More research and leadership interest needed to address concerns and attract top talent
Gender distribution in medical education has now equalized with roughly half of medical students being women. In contrast, orthopaedic surgery residency programs have lagged behind other subspecialties in recruiting women. Only 14 percent of orthopaedic residents and 6 percent of active AAOS fellows are female. It is important to address the factors that can be modified to reduce gender disparity within the field.
Concerns about the timing of child-bearing is one potential deterrence to high-quality female applicants. Given the historically low numbers of women in orthopaedic surgery, trainees may find few female orthopaedic surgeons to provide guidance with regard to starting a family while building a successful practice. In the following article, we discuss several concerns pertinent to the pregnant orthopaedic surgeon, including timing of pregnancy, risks incurred during pregnancy, and recommended precautions.
There is no perfect time to start having children. The conflict remains: Start early and logistically try to figure out coverage in medical school or residency, or wait until you have seemingly more control of your life? Always review your maternity leave policy prior to planning. In 2013, the average age for first-time mothers in the United States rose to a record high of 26 years. Pregnancy in medical school or residency, in most cases, avoids the decrease in women's fertility at age 32. On the other hand, the lack of sleep and limited income and other support may make pregnancy during residency more logistically difficult. Other concerns include the impact a maternity leave might have on fellow residents' workload and the time added to the total length of residency training.
In contrast, waiting to have children until you've started practice theoretically allows for an increased salary and ability to afford childcare and support a family. Increased autonomy in practice may allow negotiation of a flexible work schedule.
The downside to starting later is that fertility decreases more sharply after age 37. Some women decide to freeze their eggs; however, it is important to note that the percentage of in vitro fertilization cycles that result in a baby declines from about 40 percent for women aged 32 and younger, to about 20 percent for 40-year-old women. Miscarriages, gestational diabetes, and high blood pressure are more common for women over age 35. Complications for the baby, including preterm birth, poor fetal growth, low birth weight, and neonatal mortality, increase with advanced maternal age.
Occupational hazards in the OR
Beyond the considerations of timing and leave, the operating room (OR) presents unique occupational hazards relevant to the pregnant orthopaedist. Reported rates of percutaneous injury during orthopaedic surgery range from 1.7 percent to 15 percent. Hepatitis B, Hepatitis C, and the human immunodeficiency virus (HIV) constitute the three main pathogens of concern with regard to blood-borne exposure. Mucocutaneous exposure is likely underreported in the literature and poses a greater risk to orthopaedic surgeons given their frequent use of power tools and pulse irrigation, which create a splatter effect.
Postexposure prophylaxis protocols in the setting of pregnancy vary from standard protocols. Hepatitis B, Hepatitis C, and HIV pose a risk of vertical transmission (Table 1). Additionally, postexposure prophylaxis regimens pose risks of toxicity to fetuses and breastfeeding newborns, and dosing must be altered to reflect these concerns.
Exposure to harmful chemicals in the OR can also pose a risk to pregnant mothers and fetuses. Anesthetic gases such as nitrous oxide and halogenated agents may cause an inhibitory effect on dividing cell lines and chromosomal abnormalities. Positioning patients during induction may expose a surgeon to increased levels of these anesthetic gases, and leaks in tubing may lead to exposure above recommended values.
Similar to anesthetic gases, elevated levels of methylmethacrylate (MMA) can be toxic to various tissues and can be specifically toxic to developing fetuses. The U.S. Environmental Protection Agency has set the limit for exposure to < 100 ppm over an 8-hour period, and animal models demonstrate fetotoxicity at levels > 1,000 ppm. Darre et al demonstrated that this level of exposure occurs during a single total joint replacement with greatest exposure during the mixing process. Despite theoretical concern of toxicity based on animal models, serum and breast milk levels of MMA in two breastfeeding surgeons following exposure to MMA during joint arthroplasty were found to be no different than controls.
Finally, radiation exposure is increased in orthopaedic ORs. Though consensus on limits of exposure to ionizing radiation in pregnant patients and healthcare workers varies widely, the American College of Obstetricians and Gynecologists Committee Opinion states that exposure of < 5 rads (50 mSv or 50 mGy) is not harmful to the fetus. Effects on the fetus depend on the amount of radiation received and the gestational age of the fetus at the time of exposure. Risk is greatest at 3 to 8 weeks of gestation, during organogenesis, through adverse effects due to cell death or DNA damage. The effects of radiation-induced DNA damage are cumulative, and children who received prenatal exposure to radiation had a relative risk of 1.47 of developing childhood cancer, though the dose effect associated with this risk is not well understood.
