Acta anaesth . scalld. 1978, 22 , 202- 207

Occupational Hazards to Reproduction and Health in Anaesthetists and Paediatricians P. H. ROSENBERG and H. VA NTTINEN Departmen t of Anaes thesiology, H elsinki University Central H ospita l, H elsinki, Finla nd

A mail ques tionnaire was sent to Finnish anaesthetists a nd paediatri cia ns to evalu ate the risks of reproductive, tera togeni c a nd h ealth compli cations rel a ted to the profess ions. The incidence of di agnosed spontaneous miscarri ages in anaestheti sts' famil ies was 10.2% of a ll pregna ncies and it was 13.2% in paedi atricians' famil ies. Smoking see med to increase ma rked ly th e incidence of spontaneous misca rri ages, whi ch was 22 .9% in smoking female a naesth etists and 17.2% in smoki ng female paedi atri cians. The ges ta ti on times in cases of both full-term preg na ncies an d misca rri ages were shorter in th e a naes thetist group th a n those in the paedi a tricia n group. Congenital abnormaliti es appeared at a n equ al ra te in both a naes thetist and paedi a tri cia n groups, but strikingly, there were nine m uscul oskele ta l a bnormalities in the a naes th etists' children compa red to no such defec ts in paed ia tricians' children . Seri ous diseases occurred at low frequenci es, bu t three cases of hepa ti c j aundi ce and three cases of vira l myocarditis in an aes· theti sts indica te possibl e infecti ous haza rd s to health in anaesth eti c work. Different infec tious diseases to th e respira tory a nd urin ary tracts were commones t a mong paed ia tri cia ns. Ca nce r was not reported in th e a naes thetist group . The stud y d oes not indi ca te tha t gas pollution in opera ting rooms is harmful to th e person nel.

Received 18 October, accepted fo r publicatioll 17 November 1977

Studies from different countri es suggest that work in opera ting th eatres is associa ted w ith a n in creased ri sk of miscarriages, con genital malform ations in offsprings and ill h ealth (V AISMAN 1967, ASKROG & H ARVALD 19 70, COHEN e t al. 19 71 , K NILL-JO NES e t a l. 19 72, R OSENBERG & KIRVES 19 73, AM ERICAN SOCIETY OF ANESTH ESIOLOGISTS 19 74). Wh ether these are results of exp osure to waste gas p ollution, stress, infections, fa tig ue, hormona l or di etary disturba nces, sel ected popul ation, exp osure to so lvent vapours, exp osure to x-ray and microwave radiation, or oth er ca uses, or all toge th er, has been widely discussed and is no t ye t se ttl ed. In a n earlier study we showed th a t Finnish scrub nurses and in tensive care unit nurses had hi gh er ra tes of sponta neous miscarri ages (2 1.5 % and 16. 7% ) th a n h ad a naes thesia nurses (15 % ) (R OSENBERG & KIRVES 1973). The resul ts suggested that a close chron ic ex posu re to trace concen tra ti ons of anaes-

theti c gases may not be the cause of reprodu cti ve compli cati ons a mong opera ting room nurses. Th e reaso ns for th e rep orted increascd ra te of ser ious h ealth complicati ons, such as lymph a ti c m a li gna ncies (CORBETT e t a l. 19 73) a nd h ep a ti c di seases (AM ERICAN SOCIETY or A NESTH ESIOLOGISTS 1974) among anaesth esia p ersonn el in th e United Sta tes are uncl ear. A British survey (SPENCE e t a l. 19 74) did no t reveal a differen ce be twee n th overa ll in cid ences of can cer in an aes th e tists and th e control g roup . Di seases, like ulcera tive co li ti s, migrain e, p epti c ulcer, ga ll b la dd er di seases, arteri a l hyp ertension , and cardi ac a rrh y thmi as, whi ch might be rclated to stress, h ave been observed m ore frequentl y in Am eri can and British male anaesth etists than in the corresp onding co ntrol subj ects (SPENCE e t a l. 1977) . As a lread y published reports partl y confirm an d partly oppose each o ther, we consid ered

203

OCCUPATIO tAL HAZARD S I . ANAEST HESIA

a mail survey, with special reference to obstetric and health history, worthwh il e in our country. In Finland , due to a rel ative shortage of anaesthetists, the routine work in anaesthesia seems to be associated with a rather h eavy work load . Physicians of the Finnish Society of Paediatri cians served as th e control group.

