Tuesday, May 10, 2011

Radiating Yourself in Pregnancy

Last week, I wrote an entry about things that bugged me from my pregnancy during residency. One thing that ended up being a bit of a topic of debate in the comments was the issue of radiation during pregnancy. Basically (in case you didn't read the original post), when I was in my second trimester, an attending asked me to hold a patient's head while they were getting spine X-rays, then seemed shocked when I was reluctant to do so.

I certainly didn't expect all the readers to be on my side, and I wasn't disappointed. A couple of people commented that they didn't understand the big deal, since I would be covered by lead. One person went so far as to say that she would never ever consider covering for a pregnant women who wanted to avoid radiation.

I don't think I'm a weirdo for worrying about radiation during pregnancy. Most attendings never asked me to do such a thing. When we were taking an X-ray at the patient's bedside, they immediately stepped in and ordered me out of the room. On another occasion, when I wasn't pregnant, I went down to hold a patient's head, and the radiology tech grilled me about whether or not I was pregnant, even going so far as to ask if I was on birth control. Another resident in my program had her schedule for the year arranged so she could avoid a radiation-intense rotation during her pregnancy, and I don't think anyone questioned this.

Of course, there isn't a lot of conclusive research about radiation exposure during pregnancy, since it's not like they're going to be doing any double-blinded randomized controlled trials any time soon. An X-ray, I've read, provides about as much exposure as a cross-country plane flight. I spent a minute doing a PubMed search before writing this and it seemed like the only thing they knew for sure is that radiation during pregnancy causes a lot of anxiety in mothers-to-be.

I think it's an important topic for women in medicine though. After all, a lot of fields do have radiation exposure. And a lot of us get pregnant. A friend of mine is currently pregnant and working as a Pain physician, performing injections under fluoroscopy. I know she wanted to get pregnant and deliver prior to that job in order to avoid the radiation exposure, but things didn't work out that way. Sometimes you can't avoid radiation during pregnancy. But if you can, should you make an effort to try?

At the risk of causing an argument in the comments, which y'all know I really hate, I'd like to ask the readers what their feelings are about radiation exposure during pregnancy. Do you think the anxiety is unwarranted? If you were pregnant, would you have held that patient's head during that X-ray (and the 3-4 other times it came up during my pregnancy)? Would you work as a Pain physician doing injections daily with an X-ray machine? Would you agree (or better yet, volunteer) to help a pregnant co-resident who wanted to avoid radiation exposure?

31 comments:

  1. Kellie (General Surgeon)May 10, 2011 at 9:56 AM

    When I was pregnant with my son (which occurred after years of trying and pregnancy losses) my partner would do my cholangiogram injections (which we use fluoro for). If he wasn't available, the tech's would do it. I would have been covered by lead, but certainly wanted to do everything possible to make pregnancy safe for me and my child. Not sure if there are any great studies or not. I would certainly help a pregnant co-worker if needed.

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  2. Like you said, there will never be any randomized controlled studies, so who really knows if the anxiety is unwarranted? That being said, it's better to be safe than sorry. Volunteering to step in and hold the head for a pregnant woman is really not that big of a deal and I can't imagine why people make a fuss over it. I would definitely do this for others (insist) and I would hope that my co-workers would do the same for me. I don't think I could do daily injections with an x-ray machine. That would make me way too nervous.

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  3. 99% of coworkers were supernice about helping.... would actually volunteer without my even having to ask. It was just that one attending who gave me trouble, then the resident I tried to ask when the attending refused to do it.

    I never got asked to do this for a pregnant resident, but if I had been, I definitely would have stepped in.

    In pregnancy, we're told to avoid caffeine, cold cuts, and some kind of fish. I figure the least we can do is avoid radiation aimed at our uteruses.

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  4. I would certainly try to avoid it. Whenever I've gone in for X-rays (even at the dentist), I've always been asked if I might be pregnant. If patients and their babies are given this consideration, why wouldn't a doctor? I would certainly volunteer for a pregnant coworker. It is better to be safer than sorry.

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  5. Everytime I go to the doc and need x-rays or dental x-rays I am asked whether or not I might be pregnant because if I am then the x-rays would have to wait. So I don't see why we wouldn't want female pregnant doctors to avoid radiation if possible. I think there are enough people working in the hospital that you can limit your exposure.

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  6. If anyone is interested, they can check out the arguments made by some other people in the comments of the last entry.

    We do seem to be very cautious about our pregnant patients. All the X-ray forms have checkboxes for whether the patient might be pregnant. It seems like in the dentist's office, you're talking about only a few films and it's not really near the uterus, but they do try to avoid it. So it seems reasonable to avoid exposures during work.

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  7. I suspect I will be done having children by the time I reach residency - and I look forward to helping out pregnant residents when I'm in training. Just based on this blog I can see that many have suffered undue grief. Women can be catty, but we can also be very cooperative. We should make the most of this strength and support each other when going through grueling things (pregnancy and/or training!)

