004;104:647–651 ). Studies from diagnostic radiology in pregnancy show exposure below 50 mSv is not associated with fetal loss or anomaly. Other population studies suggest that exposure to 100% of the allowed radiation during pregnancy will increase the risk of having a child with congenital anomaly from 4.0% to 4.01%. The chance your child will develop cancer will increase from 0.07% to 0.11%.

7. It is difficult for me to compartmentalize my role as mother and cardiologist. It all runs together in an overwhelming way. Eight weeks pregnant, while taking progesterone for a fetus at risk I was inches away from the camera while doing CPR on a woman while my partner inserted a temporary pacemaker. I had lead on, but had not yet declared my pregnancy and did not yet have a fetal badge. That woman celebrated Mother's Day with her children last weekend. During my 2nd trimester I was exposed to acute viral myocarditis, amazingly 3 times where two of the three patients were killed. Suspected viruses can cause fetal hydrops. The surviving patient was a miracle and my ability to cure him was instrumental. My team knew I had ID consultation and special tests by Employee Health. They did not know I took a "time out" in the call room where I sobbed uncontrollably for 20 minutes.

I carried two pregnancies and worked in the cath lab both times. I checked my fetal badge religiously every month. Under my lead, over 18 months of pregnancy my fetal badge (s) summed total radiation exposure of <0.01 mSv, below the measurable limit, ZERO.

It is probable that women avoid their true calling into cardiology due to concern over the occupational hazard. It is possible those who do pursue cardiology still face additional obstacles based on current maternity policies (I think this is true of most of medicine). My experiences thus far have been challenging, and I hope we can make things better for the next generation.

Okay so you may now jump in to discuss. So let me have it, I imagine being crucified and accused of child endangerment. For the sake of full disclosure in addition to exposing both of my boys to radiation I also ate lunch meat, non-pasteurized cheese and even drank a glass of wine (or two) during my 3rd trimester. And if anyone corrects my writing/ grammar I will kick your ass.

29 comments:

  1. I am really glad that you wrote this post. I wanted to write more in my comment on Fizzy's post but ended up cutting a lot out. You said pretty much everything I wanted to say. I am certainly not going to crucify you, JC. You did your research, assessed the risk and made a decision that worked for you.

    I read an article a while back that said that more than 50% of pregnant women are seriously worried that something is wrong with their baby, which comes across to me as very sad. My hope would be that pregnancy is a joyful time, not one full of stress, fear and anxiety.

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  2. Thank you for this. I am glad you have provided this perspective for all the young women out there looking to go into cardiology or any other field who also want families. I have of late been concerned about the amount of negativity about med school, residency and pregnancy during these times I see coming through on this blog. This negativity is mainly in Fizzy's posts.

    I think this blog should be realistic, but at the same time should convey a sense of optimism and possibility for women as they embark on their careers. I had a good experience being pregnant in medical school and then again 3rd year residency and I want women to know that it IS possible.

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  3. Thanks for the well-written, informative post. I will say, though, that the thought of radiation never crossed my mind when deciding not to do cardiology. (I'm a general internist 2 years out of residency.) Maybe lifestyle played into my thinking, but more likely it was the 6 months of cards/CCU time in residency that turned me away.

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  4. I spent the summer between M1 and M2 with an ID doc who saw very sick HIV patients at a free clinic. I was also 14-22 weeks pregnant at the time. I spent the summer mildly terrified I would contract a virus or infection from them that wouldn't normally be prolific in a patient population (but is due to their HIV status). My ID doc was somewhat protective - I did not see patients who were incredibly ill and had known counts below 50. I was still terrified, because as a rising M2 - I just didn't know what I didn't know, and everything scared me.

    Thank you for your post - I think it cross specialties...I couldn't help but wonder how this would work if I were an ID doc and encountered extremely ill, full-blown AIDS patients with possibly transmissable viruses to my next unborn.

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  5. I do wonder how it would work if you got a needlestick injury while doing a procedure on a patient with HIV and a high viral load. Anybody know? I'm assuming you'd still get post exposure prophylaxis....

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  6. Nope,no accusations from me. Like any reasonable woman committed to her career in medicine, you balanced risk with the responsibilities and did your best. Brava.