There are a number of strategies available to the pregnant orthopaedist to reduce the risk of radiation exposure. Increasing distance from the source of radiation and decreasing exposure time both reduce ionizing radiation delivered to the operating surgeon. A standard 0.25 mm lead apron blocks 96 percent of radiation. Maternity aprons absorb more than 99 percent of radiation. However, these aprons weigh 1.5-times more than the standard options. The benefits of reduced radiation exposure must be weighed against the increased physical stress of the heavier apron, as it, too, has pregnancy-related implications.
Female orthopaedic surgeons face increased rates of pregnancy-related complications. In comparison to the general population, pregnancies among orthopaedic surgeons were associated with a 31.2 percent complication rate versus 14.5 percent. The most commonly reported complication was preterm labor with either preterm or term delivery, which was associated with respondents who worked more than 60 hours per week.
The physical demands of surgery place additional stresses on the female orthopaedist. Physically strenuous occupations have long been suspected of increasing pregnancy-related complication rates. Among activities that place one at such risk are night work, long hours, and standing for prolonged periods of time. In a survey of female orthopaedic surgeons, respondents reported a rate of 23.2 percent of pregnancies associated with the imposition of activity restriction and 10 percent associated with bedrest.
Beyond preterm delivery, occupational stresses may infer a greater risk of pregnancy-related complications, including premature labor, preeclampsia and/or eclampsia, or small for gestational age births. A survey of 1,293 female medical school graduates and a random sample of 1,494 wives of male physicians was conducted and demonstrated significantly greater rates of premature labor requiring bedrest or hospitalization among the medical school graduates (11.3 percent versus 6.0 percent, P < 0.001) and preeclampsia or eclampsia (8.8 percent versus 3.5 percent, P < 0.001). Similarly, Phelan et al found an increased rate of pregnancy induced hypertension (12 percent) in a survey of 1,197 surgeons, obstetricians-gynecologists, and psychiatrists across all specialties compared to the general population. Grunebaum et al found an increased incidence of low birth weight and intrauterine growth restriction in infants born to obstetricians in training.
More drastic pregnancy-associated risks such as stillbirth and miscarriage have also been reported at higher rates in populations of pregnant physicians. Using self-reported questionnaires given to female physicians, Pinhas-Hamile et al demonstrated a significant increase in the stillbirth rate among 207 physicians as compared to the general population. Similarly, Klevan et al found a 26 percent miscarriage rate in a cohort of 93 physicians. Finally, an infertility rate of 33 percent was reported among 199 plastic surgeons and residents.
Although pregnancy during a career in orthopaedics requires careful consideration of factors, including timing of pregnancy and occupational hazards, we believe that with appropriate planning, rates of pregnancy-related complications can be reduced. Use of personal protective equipment, lead aprons, and dosimeters may decrease rates of occupational exposures. Planning with regard to rotation and call distribution may reduce rates of preterm labor and preeclampsia.
However, more research is needed in each of these areas and leadership must be vested in considering these factors to attract the best talent to orthopaedics. Across medical specialties, women are underrepresented in leadership roles in academics, private practice settings, and in professional medical organizations. To create a culture within orthopaedic surgery that is welcoming to both men and women, we should build provisions for pregnancy into our practice.
Lauren E. Wessel, MD, is a resident physician in orthopaedic surgery at Hospital for Special Surgery.
Mary K. Mulcahey, MD, is an associate professor in the department of orthopaedic surgery and director of the Women's Sports Medicine Program at the Tulane University School of Medicine.
Karen Sutton, MD, is an associate attending orthopaedic surgery, sports medicine at Hospital for Special Surgery, where she is part of the Women's Sports Medicine Center. She is also a member of the AAOS Women's Health Advisory Board.
- Orthopaedic surgery residency programs have lagged behind other subspecialties in recruiting women.
- One deterrent may be the ability and/or timing of having children.
- Several occupational hazards are present in the operating room and the rate of pregnancy-related complications is higher for the female orthopaedist than for the general population.
- More research is needed and leadership must be vested in considering these factors to attract the best talent to orthopaedics.
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