Reprinted with permission by The NAVTA Journal, a publication of the National Association of Veterinary Technicians in America. Pregnant? There Are Risks Veterinary Professionals Should Consider. By Shelly Van Dusen, LVT our dental x-ray I needed to be for minimal exposure. My office manager and owner were completely willing to do whatever was necessary to keep their staff safe. In a previous pregnancy, I had my toxoplasmosis titers checked, which were negative, so I felt that there was almost no chance that I would have been exposed in such a short time. I felt that I was safe because I had the knowledge needed to keep my unborn baby away from danger. Unfortunately, I did not always follow proper precautions because it was too inconvenient, I didn’t want to burden others, and I felt it could never happen to me. I performed parasite screens without gloves, ate lunch in the lab, assisted with small animal exams without gloves and mask, lifted animals that weighed more than my weight limit, performed CPCR on a bird, and other risky tasks. Above: Shelly Van Dusen and her 2-and-a-half-year-old son, Caleb. Before deciding to have a baby, I spent a long time researching the dangers associated with working at a veterinary clinic while being pregnant. I talked with coworkers that had children, talked to my OBGYN, and searched the Veterinary Information Network and other websites for any information I needed to know. There were even more risks because my office specialized in small animals and exotics. Even before I was pregnant, I requested that our anesthesia machines be inspected for leaks and our x-ray machine technician came in with a monitor to test how far away from The NAVTA Journal | July/August 2012 My son was born full term on July 9, 2010, and within 12 hours he had a seizure and he could not keep his temperature up. He was moved to the NICU and the doctors started looking for any infectious disease that could be causing an issue. The first test for infectious disease in newborns is the toxoplasmosis, rubella, cytomegalovirus, and herpes virus (TORCH) test and he was positive for toxoplasmosis. Over the next two weeks, our lives fell apart as we found out the parasite had caused severe brain and spinal cord damage and destroyed one eye. None of his doctors had ever seen a case of congenital toxoplasmosis and they were very pessimistic about his prognosis due to the MRI images. Even though it is more likely that I contracted toxoplasmosis by not washing my veggies or from undercooked meat, there will always be the guilty feeling that I could have done more to prevent it. This article is an overview of some of the risks associated with working in the veterinary field while pregnant. If the proper precautions are followed every time, a pregnant staff member can feel confident that she has done everything possible to keep her and her baby healthy while at work. Falling, Lifting, and Moving Lifting restrictions in pregnancy are mostly to protect the mother from injury. For most pregnant women, lifting a moderate amount is safe, if done properly. Their health care professional will give them a lifting limit, and it may change throughout pregnancy. This does not mean she can lift the animal with another person if half the animal’s weight is within her limit. Animals can struggle and she may end up with more of the weight than is safe. She should let others lift heavy animals for her. If there is a previous history of miscarriage, her lifting may be even more restricted, or she may not be able to lift at all. Ligaments loosen during pregnancy, making them more prone to injury, and weight has shifted the center of gravity forward, possibly making balance more difficult. Even though the fetus is well protected, a fall could cause complications to the pregnancy, or injury to the mother. Approximately 27 percent of women fall during their pregnancy, and 20 percent of those falls caused enough injury to need medical attention. Non-pregnant staff members can assist by lifting heavy animals and knowing your coworker’s weight limit. They can also take over restraining large and rowdy animals. Infectious diseases Pregnant women have a compromised immune system, so are more susceptible to zoonotic diseases. They are also more likely to be more severely affected by a disease that others may fight off easily. In general, pregnant women should be vigilant about washing their hands after touching each animal or bodily fluid, and avoid eating around animals or in the lab. They also should avoid handling any tissues from an aborted fetus, since several diseases that cause abortions in animals have the