Special situations: Performance of endoscopy while pregnant

Accepted Manuscript

Special situations: Performance of Endoscopy while Pregnant Kerstin Austin MD , Haley Schoenberger MD , Sumona Saha MD, MS PII: DOI: Reference:

S1096-2883(19)30041-5 https://doi.org/10.1016/j.tgie.2019.06.001 YTGIE 50613

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Techniques in Gastrointestinal Endoscopy

Received date: Revised date: Accepted date:

5 February 2019 16 May 2019 7 June 2019

Please cite this article as: Kerstin Austin MD , Haley Schoenberger MD , Sumona Saha MD, MS , Special situations: Performance of Endoscopy while Pregnant, Techniques in Gastrointestinal Endoscopy (2019), doi: https://doi.org/10.1016/j.tgie.2019.06.001

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Special situations: Performance of Endoscopy while Pregnant

Authors:

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Kerstin Austin, MD Haley Schoenberger, MD Sumona Saha, MD, MS

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University of Wisconsin, Madison, Wisconsin United States

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Special situations: Performance of Endoscopy while Pregnant Abstract The rates of women entering the field of gastroenterology have been increasing over the past several years. Most of these women enter the field during childbearing years. At the same

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time, the procedural demands placed on endoscopists have been increasing as well. With these changes in demographics to the physicians performing endoscopy, more attention should be paid to the physical demands of scoping while pregnant. In this paper, we focus on several common, overlapping injuries that are frequently encountered during pregnancy and while

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performing endoscopy. Additionally, ergonomic modifications and strategies are outlined for both the pregnant and postpartum endoscopist. Given the lack of data in this area, dedicated studies aimed at this specific population would help guide further recommendations.

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Key words: Ergonomics, Endoscopy, Pregnancy

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Introduction Women have been entering the medical profession at increasing rates over the past several decades. Since 2017 more than 50% of medical school enrollees have been female [1]. The percentage of women entering gastroenterology fellowship has been increasing as well. It

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is currently estimated to be 32-34% up from just 16% in the 1996-97 academic year [2, 3]. However, gastroenterology as a field has been slower to see an equalization in the number of men and women entering the field. Data from the American Association of Medical Colleges (AAMC) in 2015 showed that women comprise just 16.4% of the total number of practicing

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gastroenterologists [4].

Although more of the physician workforce is currently male than female, multiple studies have found that female patients prefer to seek care from female physicians, with gastroenterologists and endoscopists being no exception. Several studies have shown a strong

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preference for gender concordance among women for screening colonoscopy providers and a willingness for female patients to wait to undergo their procedure until a female

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gastroenterologist is available [5-7]. Furthermore, a study within our own endoscopy unit found that female endoscopists performed a significantly greater proportion of diagnostic

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colonoscopies on female patients compared to male endoscopists, suggesting that gender concordance is important to female patients who are symptomatic as well as asymptomatic [8].

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The mean age at GI fellowship entrance is approximately 30 years [9]. Thus, most women enter their GI training and the first part of their careers as a gastroenterologist during the

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childbearing years. Prior studies examining the pregnancy risks among female physicians have primarily focused on pregnancy complications such as pre-eclampsia, pre-term labor and pregnancy outcomes such as miscarriage, stillbirth, and Cesarean delivery rates [10-12]. Some studies show higher rates of complications and adverse outcomes, and others show no differences compared to the general population. Few studies have focused on the impact of

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pregnancy on the day-to-day duties of female physicians, and none have specifically addressed performing endoscopy by the pregnant gastroenterologist. As endoscopy figures prominently in the careers of most gastroenterologists an understanding of the impact of endoscopy on the pregnant gastroenterologist is important. This

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review addresses overuse injuries commonly encountered during pregnancy and the workrelated complications for which the pregnant and post-partum endoscopist may be at risk.