MATERIALS AND METHODS A ques ti onn a ire, covering th e peri od from 196 1 to 19 76, was sent twi ce to all members (2 12 a naes th etists) of th e Finnish Society of An aes th esiologists (FSA) a nd to all members aged less than 65 yea rs (356 paediatri cia ns) of th e Finnish Society of Paed ia tri cia ns (FSP) . The paed ia tri cians were co nsid ered to have th e grea tes t moti vat ion of non -anaes th etist physicia ns to respond. After the second mailin g th e response ra tes in th e FSA a nd FSP groups were 85% a nd 64% respec tively. The qu es ti ons, whi ch were a nonymo usly a nswered , in cluded: number, fa te and ges ta ti on tim e of pregna ncies a nd misca rri ages; sex, congenital abnorm alities, diseases of chi ld ren ; work, age, diseases, drugs, smoking habi ts before and during pregna ncy; fr equ ency of on-ca ll duti es, ex pos ure to a naes th eti cs an d x-ray rad ia ti on (scored indi vidua ll y by subj ec ti ve rememberin g fr om 0- 3/ yea r or working peri od ) a nd th e co ntrac ti on of infec ti ons a t work (scored as above from o to 3) . Th e sta tisti ca l sig nifi can ce of th e difference be twee n two freq uencies was evalua ted with th e X 2 - test and th a t of th e difference betwee n two mea ns with Student's I-test.

Table I Th e number of pregnancies in anaes thetists' (FSA) and paedia tricians' (FSP) fam ilies. In four cases of the pregn a ncies in th e FSA group, both pa rents worked in th e operating room.

FSA

FSP

(operat ing room ) No. of pregnanc ies durin g 196 1- 1976

248

No. of pregna ncies when 166 fa th er worked in ope ra tin g room dur in g 196 11976 No. of preg nancies when 86 mother worked in opera ting room during 196 11976 No. of sponta neous mi s- 25 ( 10.1%) ca rri ages wh en eith er parent worked during 196 1- 1976 No. of spontaneous mi s- 17 ( 10.3%) ca rri ages wh en fa th or worked in opera ting room No. of spo ntan eous mi s- 8 (9.3%) ca rri ages when moth er worked in op era tin g room No. of sponta neous m is- 2 ( 1.4'lo) ca rri ages prior to commencin g op ra tin g roo m wo rk

266 (parents not working in operat ing room) 55

16

35 ( 13.2%) (pa rents not working in opera tin g room) 5 (9. 1%)

3 ( 18.8%)

RES U LTS The numbers of pregnan cies a nd mi sca rriages 111 th e anaestheti sts' and paediatri cians' fa mili es are seen in Table I . Th e rate of di agnosed sponta neous mi s arr iages among paediatri cians not work ing in operating rooms, including wives of paediatri cians, was 13.2 %, compa red to 10. 1% (N .S. ) among fema le anaesthcti sts and wives of anaesth eti sts. When the fa thers in th e FSA group were working 111 operating rooms, th e mi scarriage ra te was 10.3% , a nd wh en th e mothers were working th eir mi scarriage rate was 9.3 %. Pri or to entering anaes theti c work th e di agnosed mi sca rri age rate in th e

FSA gro up was on ly 1.4% (mean age of mothers 22 .3 y). Some paed iatricians were temporarily employed as anaesth eti ts, during whi ch tim e 3 out of 16 pregna ncies (18.8 %) ( 1.S . compared to fema le anaestheti sts) in female ph ysi ians ended in mi scarriage. The number investiga ted for infertility wa four (two male and one female anaesth etist, an d one spouse) in the FSA gro up and 22 (18 femal e paediatri cia ns a nd four spouses) in th e FSP group . During 196 1- 1976, th ere were more girls born to a naes th eti ts' famil ies (56.1%) than