    I worry about discouraging women from doing specialties because "they will be hard in motherhood." Doesn't this create a prejudice of low expectations and perpetuate myths about ability? I think that if you love what you do, you will do that job better and other aspects of your life will benefit from your fulfillment. If cardiology is what floats your boat, do it. Will you have to make adjustments and compromises, absolutely. but I think it would be harder to justify the time committments, stress etc of a field if you did not enjoy the day to day. Your actual period of childbearing will be overall short compared to the length of your career(demands of motherhood are another question entirely). What is helpful is creating a community of support: attendings, fellow residents, etc to provide guidance and help when you need it. Helping each other out is critical.

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  7. Let you have it? I think it was an awesome post.

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  8. I think it is important to balance conveying optimism about being a MiM with not sugarcoating the undeniable hardship that it is. It is important to not minimize that there is a significant amount of anxiety & stress involved for many of us. If none of that ever bothered the OP, hats off to you, but we're not all like that.

    Personally, I came within inches of quitting my residency when my daughter was 11 months old and STILL waking me up every two hours. Am I eternally grateful that I didn't, now that I enjoy the good life as an attending? Yes. But that doesn't mean it never happened and it is ok to talk about it and get some support from sympathetic others.

    Oh, and concerning radiation: I worked with it every day during my pregnancy, and did lots of cardiac injections. My dosimeter never showed above background. I am pretty sure that the reason for that is because I knew exactly what I was doing, how radiation works, and how you minimize absorbed dose to your body.

    Still, I understand that if you're on a rotaition during your pregnancy and don't routinely work with radiation, it causes major anxiety to pregnant women. I would always respect that. I think there is nothing to it to help out, even if I do think it is not based on concrete risk, but on irrational fear. Who cares? It's hard enough to be pregant IMO, so I'll go easy on the colleagues who are.

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  9. I got a non-hollow needle poke from a Hep-C positive man with unknown HIV status. I finished the case in record time and pagIng both HIV specialist and my OB, I decided to take the prophylaxis. Thankfully the pt was neg for HIV and I did not contract hepititus.

    Radiation exposure (I'm an orthopedic fracture surgeon) and exposure to blood and tissue did not enter my mind when choosing a specialty. I admit, it enters my mind now when I see my beautiful, healthy son.

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  10. JC: I'm sorry you took that initial post as a personal attack (b/c of the radiation part? not sure). The reason I made the second post was because I felt like none of this is a clear-cut issue and I was curious what other people thought. I talked to my own father about it and he said to me, "Well, I'm sure it would have been OK, it's so little radiation." Like you said, pregnancy is emotional... I once started crying because I forgot and ate some cold cuts. I mean, how crazy is that? (And also, a colleague told me that I was putting my baby in danger by wearing my pager on my belt.)

    I very much doubt that having stepped in for that X-ray would have put my baby in any danger. I guess it just seemed so simple/fast/easy for the attending to step in to help me and was kind of miffed that she refused. I think I said in my second post that the only thing they were able to prove for sure is that radiation is a source of anxiety for pregnant women. And we're already exhausted, stressed, lots of hormones, etc.

    Personally, I'm not a big fan of radiation exposure in general, even with protection. After my pregnancy, I was always willing to go into the fluoro lab during residency, but I was nervous about making it into a career. But that still, I think, makes me less neurotic than my mother, who will not speak to me if I'm on my cell phone.

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  11. The conversation between fizzy and JC is important not just because of the radiation question, but because of risks in medicine in general. And then, when pregnant, we all tend to worry a little bit too much.
    I was doing ID at a university hospital during my pregnancies - the SBE and post-op unusual infections are fine - but we also dealt with the famous swine flu epidemic at that time and the first cases of Legionella. If you have seen any historical pictures, we looked like the alien squad from the movie ET. Then there was acute/febrile generalized CMV, unexpected in a healthy 50 year old. And the pregnant varicella pneumonia patient who almost died and caused me a few minutes panic until I realized - I had the disease at age 7 or 8, I'm immune.
    During my residency in a large city hospital, one male surgery resident was stabbed almost fatally by a patient and after I left a female pathologist there was killed by strangling.
    So, in any of the specialties, we have to be aware of the risks, and try to be knowledgeable about the relative risk and actual absolute risk and preventive measures. But I'm afraid that once pregnant physicians start to ask too frequently for special accommodations, we'll find that some of the best training programs and some of the best jobs will be off limits. Overt discrimination will not be tolerated of course, but there will always be some other reason not to accept a potentially pregnant candidate for the position.

