Thomas Davis, CRNA
Chief CRNA
The Johns Hopkins Hospital

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Protecting the Pregnant Worker
Compliance with State/Federal Law
Getting the job done

Beth is a CRNA who has worked on your staff for 8 years. She went into premature labor at 33 weeks with her last pregnancy and blames work related stress and fatigue.
She is requesting shorter work days and limited lifting.

Amy is a CA3 Resident who believes that
Universal Precautions are not truly effective in the chaos of the Operating Room and requests NOT to be assigned to any patients who have known communicable diseases.

Juanita is a new graduate in her first year of practice and newly pregnant. She says that the first trimester is critical for development and refuses to work in any cases involving radiology.

Heather was a pediatric ICU nurse prior to becoming an anesthetist. She has requested NOT to be assigned to do inhalation inductions while pregnant.

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What are the concerns of the pregnant OR worker?
What Laws protect the pregnant worker?
What can we do to provide reasonable accommodation?

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Pregnancy Discrimination Act of 1978
• PDA, 42 U.S.C 2000e(K)
Family and Medical Leave Act
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Employer may not discriminate on the basis of sex to include pregnancy
Childbirth must be treated as any other medical condition
Employer sick leave applies to childbirth
Employer health care plan must cover childbirth as any other health condition.

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Employer may not discharge you for taking time off for childbirth
You must be reinstated in the same manner as other employees with temporary disability
Employer can not require you to take maternity leave
For male employees, wife must receive the same health care benefits as female employees.

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Title VII of the Civil Rights act of 1964
• Male employees who go on paternity leave must be treated in the same manner as a female who takes leave for child-care purposes.

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Applies to any employer with 50 or more employees
Entitles person to up to 12 weeks of unpaid leave
◦ Based on a 12 month rolling calendar
State laws may also apply.

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Employee MUST have worked 12 months and at least 1,250 hours to qualify.
Time off authorized for:
◦ Care of newborn
◦ Care of new adopted child
◦ Care of seriously ill family member
◦ Care for yourself after serious illness or injury

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Employee must be reinstated unless:
• They are physically or mentally unable to do the job
• They are considered a “key” employee and the company could suffer substantial eccnomic injury

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Must provide 30 days written notice unless it is an immediate emergency
Provide medical proof
Clarify use of sick time versus unpaid leave
Respond to employer’s request to update/verify status

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Inhalation Agents
Radiation
Exposure to infectious disease
Stress/fatigue

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Prospective studies are not available
National Institute for Occupational Safety and
Health (NIOSH)
◦ Clinical research
◦ Animal studies
◦ Epidemiologic studies

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Anesthetic Gases: Guidelines for Workplace Exposure, OSHA
Directorate of Technical Support and Emergency Management
[formerly Directorate of Technical Support] July 20, 1999
Revised May 18, 2000
Waste Anesthetic Gases, Information for Management in
Anesthetizing Areas and the Postanesthesia Care Unit (PACU),
ASA Task Force on Trace Anesthetic Gases of the ASA
Committee on Occupational Health of Operating Room
Personnel

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Human epidemiologic studies
Animal studies
Nitrous Oxide interacts with Vit B12
• Inhibits Methionine synthase
• Inhibits thymidine synthesis and effects DNA
Women who work with Nitrous Oxide in the absence of adequate scavenging have increased risk of spontaneous abortion.
• Rowland et al, Am J Epidemol 1995;141(6), 531-8

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Halothane & Isoflurane
• Early studies (1980’s)
• Increased spontaneous abortions
• Increased premature deliveries
• Later studies
• No increased risk for anesthesia providers in the OR
• Female Veterinarians (2009)
• Increased spontaneous abortion and premature delivery when working in unscavenged areas.

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Desflurane & Sevoflurane
◦ Little evidence of risk with newer agents
◦ OSHA recommends max exposure of 2ppm
 Based on time weighted averages.
◦ Spontaneous abortion slightly higher in pediatric anesthesiologists doing inhalation inductions.