204

P. H. R OSENBE R G AND H. VA NTTINEN

who temporarily were not exposed to operating room conditions) had 48 pregnancies, II of whi ch (22 .9%) (P < 0.01 compared to wives of smoking m a le a naesthetists) en ded in miscarriage. When onl y a naes thes ia-exposed smoking mothers were considered , their miscarri age in cidence was 17. 5% (P < 0.05). Wives of smokin g paedi a tricia ns a lso had 70 pregna ncies, a nd five (7.1 %) of th em ended in miscarriage, whil e smoking femal e paediatri cians had 58 pregna ncies, 10 of which (17.2%) end ed in miscarri age (N. S. compared to smokin g mal e paedi atri cia n group. ). Tabl e 2 Th e m ean frequency of on-call duti es Ges tat ion time a nd age of mo ther a t concep tion In imm ediatel y before and during gesta tion was anaes th eti sts' (FSA ) and paed ia tricians' (FS P) families. 6.4 days/month for working fath ers a nd 5. 1 days/month for working mothers in th e Fu ll term Spontaneous FSA group with full-term pregna ncies. Wh en FSA pregnancies misca rri ages their pregnancies ended in miscarriages th e M ea n ges ta tion t ime 39.2 0.23 8.53 ± I .17 on-call frequencies were 6.7 days/month and (weeks ± s.e.mea n ) when 5.8 days/month , resp ectivel y. In th e FSP fa ther worked in operatgroup th e on-call frequencies we re 4. 2 days/ ing room month for m ale physicians a nd 5. 1 days/ 7.4 ± 2.00 M ea n gestation tim e 38.8 ± 0.33 month for fema le physicians before a nd (weeks ± s.c. mean ) when moth er worked in opera tduring full -term pregna ncies, and 7.9 days/ ing room month a nd 5.8 days/month , respec tive ly, in Mean age (± s.e.mea n) 29.4 ± 0.2 7 29.7 ± 0.67 cases of mi scarri age. of mother a t conception The individua l subj ective scoring of con(either pa rent a naestracti on of infecti ons (score 0- 3) showed a thetist) M ea n weight (g ± 3455 ± 5 1 possibl e higher ri sk of occ upa ti onal infec tions s.e. mean ) of children a t in the FSP group: th e scores were 1.7 for birth male a nd 1.9 for fema le physicia ns duri ng full-term pregna ncies, a nd 1. 95 a nd 1.8, FSP M ea n gestation tim e 39.6 ± O.23 10.90 ± O.59 resp ectively, during p regna ncies en ding in (weeks ± s.e.mea n) when mi scarri ages. The corresponding scores either pa rent worked (not a mong anaesth etists were I. I for m a les a nd in operating room ) 0.8 for fema les during full- term pregnan cies 31.5 0.90 M ea n age (± s.e.mean) 29.9 ± 0.30 and 0.75 and 1.4, respectively, in cases of of mot her at conception (either parent paediamiscarri ages. tricia n) Exposure to ha loth a ne a naesth eti c vapour M ean weight (g ± 352 1 ± 45 at work in th e FSA group was subj ectively s.e.mea n ) of children a t evaluated to be slightly lower in cases of birt h m iscarriages (m a les 1.2 and fem a les 1.2) compared to exposure in the period immediNon-smoking wives of smoking ma le a tely before a nd during fuji -term pregnancies anaesthetists had 70 pregnancies, th ree of (m a les 1. 6 a nd females 1.4). There was a which (4.3 %) ended in miscarri age, whil e low estimated ex posure to x-ray radi ation in smoking female anaestheti sts (incl uding those a ll groups. to paedi a tri cians' famili es (49.2 %) . H owever, prior to entering opera ting room work the FSA group had a n even higher percentage of girls (58.25 %) . The di agnosed m iscarri ages in a naesthetists or their wives occurred earli er (8. 2 ± 0.65 weeks, s.e. mean) tha n those in th e FS P group (10.9 ± 0.6 weeks) (N.S. ). Somewhat sma ll er children were born to anaesthetists, a nd the week of ges ta tion in full- term pregnancies was lowes t for femal e a naesth eti sts, a lth ough th e differences were small Cf able 2).

OCCUPATIONAL HAZARDS IN ANAESTHESIA The commonest congen ital malformations in both groups are listed in Table 3. A striking difference was observed in the incidence of musculoskeletal anomali es: there were six congenital luxations of the hip joint and three congenital inguinal hernias in the FSA group, co mpared to no such anomali es in the FSP group. The most common malformations in both FSA and FSP children were non-malignant skin defects. Table 3 The number of congenital a bnorm alities in children of a naesthctists' (FSA) a nd paedia tri cia ns' (FSP) fa mili es during 196 1- 1976.