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  12. JC, I really appreciate your post, specifically the research. I found out I was pregnant just before starting a vascular rotation. I had planned to spend a significant amount of time in the interventional suite since I have an interest in vascular surgery, but instead elected not to. I went to my GME office, the occupational health office, the hospital safety officer, pub med, OR nurses and the interventional radiology department to try to find out information/protocols about protecting myself from radiation exposure. No one could answer my questions. My OB just told me to try and minimize exposure and no one at the hospital seemed to know how to get me a fetal badge. Finally, someone suggested talking to someone in the cardiology department, but by that time I had given up and was soon heading to the lab. The experience turned me off a little to vascular surgery as a possible career because I couldn't find a way to quantify this risk (and we have no female vascular surgeons at my institution). Thank you for helping shed some light on this.

    I think the fear would be significant lower if there were better protocols established for health professionals in this situation. When I started in the lab, I was assigned a safety officer who came to assess my workplace and gave me a personalized detailed plan to minimize radiation and chemical exposures. Because of this I was able to comfortably do my job without unnecessary fear.

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  13. JC: excellent article, very objective and based on good and proven scientific evidence. I worked 12-14 hr long days in the cath lab for almost all of my pregnancy and even though my instituition had not followed the standard policy in place to protect the unborn fetus,(now my beautiful healthy son); once I presented the evidence to them (from the NRC published guidelines in place) they gladly adopted it. Fizzy's post made no contribution to educate members on more important issues that face us in medicine (like advocating for the enforcement of afore mentioned guidelines), instead her post clouded the issue of radiation with emotional decisions made during her training( its her perogative to do so though, but by no means a way to look at medical training). Women are maligned enough in medicine as it is, to introduce a concept that we need protection from all variables while pregnant will do nothing to advance our individual or collective career goals and objectives nor allow us to be treated as equals with men in medicine. There are a lot of potential risks to doctors wether it is in blood draws, attacks from patients, viral illnesses or occupational risks to us or to our ability to procreate that if we focused on, we would be completely paralysed and unable to end up in ANY specialty (and this is irrespective of sex). Just as our soldiers and cops accept a level of risk that comes with their jobs, the very call to practice medicine involves risks, to ourselves, families and careers...thankfully most of us go on to have long, bright and succesful careers, while mothering bright, healthy and successful children.
    Again thanks JC for putting this issue in perspective and avoiding the hype

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  14. I can't imagine why anyone would criticize this piece. A fantastic, level-headed, evidence- and experience-based post. One of the best things I've read on MiM in a while!!

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  15. Ladies do not be too hard on Fizzy. I love reading her posts and occasional feisty commentary. I feel like we achieved a real moment here, this would not have been possible without her courage to share her feelings and recollections from pregnancy.

    Thank you all for the support and encouragement- while I am on a high let me share one more thing:

    My levelheadedness about this issue evolved. True to Darwin my CPR close to the camera without a fetal badge shocked the ecosystem, so to say. At the time I was conflicted over disclosing my pregnancy- with potential for miscarriage. With new clarity the next morning I submitted my fetal declaration form and boldly moved forward.

    I hope we remember that it is okay to not have it all figured out. It is also okay to make a misstep, or swing wildly from the left then the right of your favored middle place. I imagine certain truths come naturally to some, and others require a little more... let's say evidence. And I am not talking about radiation anymore.

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  16. Cardiomom: You're right... the purpose of my second post was NOT to educate, because radiation and pregnancy is not something I know a lot about. I was simply sharing an experience I had and how it made me feel. Believe it or not, I don't do a pubmed search prior to my posts. I was trying to elicit opinions from others, which is why my entire last paragraph was questions to the readers. I don't claim to know a lot about the topic and it's not something I looked into much, since my own exposure was so minimal. I sincerely appreciate JC, who clearly does know a lot about the topic, taking the time to educate us.