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  8. My feeling is that if you can avoid a risk, do so. I skipped coffee and its bad effects are dubious. I did have a fall with a broken ankle that required Xrays but felt awful about it. (baby is fine thanks)

    During my residency we regularly stepped in for our colleagues. Of course those were the days of no days of and 120 hour weeks, so if you did not help each other you did not survive.

    I do not know why people pooh-poohed your risk or your trying to avoid it. Aren't we supposed to put baby's health first?

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  9. I refuse to inject intrathecal chemotherapy while pregnant. Not sure of the data either way, but it is my choice. In this situation, you get to do what you think is best. Enough said.

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  10. Sunniday: I actually also required an X-ray late in my third trimester, when the theoretical risk is lowest, and I could tell the doctor was agonizing over whether to do it, even though I had a trauma and really needed it.

    I was especially surprised that the attending who wanted me to do it was a mother of three. I wonder if she had X-ray exposures during her pregnancies.

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  11. I agree with the post above. If it can be avoided, why not - the impact of radiation exposure on the fetus is too unclear. I got exposed to only a couple of x-rays while wearing lead when there was an acute trauma in the trauma bay. But for all the other times, I was always able to find someone to stand in without argument. I also refused to do fluoro in vascular cases and didn't get any push back.

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  12. In some ways, yes, I think the anxiety is unwarranted. That's not to say that I don't understand or empathize with the anxiety, and that I wouldn't gladly step in if a pregnant colleague of mine asked. If asked about elective radiation by a patient, I would counsel her to avoid any unnecessary exposures because of the skewed risk-benefit ratio. I just think that like many of the other possible exposures in pregnancy, the risk perceived by the public is out of proportion to what the evidence actually suggests, which is that you would likely need a radiation dose equivalent to more than 500 chest x-rays in order to see an increased risk in birth defects/miscarriages.

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  13. I'm in peds. I also avoided going into isolation rooms with chicken pox patients, and avoided CMV and HSV patients. I return the favor now by seeing those patients, (doing all the viral swabs etc.) for the pregnant residents.

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  14. Theoretically radiation is most worrisome during the period when there's a lot of growth and cells are dividing rapidly, ie in utero and childhood. I'd be a little anxious about malformations (warranted or unwarranted) but also worried/feeling guilty about the adding to the cumulative doses of radiation the kid would be getting and the lifetime effects. A little bit here, a little bit there... it adds up! I think you're right to protect the baby as much as possible.

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  15. I strongly agree with tyring not to be hysterical about every minute detail of pregnancy (or motherhood for that matter!), but I think you should be able to say "no" to anything you perceive is putting you at risk. I know a chemist who choose to stay in the lab during pregnancy, wore protection and the whole bit. Her baby was born with Bochdalek syndrome. She wasn't exposed to any particular thing known to cause it, but that doesn't mean she doesn't feel responsible. Again, no way to know if the association is real, but her guilt sure is. It's almost a peace of mind issue.

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  16. Weather the anxiety is warranted or not is a purely academic debate at this point. However, a mother trying to do her best to protect her child's growing little body, to give that child the best chance at a healthy life, is a very practical issue.

    What unsettles me is that as a society we fall so short in our commitment to our future (babies are the future, it's undeniable, no matter how militantly deluded someone may be in their bias against children). Not only should the attending and other resident NOT have given you a hard time, but they should have been actively acting to protect you throughout your pregnancy! This does not mean that you should not having been doing your share of the work, but that whenever there was greater than average potential for harm, they should have stepped in.

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  17. I was still a nurse in the OR when pregnant, and I was exposed to radiation pretty regularly. I'd request to stay out of ortho rooms and other rooms that were using xrays, but sometimes it just wasn't possible to avoid them. I always wore lead, but I didn't have a meter. No one I worked with seemed too concerned about that, but the dr who read my ultrasound got pretty freaked out about it.
    The crazy thing is, at around 22 weeks I had strike symptoms (just bad migraines) and the ob resident sent me for a ct (when I questioned the decision, she came back with a hand written consent on a dr's note sheet). I asked to speak to the radiologist, who strongly advised me to not get the ct. When I told the resident I'd go in for an MRI later instead, she got angry and tried to get her attending to "talk" to me.
    I think the woman who refused to help you had something else going on- personal or otherwise. Even if I didn't thinkit was a huge risk, I'd still help someone who did.

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  18. pregnant ortho resident here -- can't avoid it, really; i can't exactly refuse to do almost all cases on my current xray heavy rotation (trauma.) so i wear a lead skirt and a full-length lead apron over top of that. (plus thyroid shield.) it can get heavy and hot but it's manageable. and i'm ok with it. there have been 3 other residents recently in my program before me (with 5 babies between them during residency!) all with the same situation. all healthy babies. but that's just our little anecdotal n=5, FWIW. :)

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  19. Ortho Anon- good wishes for your pregnancy. I think we all have situations where risk is unavoidable and you just do your best. I was pregnant as an attending on a BMT ward. There really was no way for me to avoid HSV and CMV exposures because that would have meant not ever attending. So I did my best to use gown and gloves when I definitely knew or highly suspected. That said, if there was a way to avoid exposure, I did. The key is while Fizzy's risk is overall low, if there is a way to easily avoid it, why not ask for that?