ASD VSD Pa tent Ductus flota lli Luxat ion of hip j oint Ing uin al herni a Spin a bifida Cuta neous haem angioma, naevus, birthmark ctc. Other Tota l

FSA

FSP

I 2

0 3

I

0

6 3

0 0

13 2

13 II

29

28

H epati c jaundice occurred in three anaesth etists, including one halothane hepatitis suspect. A halothane exposition test made after her recovery was, however, nega tive. Vira l myocarditi s was diagnosed in three anaesthetists, while other severe infec tions were encountered sporadically in both groups . Among paediatri cian s, differen t serious infections of the respira tory and urinary tract were th e co mmonest di sease groups. On ly one case of cancer was reported: breast cance r in a femal e paediatri cian .

DISCUSSION Due to a rather small material a nd a certain inhomogeneity of the working co nditions of th e groups studi ed , on ly limited conclusions can be drawn . However, the results indica te that in Fin land work in an op erating room (or gas polluti on IJer se) does not produce a

205

high er risk of reproductive or teratogenic complications or malignancies as compared to work in paediatrics. The rate of di agnosed spontaneous miscarriages was slight ly lower in anaesthetist's famili es tha n that in paediatri cians' families. Compared to Finnish anaesthesia nurses (ROSEI,BERG & KIRVES 1973 ) and anaesthesia personnel IJ1 several other studi es (cf. SMITH 1976), the miscarriage rates among Finnish a naesthetists and paediatri cians are lower ; but on the other hand , they are somewhat high er tha n th e rate of diagnosed spontaneous miscarri ages in the average population in corresponding age groups (JAEVERT 1957). Th e ac tual rate of spontaneous miscarriages, the m ajority of which occur undiagnosed very early after concepti on, is uncerta in, but may be over 25 % of a ll conceptions (HERTIG et a l. 1959). Wh ether th e employee was the husband or wife seemed not to influence the rate of miscarri ages in the FSA group, but an increased rate of miscarriages occurred when femal e paediatricians temporarily worked in anaesthesia around the time of conception. Prior to th eir entering anaesthetic work, the miscarriage ra te of future femal e a naesthetists was very low (1.4%) , proba bly due to the rela tively young ages of the parents and lack of occupational stress. Smoking physicians had in creased incidences of m iscarri ages, the highest (22 .9%) being observed in smoking female anaesth etists. The smoking habits, and rela ted di etary habits, were, however, not scrutinized. It is a known fact th at cigarette smokers give birth to sm all babies (LOWE 1959, FRAZIER et al. 196 1) a nd the carbon monox ide in cigarette smoke, as is th e case with many drugs, seems to interfere with oxygen transport in the placenta by inhibiti ng th e cytochrome P-450 fun ction (GURTNER & BURNS 1975 ). Congen ital birth malformations occurred at an equ a l rate in both groups. The reason for the relatively frequent occurrence of musculoskeleta l malformatIOns (mainl y hipj oint anomalies) in anaesthetists' children