    I can say that pregnancy is an emotional time for most women and I don't think it's unreasonable to avoid certain things, if possible, that are going to drive you crazy with worry. I didn't advocate that my pain specialist friend quit her job while pregnant. But if it's a matter of a single (and pointless) exposure to something that's going to make you anxious, why not avoid it?

    And I'm sorry that some people feel that I only share negative experiences about medicine. First, it's not entirely true... although people seem to take more notice of the negative posts. Second, a lot of people do have negative experiences during their training. It's a fact. A childhood friend of mine made a suicide attempt during internship and that's something I will never be able to forget. Honestly, aside from internship, I don't think my training was even that bad (I actually enjoyed a lot of it and had some wonderful attendings and colleagues, for the most part), but I write about the bad things that happen so that people having a hard time can relate. I wish I realized that other people were unhappy when I was an intern, instead of only finding out about it much later. I felt very alone at the time.

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  17. Kind of sad, that CardioMom denies hard working pregnant physicians their right for sympathy. I view this blog as support, and reflection on our incredible journeys in motherhood and medicine.I have little doubt that cardimom and many in general public would have much more sympathy for stay at home mom's blog site where moms would complain about boredom, routine or super-diffiuclt tasks they manage at home, and yet are so deprived of more challenging (work) experiences. Guess what most of us manage all that AND our work. Yet phsycian woman have no right to be weak, emotional, struggling, doubting, or they will be blamed for being unfit for profession (you knew what you were getting into !). Fizzy's posts helped me personally to realize I was not alone in my training, but I did feel isolated like her, mostly afraid to ever admit to anybody it was very diffuclt to work full time while newborn was awake every 2 hours. Fizzy's post is a reflection on the past, and it helps some of us to affirm and validate our exepriences too."Advocating for guidelines" will not happen if many women doctors feel its OK to work 120 h/week, radiate yourself, have your waters break at work, ask for help, etc. My fellow trainnee for instance passed out while pregnant doing rounds. Trust me, CardioMom, our cops and troups have more protection/med coverage/disability benefits than any of us will ever dream of. They give service to society but society protects them in need.

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  18. Excellent post, JC. I didn't consider cardiology either, but radiation exposure did not factor into the equation for me. It was more of a personal preference.

    In my own specialty, I didn't have to worry about the hazards of radiation, but I did worry about infection exposure. I stayed out of the room when the brain saw was going during autopsies and let organs from HIV and Hep C patients fix in formalin according to the guidelines of my most conservative attending, who lost a neuropathology mentor to HIV/AIDS that he contracted from a brain during autopsy.

    I also turfed fetal autopsies - largely for emotional reasons, which I think are important to respond and attend to, as much as I encourage science-based decision making. My male and female colleagues were more than happy to trade more complex surgical specimens, such as whipples, for them, and I didn't have to eviscerate organs from pre-term IUFD babies and compare them to my own unborn children, something for which I am eternally grateful.

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  19. I feel a need to make another comment here, since I'm getting kind of trolled on my last post. Unfortunately, a lot of the comments here got deleted.

    JC: I actually had no clue how much radiation cardiologists got exposed to until I read your post. Probably the biggest reason most women I know shied away from cards is because of the lifestyle. After all, there are a lot of female radiologists.

    I also think it is great that JC provided research about radiation exposure during pregnancy, but at the same time, it bothers me that some people seem to be contorting her words to say that women who want to avoid radiation during pregnancy are "irrational and overly emotional." I think it is very "rational" to want to avoid something that your doctor and society as a whole tells you to avoid. Is it *correct*? Well, that's a whole different argument. In the future, maybe there will be a definitive study and we won't have checkboxes on X-ray forms for pregnancy. But right now, as physicians, we all know that there's a hesitation we have in sending pregnant patients for X-rays, etc. Until that changes, pregnant women do have a "rational" reason for wanting to avoid radiation.

    JC looked up the data and made the decision that she didn't want to miss out on an important part of her training by avoiding radiation. I totally respect that decision. But at the same time, I think we should also respect the decision of pregnant women who want to try to minimize their exposure to radiation, especially in the case where it's rare exposures that add absolutely nothing to the educational process. In my case, it wasn't as if I wanted to get out of a rotation or even one clinic--it was 10 minutes of scutwork that would have taught me nothing.

