Reproductive and Developmental Toxicology
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A detailed exposure history of chemical, physical, and biological agents to which the employee is potentially exposed at work and in the home is critical. In this case of an operating room nurse, anesthetic gases, ionizing radiation exposure, infectious agents, prolonged standing, and shift work are among the occupational exposures to be considered. In addition, the work exposures of her spouse should be identified. These would include active and inert ingredients. Material safety data sheets can be obtained from employers to assist in identifying the components of various products used in the workplace.
Nonoccupational exposures to be considered for both spouses include smoking, infectious agents, use of alcohol, exercise, hobbies, personal care products, and cleaning agents. A hazard evaluation of the agents to which the employee and her husband are exposed at work as well as at home, then needs to be completed to identify which agents may pose reproductive or developmental hazards. However, material safety data sheets rarely provide detailed information about reproductive and developmental toxicity. For resources that may be useful in identifying reproductive and developmental hazards see the Appendix.
Next, the extent of the employee's and her husband's exposures to the agents identified as reproductive or developmental hazards must be assessed exposure assessment. Estimates of frequency of exposure, duration of exposure, and route s of exposure, and concentration or intensity should be obtained for each agent that may cause reproductive effects. It is also important to ascertain whether any exposure control measures, such as engineering controls or personal protective equipment, are used in the workplace or at home. If the employer has conducted personal exposure monitoring for the employee or her husband eg, radiation dosimetry or ambient exposure measurements in the workplace, the results should be obtained and reviewed.
A worksite evaluation by an industrial hygienist may be very useful. For selected agents, such as lead or mercury, biological monitoring may aid in quantifying exposure. Their estimated exposure levels should be compared with levels that have been demonstrated or strongly suspected to cause adverse reproductive effects in epidemiological studies or animal studies. In the classical risk assessment paradigm, if either the employee or her husband is exposed to an agent above or near levels associated with adverse effects, then there is considered to be significant risk. However, in the real world there may be incomplete data both on the hazard identification side and on the exposure side, and recommendations must be made on the basis of the available information.
Risk communication is the next critical step in which the employee and her husband are provided with the information they need to make informed decisions about the reproductive health risks of their exposures. It is important to answer all questions fully and to provide the best available information, including a discussion of the limitations of that information.
Risk management is the final step in the evaluation.
- 2nd Edition!
- History and Evolution of Reproductive and Developmental Toxicology Guidelines?
It requires that the physician, patient, her husband, and their employers work together to decrease or eliminate any potential workplace or nonworkplace reproductive risks that were identified. Exposure reduction or elimination is the most desirable approach to risk management. Options include eliminating the chemical s or agent s or replacing it with a safer one, implementing or improving engineering controls, designing and enforcing safer work practices, and issuing or upgrading personal protective equipment.
If none of these can achieve a safe environment, restrictions or a temporary transfer may be required. If the employer cannot or will not reduce exposure and no unexposed job locations for a temporary transfer are available, then the employee and her husband may face the difficult decision of quitting their jobs or continuing to work in situations that pose potential reproductive risks. Temporary disability benefits may not be available for a woman or spouse attempting to avoid exposure to prevent a possible adverse reproductive outcome. Temporary disability benefits are more likely to cover a pregnant woman in situations deemed to be high-risk or with current pregnancy complications.
Permanent removal from a job is the least desirable action, and it is important to help the employee and her husband evaluate all other possible options and uncertainties that might still exist with other workplace assignments. A year-old aircraft maintenance technician, whose duties include engine testing, refueling, and repair of airplanes and helicopters, is referred to the occupational physician after a positive pregnancy test.
Her supervisor requests your recommendations regarding her fitness for duty. On the day of her clinic visit, it has been 8 weeks since her last menstrual period. This is a much more common scenario than Case 1.
Reproductive and Developmental Toxicology
It is too late to prevent exposures during the preconceptional period and during the embryonic period, when many of the major organ systems are forming. A hazard evaluation and exposure assessment similar to Case 1 of employee's occupational and home environments needs to be performed to characterize the risks of the exposures that have already occurred and those that can be changed or stopped to prevent further damage.
Examples of possible hazards she may have been exposed to include jet fuel, degreasing agents, and other solvents. Exposure to organic solvents during pregnancy has been associated with increased risk of spontaneous abortion, and may also be associated with increased risk of birth defects. An airplane technician may be exposed to high noise levels that may reach up to decibels during engine testing and there is some suggestion that high noise exposures may affect the fetus although this is controversial.
If the risk assessment indicates that significant exposures to developmental toxicants may have occurred, the development of the major organ systems can be evaluated with fetal ultrasound examination. If significant exposure to mutagens may have occurred, amniocentesis may be indicated. Termination of pregnancy is rarely indicated unless there is frank maternal poisoning or documented fetal effect. If exposure is negligible or low then reassurance is generally indicated.
In the intermediate situation in which no maternal poisoning or documented fetal effects have occurred, but the risk characterization leads to the conclusion that significant developmental risks exist in the workplace or home, then prevention of continued exposure to these risks must be the priority. In all of these possible situations, it is important to fully communicate to the patient that the results of the risk characterization, including an assessment of the uncertainties and limitations in the conclusions that have been reached.