206

P. H .

ROSENBERG AND H. VANTTINEN

remalOs obscure. No birth malformations of severely ill patients. Immunosuppression related to sex chromoso me anomalies were due to fatigu e or stress (cf. D UNCAN & CULLEN reported . Nor have any structural changes 1976 ) would enhance th e risk of acquiring in lymphocyte chromoso mes of operating- any exogenous or latent endogenous infection room nurses bee n detec ted (ROSENBERG & and of triggering the outburst of other latent K ALLIO 1977 ). diseases, or for the spread of malignancies. This retrospective study, which was No cases of malignant tumours were, howa nswered by a sa tisfactory number of Finnish ever, reported in the Finnish anaestheti sts, anaes thetists and paediatricians, showed that whi ch supports the results of th e British anaestheti c gas pollution may not be hazard- anaesthetists' survey (SPENCE e t a l. 1974). ous to the reproductive system . As trace concentration s of inha lati on anaestheti cs are proportionatel y metabolized to a greater ACKNOWLEDGEMENTS extent in th e body th a n are anaestheti c The authors g ratefull y acknow ledge the pl easa nt concentra tions (SAWYER et al. 1971 ), and as co-operation of their coll eagues in the F innish Socie ty a naesthetists m etabolize inha lation an aes- of An aes thesiologists a nd th e Finnish Society of thetics faster than e.g. pharmacists (CASCORBI Paedi a tri cia ns a nd th e va lu a bl e help provid ed by Mrs. Marj a Nykiine n . et al. 1972), th e normal gas pollution in operating rooms may not have ha rmful chroni c effects on th e personnel. Clearly, REFERENCES there is a need for more experim enta l work AMERICA:'< SOCIETY OF ANESTIIESIOLOG ISTS ( 1974) on th e effec ts of trace concentra tions of Occupa tion a l di sease a mong opera ting room inhal a tion anaestheti cs. In th e m eantim e, perso nnel: A na ti ona l stud y . Anesthesiology 41, 32 1. the operating-room anaesth etic traces should AsKROG, V. & H ARVALD, B. (1970) T eratogen effekt a f inha la tions anaes tetika. Nord. /vIed. 83, 498. be considered as po tentia l polluta nts, or at leas t as disturbing contaminants, and efforts CASCO RBI, H. F. , BLAKE, D. A. & H ELRI II , M . ( 1972 ) H a loth a ne bi otra nsformati on in mi ce and m a n . should be m ade to install effect ive gas Cellular Biology and T oxicity oj Anesthetics, cd . F INK, scave nging devices. B. R ., Wi lli ams & Wilkins Co., Ba ltimore, pp. Th e gas pollution in combinat ion with 197- 204. emotiona l and physical stress may, on th e COHEN, E. N., ll ELLV IL LE, J . W . & llROWN, B. W . (J r.) ( 1971 ) Anaesth es ia, pregna ncy a nd misca rriage : A o ther ha nd, disturb the hum a n body fun cstud y of opera tin g room nurses a nd a nes th eti sts. tions. Chronic stress a nd a lertness may cause Anesthesiology 35, 343. immunosuppress ion and provoke di seases, or CORBE'rr, T. H ., C ORNELL, R. G., LIIl DING, K . & cause hormonal di sturbances, anovu latory E ND RES, J. L. ( 1973) Tncicl ence o f cance r a mong Mi chigan nurse a nesth etists. Anesthesiology 38, 260. cycles, conception anomalies and frigidity. Diminished placental blood flow and oxy- D UNCAN, P. G. & CULLEN, ll. F. ( 1976) An es th esia a nd immunology. Anesthesiology 45, 522. genation during stress ful situations may result FRAZ IER, T . M ., D AVIES, G. H ., GOLDSTE IN, H . & in premature deliveries and sma ll babies. GOLDBERG, T. D. ( 196 1) Ciga rette smoking a ncl Indeed, anaes thetists in thi s study, as well as prema turity: A prospective study. Amer. J . Obstet. Gynec . 81, 988 . anaesthesia nurses 10 an earli er study (ROSENBERG & KIRVES 1973) had the small es t GURTNER, G . & ll URNS, B. ( 1975) Ph ys iologica l evid ence consis tent with th e prese nce of a specifi c babi es and sli ghtl y shorter gestation times 0 2 carri er in th e pl acenta. J . a/)/)I. Phys iol. 39, 728 . than the other groups. H ERTIG, A. T ., R OCK, J ., ADAMS, E . C. & M EN KI N, No parti cul ar group of diseases occurred M . D . ( 1959) Thirty-four fertilized hum a n ova, goocl , bad a nd indifferen t, recovered fr om 2 10 wom en of very frequentl y in anaestheti sts and paediaknown fertility. A stud y of bi olog ical was tage in tri cians, but th e cases of hep a tic jaundice a nd ea rl y hum a n pregnancy . Pediatrics 23, 202. m yocarditi s may be related to the occupation J AEVERT, C. J . ( 1957) Spontaneous and Habitual Aborin anaesth esia, where th e physicians are tiolls. M cG raw-Hill , New York , p . 209. closely in contact with blood and excretion s K NIL L-J ONES, R . P., M OIR, D . D. , R OD RIGUES, L. V.

OCCUPATIONAL HAZARDS IN ANAESTHESIA

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SPENCE, A. A., COHEN, E. N., BROWN, B. '''' ., KNILLJONES, R. P. & HIMM ELBERGER, D. U. ( 1977) Occupational hazards for operating room-based physicians. J . Amer. med. Ass. 238,955 . SPENCE, A. A .. KNILL-JONES, R. P. & NEWMAN , B. J. ( 1974) Studies of morbidity in a naesthetists with special reference to obstetric histOI),. Proc. roy. Soc. lIIed. 67, 989. VAISMAN, A . r. ( 1967) Working conditions in surgery and their effects on h ealth of anaesth esiologists. Eksp. Khir. Anesth. 3, 44. Address: P. I-I. Rosenberg, M.D. D epa rtment of Anaesthesiology H elsinki University Central H ospi ta l SF-00290 Hel sinki 29 Finland