same result in humans. These are only a few of the zoonotic diseases that can cause issues in unborn babies. Each type of clinic has different risks for disease transmission. A pregnant staff member in a large animal clinic has a higher risk of contracting listeria while at work than at a small animal clinic, and a pregnant woman working at a small animal clinic has a higher risk of contracting toxoplasmosis while at work than a lab animal technician. All of this isn’t to say that you live in a plastic bubble during your pregnancy, but rather to take proper precautions and have as much knowledge to make your risk as low as possible. Q fever It is recommended that pregnant women do not assist in cattle, sheep, and goat births due to the risk of Q fever. Q fever can cause miscarriage, stillbirth, and low birth weight. The disease causes severe flu-like symptoms with high fever, weight loss, and pneumonia. It also has the risk of becoming a persistent infection and causing hepatitis and endocarditis. Influenza Pregnant women are more than five times as likely to be hospitalized for influenza as a woman who isn’t pregnant. This is most likely due to a compromised immune system and a decreased ability to expand their lungs, leading to secondary pneumonia. Ferrets are capable of transmitting many strains of influenza to humans and the H1N1 flu has been reported in dogs, cats, pigs, turkeys, and other animals. Symptoms of influenza in animals are similar to humans, such as fever, lethargy, nasal discharge, and decreased appetite. Pregnant staff members may want to avoid direct exposure to animals, especially ferrets, with these symptoms and get a flu shot. The American Congress of Obstetricians and Gynecologists recommends pregnant women receive a flu vaccine. Top: MRI of Shelly Van Dusens sons brain at 3 months old. The arrow indicates one of several toxoplasmosis lesions in the brain. Note the difference in sizes of the eyes which is a typical manifestation of the disease Lower: MRI of Calebs brain at 3 months old severely effected by toxoplasmosis Toxoplasmosis Toxoplasmosis is the most common parasite, infecting an estimated 2 to 3 billion people. Toxoplasmosis causes miscarriage, stillbirth, and many congenital abnormalities on surviving children. Those not diagnosed at birth develop eye lesions, learning disabilities, and other neurologic conditions such as seizures later in childhood. Many OBGYNs tell their pregnant patients to avoid cleaning litter boxes, and unfortunately some doctors may tell the patients to get rid of their cats. The truth is a person is much more likely to become infected by eating unwashed Publication of the National Association of Veterinary Technicians in America Reprinted with permission by The NAVTA Journal, a publication of the National Association of Veterinary Technicians in America. Tips Steps to decrease anesthetic exposure to the pregnant employee: §§ Check regularly for any leaks in the anesthesia machine and for proper functioning of the scavenger system. §§ Have someone else fill the vaporizer. §§ Attach the hose to the patient before turning the anesthetic gas on. §§ Leave the patient hooked to machine for as long as possible after turning off the gas, so that the scavenger system removes the off-gassing from the patient. §§ Recover patients only in well ventilated areas. §§ Masks with charcoal-activated filters remove halogenated gases from the air and can be used in high exposure situations, such as boxing down a feral cat or using uncuffed endotracheal tubes. veggies or undercooked meat, or after coming in contact with contaminated soil. Toxoplasmosis oocysts take more than 24 hours to become infective to others, so as long as litter boxes are thoroughly cleaned twice daily in the veterinary hospital, there is no risk. The risk to staff members comes from fecal samples brought in by owners that are more than 24 hours old, and from cats that have feces on their coats. All staff members should always wear gloves and wash hands when handling any type of feces. Unrelated to the work environment, pregnant women should cook meat, especially pork, to 160 degrees Fahrenheit and properly wash vegetables. Dr. Rima McCleod, leading world expert on toxoplasmosis, recommends the following: Pregnant women or those planning on becoming pregnant should be tested for IgM toxoplasmosis antibodies as early as possible, and if positive, then test for IgG antibodies for current infection. They should be tested monthly for IgG antibodies throughout pregnancy. If any test is positive at any time during pregnancy for toxoplasmosis, treatment can begin immediately