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Poor ventilation / scavenging
Tank valves
High/low pressure machine connections
Breathing circuit connections
Defective hoses, reservoir bags, ventilator bellows

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Leaving vaporizer on
Spillage of liquid agent
Poor face mask fit
LMA or ET cuff under inflation

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“There is no association between occupational exposure to trace levels of anesthetic gases in properly scavenged operating rooms and adverse health effects in pregnant women”

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Effective Scavenging systems
Dilution ventilation
Anesthesia technique
• Gas off when circuit not connected
• Proper cuff inflation
• Proper mask fit
Proper equipment maintenance
Environmental monitoring
• Air quality checks
• Individual detection badges available

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Methyl methacralate (Bone Cement)
◦ No known harmful effect to pregnant worker or fetus.
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Homlar K, et al Journal of Arthroplasty 2013;28(3) 406-9
Organic Solvents
◦ Have not been studied in the operating room
◦ In industry associated with spontaneous abortion, premature delivery, impaired neurocognition and language.
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Laslo-Baker Arch pediatr adolesc med 2004 158(10);956-61

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Utilize your internal resources
• Radiology safety officer
• Protocol for pregnant radiology technicians
• HR Department
• Occupational Health
Review established guidelines
• American college of Radiology
• CDC Radiation and pregnancy fact sheet

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First 2 weeks after conception are the greatest risk for fetal loss (all or none effect)
3-4 weeks is most lethal for fetus
4-8 weeks; malformation/growth restriction
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8-15 weeks; growth restriction/cognitive impairment
15 weeks-term; growth restriction/imtellect impairment.
Brent, RI Am J Obstet Gynecol 2009;200(1):4-24

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No documented genetic risks for exposure prior to conception
No risk until levels exceed 150mGy
◦ Radiologic study approx <20mGy
◦ CT scan 10-35 mGy

Rev McCollough. Radiation Exposure and Pregnancy: When Should We Be
Concerned? Radiographics 2007, Jul-
Aug;27(4)909-17

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Limit time near radiation source
Increase distance from source (6 ft.)
Shielding
• Wrap around apron
• Thyroid shield
• Eye protection
Exposure monitoring
• Double badge when pregnant.

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Strict adherence to Universal precautions
Effective handwashing
Vaccination
(Centers for Disease Control and Prevention
[CDC], 1998).

Disease
AIDS/HIV
HUMAN PARVOVIRUS B19
(Fifth Disease)
(Erythema Infectiosum)
CYTOMEGALOVIRUS
(CMV)
HEPATITIS A
HEPATITIS B
HEPATITIS C
HERPES SIMPLEX
(Types I and II)
HERPES ZOSTER
(Shingles)
VARICELLA
(Chickenpox)**
RSV
RSV being treated with
Ribavirin
RUBELLA**
RUBEOLA (Measles)**
TOXOPLASMOSIS
TUBERCULOSIS
Category of Isolation
Universal/
Standard Precautions
Universal/
Standard Precautions
Respiratory Precautions
Universal/
Standard Precautions
Universal/
Standard Precautions
Contact Precautions
Universal/
Standard Precautions
Universal/
Standard Precautions
Universal/
Standard Precautions
Universal/
Standard Precautions
Contact Precautions
Airborne Precautions
Universal/
Standard Precautions
Contact Precautions
Universal/
Standard Precautions
Contact Precautions
Universal/
Standard Precautions and
Respiratory Precautions for postnatal rubella
Universal/Standard precautions and contact precautions for congenital rubella
Universal/
Standard Precautions
Airborne Precautions
Universal/
Standard Precautions
Universal/
Standard Precautions
Airborne Precautions x x
Reassignment
Necessary?
Yes No x x x x x x x x x x x x
Comments
It is highly advised that pregnant personnel not care for patients admitted with aplastic crisis only
Studies of HCW have not shown transmission of
CMV from patient to personnel, but should observe universal/standard precautions at all times
Immunization against hepatitis B encouraged
Avoid direct contact with lesions
The non-immune HCW, pregnant or not, should not have contact with Varicella or zoster (shingles) patients who have vesicular or open draining lesions. The immune HCW, pregnant or not, can safely care for a patient with shingles or Varicella
It is highly advised that a pregnant employee not provide direct care to the patient during the administration of Ribavirin and clean-up thereafter
The non-immune HCW, pregnant or not, should not have contact with patients with rubella
The non-immune HCW, pregnant or not, should not have contact with patients with rubeola
Annual PPDs should be administered
Note.
Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