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  20. It is not wrong to ask for help when you are pregnant. But why would it be a low expectation if if you hear about hardships of certain specialties. Isn't being a doctor a great achievement already? Some women are fantastic and want to be on the front lines in OR, those who can really handle it would not abandon their dreams.But women in doubt should know being a family practice physician does not make them loosers.

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  21. Thanks for the post. As someone who recently waded through the decision of which medical/surgical career to pursue, I wouldn't agree that radiation exposure plays into the decision of whether or not to pursue cardiology. Lifestyle, sure, but for so many students or residents, it's just not what piques our interest. And for some, an internal medicine residency isn't a prerequisite worth enduring (a lot of call, difficult inpatients, etc.). I feel fortunate that the specialty I chose excites me the most intellectually, but is also reasonable for those with families.

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  22. Anon@ 12:10-What I meant about low expectations is that we want to be able to do the specialties we choese. If there is a stigma associated with pregnancy in the minds of people chosing candidates for specialities, then women "might" become limited in what they get chosen to do. They have every right to choose which ever specialty but I would shy away from language indicating that women should avoid "tough" specialties because it will be hard during pregnancy. Choose what stimulates you, what fits your personality, what works for your life circumstance and then adjust what you need to do if you get pregnant. That is why I love JC's blog. She did what she had to do after she assessed the risks. Was it easy? of course not.

    We have had many blogs here about loving what you do. If I did not love what I did in my niche, I would not be able to justify the time away from my kids. If I had chosen something else for the lifestyle, I do not know if I would have been so content. I would not want those choices taken away from me because they are "hard."

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  23. thanks for the Great post. I'm a doc, and pregnant with my third, and had two hot dogs for dinner.

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  24. Hi JC, I just wanted to applaud you for the hard work you put in as a pregnant cards fellow. My husband is a cardiology fellow and told me about one of his colleagues, who will in fact be one of those crazy interventional people, double-leading through her pregnancy. It reminds me of Ginger Rogers doing everything Fred Astaire did, except backwards and in high heels. Good for you :)

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  25. As a woman and a cardiology fellow, I'd like to weigh in.

    In my program, decision taking is also taken away from the women. Pregant women, nurses, techs and fellows alike (there are no female attendings) are immediately banned from the lab. I personally do not support this policy. I looked up the data and felt safe.

    So when I became pregnant some time ago, I decided to wait a couple of weeks before declaring my pregnancy. I told no-one about the pregnancy and kept on cathing.

    My pregnancy progressed well, and at 7 weeks I was finally able to detect a heartbeat with te TTE machine. That stolen moment of pure joy as I sat in the empty echo lab all by myself looking at that tiny flicker is forever etched into my memory.

    36 hours later I miscarried.

    My rational mind keeps telling me that this miscarriage has nothing to do with my decision to stay in the lab, and everything with a chromosomal abnormality in the embryo. My husband, who is an engineer, keeps telling me that I have had less exposure standing in the cathlab wearing lead, than standing outside without it.

    And still I don't know whether I'll keep cathing during my next pregnancy. Rationally: yes. Emotionally: don't know yet.

    But I still feel the decision should be MINE and no-one else's. Women in cardiology face enough discrimination as it is.

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  26. Dear Anon (6/13/11)

    For me, two pregnancies total fetal badge radiation= zero.

    I miscarried my first pregnancy too. It was devastating. It was supposed to be the "ideal" time. I was in a basic science lab as a post doc.

    What you are going through is so hard. Whatever you decide regarding the cath lab will be right. Value what you personally/ emotionally need.

    JC

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  27. JC,

    Thank you for posting this!. I am an interventional cardiologist and just found out that I am pregnant. I plan to continue working in the lab but will admit I am cutting back from 4-5 days per week to 1-2 days per week. Your post has reassured me that if I am careful and keep on top of my radiation badge readings I should be ok. Thanks again!

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  28. Hi,
    I was wondering what everyone's opinion was. I recently found out I'm pregnant (only about 3-4 weeks). I am a cardiology fellow and still have 2 days of cath left next week and then another month this year. I am hesitant to disclose my pregnancy to the department yet. It's just so early. But also don't want to do anything that will harm my child. Sounds like the amount of radiation I'm exposed to is minimal. Do you think it's safe to at least finish off this month? (just 2 more days) Thanks!

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