to prevent infection to the fetus. This is the protocol currently used in France. Healthcare professionals often know only the minimum about toxoplasmosis, so pregnant women will have to inform their healthcare professionals more about the risks and testing. Lymphocytic Choriomeningitis Virus Lymphocytic Choriomeningitis Virus (LCMV) is a relatively little known disease that is transmitted by rodents and causes miscarriage or severe disease in unborn babies similar to toxoplasmosis, but there is no treatment. Adults have only flu-like symptoms. Pet rodents can be infected by coming in contact with wild rodents, usually in a breeding facility. Most cases of LCMV in people were from coming in contact with wild rodent feces, urine, saliva, or nesting material, but there have been reports of pet mice, hamsters, and guinea pigs causing infection. A pregnant staff member should talk to their healthcare professional for a recommendation on working around rodents at work. X-rays It is common for pregnant staff members to avoid taking radiographs. Exposure to high levels of radiation may cause a miscarriage, a child’s reduced IQ, mental retardation, increased cancer incidents later in life and growth retardation. wThe greatest risk to the fetus for survivable damage is between 2 and 15 weeks of pregnancy. After about 26 weeks of pregnancy, the fetus is no more sensitive to the effect of radiation than a newborn baby.8 The National Council on Radiation Protection recommends limiting the dose of ionizing radiation (the type used in x-ray machines) in pregnant women to 500 mrems (0.5mSv), which is equal to as little as 1 pelvis radiograph. For those who take radiographs before they know they were pregnant, it is recommended to wear Personal Protective Equipment (PPE) that reduces one’s exposure to radiation. If proper protocols are used, staff members should only be exposed to a very low amount of scatter radiation. The NAVTA Journal | July/August 2012 OSHA does not have a specific recommendation for occupational use of x-ray machines while pregnant, but they defer to other expert organizations in order for you to make an informed decision on taking radiographs. Human hospitals do not require that their employees stop taking radiographs, but due to the nature of our patients, we often need to physically restrain them for proper views and are much closer to the radiation source. To have the best information in order to decide whether or not to take radiographs, a pregnant staff member may want to check their last 12 months of radiation badge reports, which the employer is required to keep. Remember that the badges are worn on the outside of the lead apron, so they will have higher doses than a fetus would receive. The PPE should also be radiographed on a regular basis to make sure there is no damage allowing more radiation through. One may also want to discuss with the veterinarian whether to sedate patients or look into other restraint devises while taking radiographs so no one has to be exposed to any excess radiation. A pregnant staff member should address any questions about their work environment with their healthcare provider. Anesthetic Gases There is some evidence that operating room personnel who handle anesthesia while pregnant may be at increased risk for miscarriage and low birth weight. The National Institute of Health and Safety recommends that exposure to anesthetic gases not exceed 2 parts per million per hour for all employees. If you can smell the gas, the level is 5 to 300 ppm. To test the exposure level of staff members, there are personal monitoring badges available (VetEquip, Inc. and others) that are worn for an 8-hour shift and then evaluated by a laboratory. By doing this on a regular basis, it will benefit all staff members who may possibly be exposed to anesthetic gases. (see Tips) Your Career Online Resources Pharmaceuticals Pregnant women should avoid all chemotherapy agents, and all patient body fluids that contain chemotherapeutic agents or radioactive isotopes. Cancer drugs attack rapidly dividing cells, and so it is especially harmful to fetuses. Other drugs to avoid touching include oxytocin, prostaglandins, streptomycin and thyroid medications. Cats being treated for hyperthyroidism may also excrete medication in their bodily fluids, so pregnant women should wear gloves when cleaning vomit or litter boxes of these cats. Before my son was born, I had plans of spending the rest of my life being the best LVT that I could be, continuing to advance my knowledge, and possibly even becoming an anesthesia specialist. Because of my son’s multiple impairments and medically