AIDS/HIV Universal/
Standard
Precautions
X
HUMAN
PARVOVIRUS
B19
(Fifth Disease)
(Erythema
Infectiosum)
CYTOMEGALOVI
RUS
(CMV)
Universal/
Standard
Precautions
Respiratory
Precautions
Universal/
Standard
Precautions
X It is highly advised that pregnant personnel not care for patients admitted with aplastic crisis only
X
Studies of HCW have not shown transmission of CMV from patient to personnel, but should observe universal/standard precautions at all times
Note.
Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

HEPATITIS A
HEPATITIS B
HEPATITIS C
HERPES SIMPLEX
(Types I and II)
HERPES ZOSTER
(Shingles)
VARICELLA
(Chickenpox)**
Universal/
Standard
Precautions
Contact
Precautions
Universal/
Standard
Precautions
Universal/
Standard
Precautions
Universal/
Standard
Precautions
Universal/
Standard
Precautions
Contact
Precautions
Airborne
Precautions
X
X
X
X
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Immunization against hepatitis B encouraged
Avoid direct contact with lesions
The non-immune HCW, pregnant or not, should not have contact with Varicella or zoster
(shingles) patients who have vesicular or open draining lesions. The immune HCW, pregnant or not, can safely care for a patient with shingles or
Varicella
Note.
Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

RSV
RSV being treated with Ribavirin
RUBELLA**
Universal/
Standard
Precautions
Contact
Precautions
Universal/
Standard
Precautions
Contact
Precautions
Universal/
Standard
Precautions and
Respiratory
Precautions for postnatal rubella
Universal/Standar d precautions and contact precautions for congenital rubella
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X
X
It is highly advised that a pregnant employee not provide direct care to the patient during the administration of Ribavirin and clean-up thereafter
The non-immune HCW, pregnant or not, should not have contact with patients with rubella
Note.
Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

RUBEOLA
(Measles)**
Universal/
Standard
Precautions
Airborne
Precautions
TOXOPLASMOS
IS
Universal/
Standard
Precautions
TUBERCULOSIS Universal/
Standard
Precautions
Airborne
Precautions
Note.
Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008
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The non-immune HCW, pregnant or not, should not have contact with patients with rubeola
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X
Annual PPDs should be administered

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Most common intrauterine infection in U.S.
Frequent contact with children is greatest risk
400 infant deaths/3,400 cases of infant injury per year
Causes placental inflammation and reduces oxygenation
Birth injuries related to CMV
• Growth retardation, hydrocephalus, microcephaly, hearing loss, hepatomegaly

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Transmitted via respiratory secretions
Exposure to children is the greatest risk
Inhibits the production of red blood cells
Effects on Fetus
• Miscarriage, stillbirth, fetal anemia, inflammation of the fetal heart.
Most adults have immunity
Less than 1% fetal problems when mother gets the disease.

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Greatest Risk to fetus in first trimester
• Deafness
• Eye abnormalities
• Congenital heart disease
Other problems
• Spleen, liver, bone marrow problems
• Low birth weight
• Hepatomegaly
• Developmental delay

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Vaccination
Immunity testing where appropriate
Universal Precautions
Consider reassigning if:
• Fifth disease
• RSV treated with Ribavirin
• Rubella
• Rubeola (measles) if non-immune

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Many references on the web
• HHS
• CDC
• March of Dimes
• State health web sites

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Risks of stress
• Spontaneous abortion
• Premature labor
• Heart defects in the baby
• Increased risk for stillbirth
• Infertility

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Break time for nursing mothers is protected
◦ US Dept of HHS
◦ US Dept of Labor
◦ CDC
◦ US Breastfeeding Committee
◦ Affordable care act
◦ FLSA (Fair Labor Standards Act, sect 7)
◦ State Labor laws

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State law prevails if it provides greater protection for the mother
Applies to companies with 50 or more employees
Applies only to non-exempt employees

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Thomas Davis, CRNA
Chief CRNA
The Johns Hopkins Hospital