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  20. Yeah, that's what my argument to the attending was, "Why should I take that risk?" It was a situation that came up every other week, if that often, and didn't provide any learning and wasn't a huge time obligation. Ordinarily, I would never ask an attending to do scut for me, but I think in this one situation, she could have taken the 10 minutes to help me out.

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  21. Also, on the other post, someone just commented that if pregnant women are exempt, then maybe residents with a family history of cancer should be too. But I don't necessarily agree with that one.

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  22. Erm, not to be totally nitpicky, but shouldn't it be IRradiating yourself in pregnancy? Radiating yourself sounds like beaming your glowing pregnant self out to the world...not a bad image, but not really what you meant.

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  23. You're right, Anon. And I always find it very helpful when there's a discussion online and one person decides to start correcting grammar. :P

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  24. Get informed and stay safe (saw that on a HIV education billboard). There is more irrational anxiety and fear of OCCUPATIONAL radiation risks to mother and unborn than you can imagine. Knowledge is power, the evidence (most of which was extrapolated from Hiroshima survivors and their offspring who were exposed to sublethal doses of radiation - data available on NRC website); does not support an unacceptable level of risk to medical professionals. We shouldnt perpetuate irrational fear but re-educate our techs, nurses and fellow physicians. Proper protective gear should be worn by every physician who works with radiation wether male, female, pregnant or not. Improper 'leading' in presence of radiation is akin to performing a vaginal exam without gloves (yuck!!! - i say that ONLY half jokingly)

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  25. >>on the other post, someone just commented that if pregnant women are exempt, then maybe residents with a family history of cancer should be too. But I don't necessarily agree with that one.>>

    No, on the other post, someone commented that residents with a family history of cancer should not be criticized for refusing to cover for pregnant women. Sheesh.

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  26. From the second to last comment on the other post:

    "I think that family history (i.e having a specific gene) could actually be a good argument for stepping out"

    Double sheesh! :)

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  27. Stepping out for purely emotional reasons is not valid, and unreasonable, IMO. I am glad JC discussed actual risk at length, from an intelligent, informed perspective.

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  28. First, I think when people post as Anonymous, it signals "troll" to me. If you have a comment to make, at least give yourself a name. I put myself out there, yet all these Anonymous commenters can't be bothered to do the same.

    Second, I don't think anyone would call avoiding radiation during pregnancy to be "purely emotional." When doctors advise against pregnant women getting an X-ray or CT, is that a purely emotional decision? Whether there's a risk or not is debatable, but I don't think you could possible call a pregnant woman who doesn't want to expose her fetus to radiation "just emotional." That said, if there were a pregnant woman or anyone who had a valid personal, emotional reason for wanting to avoid something (i.e. not wanting to do a fetal autopsy while pregnant), I would honestly do my best to pitch in and help them.

    While I appreciate JC sharing her knowledge, at the same time, I feel that people are contorting her words to say that women who want to do minor things to avoid *possible* risks to her fetus, even if those risks may be very small, are emotional and irrational nut jobs. It's not an "irrational worry" if your doctor, radiology techs, and society as a whole are all telling you to avoid radiation. They may be wrong, but it's certainly not "irrational" to believe them.

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  30. Thanks for weighing in, Bekkles. That was always a fear of mine when I was doing something with a patient seconds before they were taking an X-ray in the room... that someone overeager might snap it before I could leave the room. The other thing to consider is that women who get exposed to radiation regular are probably better at draping themselves and avoiding accidental exposures (the way you mentioned) than women who do it more rarely.

    But the bottom line, as I've said, is that just the same way some pregnant women choose to work the cath lab, other pregnant women should be allowed the option to avoid it without being labeled an "irrational nut job." I think taking away that option from women is definitely a step back.

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  31. I am a nurse and work in pain managementin the OR for sometimes 12 hours shift. Lots of injections - sometimes 20-30/day under my care. The matter of fact is that I told my facility that as of today I wont do any Xray related procedures, that if anything I would work in Preop or Pacu. My biggest concern is that for the first 3 weeks of pregnancy I worked 3x week in the OR being exposed to Xray using a front leaded apron/thyroid collar, sometimes the skirt and top apron... My other concern is that a couple of days before I found out I was preg I got an xray of my lower pelvis and neck due to back pain at the chiropractor's office. Now that I know (I'm 5 weeks) I am abstaining myself from any Xrays. Have anyone had a similar situation and had their baby was born completely healthy (or not)? I just need to know...

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