fragile state, I consider my new career to be as his personal manager. Our days together consist of therapy, tube feedings, doctors’ appointments and medications, but also include constant smiles, laughs, playing and cuddling. Even though Caleb has many challenges, he has amazed every specialist at his abilities and he has brought our family and friends closer than I would have ever imagined. I am able to get my technician-fix by volunteering regularly at my local animal shelter and I hope someday to be able to return to work at a clinic. Even though I don’t know exactly how I contracted toxoplasmosis, I still feel immense guilt that I did something to cause Caleb’s disability that I could have prevented. Know your environment and your risks, and help others do the same. No one should have to ask him- or herself: Could I have done more to protect my child? References 1. Dunning K, Lemasters G, Bhattacharya A. (2009, August 13) A Major Public Health Issue: The High Incidence of Falls During Pregnancy. Maternal and Child Health Journal. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/19672702 2. Fyksen, F., (2010, June 4) Zoonotic Diseases in Cattle: Practice Good Hygiene. Published in Agri-View, an agricultural newspaper in Wisconsin. www.acog.com 3. Center for Disease Control and Prevention. (2009, January 11) Q Fever. Retrieved from http://www.cdc.gov/ncidod/dvrd/qfever/index. htm The American College of Obstetrics and Gynecologists provides a physician directory, health columns and much more through its website. 4. Palo Alto Medical Foundation. (2010) Pregnancy and the Flu. Retrieved from http://www. pamf.org/flu/preg.html http://acva.org/docs/Waste_Gas 5. American Veterinary Medical Association. (2010, June 25) 2009 H1N1 Flu Virus Outbreak. Retrieved from http://www.avma.org/ public_health/influenza/new_virus/default.asp 6. McLeod, L., (2010) Ferret and Influenza: Ferrets can catch the flu, too. Retrieved from http://exoticpets.about.com/cs/ferrets/a/ferretsflu.htm 7. Center For Disease Control and Prevention. (n.d.) Lymphocytic Choriomeningitis Virus from Pet Rodents. Retrieved from http://www.cdc. gov/healthypets/lcmv_rodents.htm 8. Center for Disease Control and Prevention. (2006, May 10) Radiation Emergencies: Radiation and Pregnancy: A Fact Sheet for the Public. Retrieved from http://www.bt.cdc.gov/ radiation/prenatalphysician.asp 9. Occupational Health and Safety Administration. (2008, October 14) Ionizing Radiation Health Effects. Retrieved from http://www. osha.gov/SLTC/radiationionizing/healtheffects. html 10. Stabin PhD, CHP, Michael G. (2010, August 9) Doses from Medical Radiation Sources. Retrieved from http://www.hps.org/hpspublications/articles/dosesfrommedicalradiation.html 11. Cornick-Seahorn, J., Cuvelliez, S., Gaynor, J., McGrath, C., Hartsfield, S. (2006, March 17) Commentary and Recommendations on Control of Waste Anesthetic Gases in the Workplace. Retrieved from http://www.acva. org/professional/Position/waste.htm 12. Dosch, M. P., (2009, June) The Anesthesia Gas Machine. Retrieved from http://www. udmercy.edu/crna/agm/14.htm 13. University of Illinois at Chicago College of Pharmacy. (n.d.) Occupational Exposure to Hazardous Drugs—Recommendations for Oral Dosage Forms. Retrieved from http://www. uic.edu/pharmacy/services/di/faq/hazardous_drugs.php 14. Lau, E., (2010, February 10) New Feline Thyroid Drug Raises Safe-handling Questions. Retrieved from http://www.vin.com/ MEMBERS/CMS/Misc/VINNews/Default. aspx?id=14933 The American College of Veterinary Anesthetists’ position paper on controlling waste anesthetic gases also covers the health and performance of operating room personnel, including complications during pregnancy. www.ama-assn.org The American Medical Association’s official website. www.americanpregnancy.org Whether trying to get pregnant, or already pregnant, the American Pregnancy Association will likely have the information you are seeking. www.amazingpregnancy.com Amazing Pregnancy is an online source about conceiving and the stages of pregnancy. www.lalecheleague.org La Leche League provides information about breastfeeding. www.mayohealth.org Mayo Clinic is a well-respected, nonprofit leader in medical care, research and education. The clinic’s website has an extensive women’s health section, in addition to covering a wide-range of medical topics. www.nlm.nih.gov The National Library of Medicine’s website provides a diverse wealth of health-related information. To read more from The NAVTA Journal, become a member at NAVTA.net and log in to the online archives. Publication of the National Association of Veterinary Technicians in America