Rights of Pregnant Workers

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Pregnant women are protected by the Pregnancy Discrimination Act, amended Title VII of the Civil Rights act of 1964 which classifies discrimination on the basis of pregnancy, childbirth or related medical condition as unlawful sex discrimination. This act includes protection of pregnant women against discrimination regarding hiring practices, health

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insurance, fringe benefits and leave and classifies it as similar to temporary disability. Any employer with more than 15 employees must treat pregnant women the same as other

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applicants or employees with similar abilities or limitations [13]. The Family and Medical Leave Act further ensured 12 weeks of unpaid leave following childbirth without losing one’s job [14]. In

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2010, the Fair Labor Standards Ave was amended to require employers to provide a place other than a bathroom which may be used to express breast milk. Additionally, an employee must

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receive reasonable break time to express breast milk for 1 year after the child’s birth [15].

Musculoskeletal Changes in Pregnancy Significant hormonal and anatomical changes occur during pregnancy, which may lead

to the development of new musculoskeletal complaints or worsen pre-existing disorders [16]. Elevations in hormone levels, particularly of relaxin, progesterone, and estrogen, increase joint laxity in pregnancy to widen the symphysis pubis in anticipation of delivery [17-19]. This joint

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laxity also places additional stress on joints and tendons and causes low back pain (LBP) and pelvic pain in pregnancy [20]. Furthermore, physical changes, fluid retention and weight gain lead to forward movement of the center of gravity. This shift increases stress on the lumbar spine and abdominal musculature, and raises the risk for LBP, knee and hip pain, as well as

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carpal tunnel syndrome (CTS) [16, 21]. These physiologic changes of pregnancy lead to nearly universal report of musculoskeletal discomfort by pregnant women and disabling symptoms, at least temporarily, in 25% [22].

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Low back pain of pregnancy

LBP is one of the most common complaints of pregnant women and is reported four times more frequently in pregnant women than age-matched non-pregnant women [23]. The estimated incidence of LBP in pregnancy ranges from 50-90% [24-27]. It is a common

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consequence of repetitive physical labor and is likely to be exacerbated by the physical changes associated with pregnancy [28]. Lifting is an important risk factor for LBP and injury. As

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pregnancy progresses, anything lifted will increase load on the spine due to increased abdominal size requiring objects to be held further from the body [29, 30]. LBP can be

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encountered any time during pregnancy, but is most often reported at or after 22 weeks’ gestation. After that point, the growing uterus places mechanical strain on the lower back,

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causing exaggeration of the existing lordosis of the lumbar spine, and an anterior shift to the center of gravity [31]. In addition, the sacroiliac joints become more relaxed during pregnancy,

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creating additional strain on the pelvis and lower back. Relaxin levels have been found to be higher in women who report higher levels of LBP [32]. LBP of pregnancy can often lead to disability and loss of work. A prospective, controlled

Scandinavian cohort study by Noren et al. found that 20% of women took sick leave during or after pregnancy due to LBP. The average loss of work due to LBP was high (30 days) despite active treatment with physiotherapy, signifying a large economic burden [33]. Risk factors for

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LBP during pregnancy include a prior history of back pain, multiparity and low endurance of back flexor muscles [34,35].

Pelvic Girdle Pain

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Pelvic girdle pain typically presents for the first time in the first trimester and causes intermittent pain which localizes to the area between the posterior iliac crest and the gluteal fold near one or both sacroiliac joint [20]. Although less common than LBP, one Danish study found pelvic girdle pain to complicate approximately 20% of pregnancies [36]. It may occur in

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conjunction with the pain in the pubic symphysis [37]. It is worsened by exercise and weightbearing activity and can also be precipitated by prolonged sustained postures or by routine activities such as walking, sitting or standing [25,38,39]. Pelvic girdle pain may lead to gait changes and subsequent knee and hip pain. In rare circumstances, bony resorption about the

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symphysis and ossification can occur, resulting in osteitis pubis [31]. This condition is characterized by the gradual onset of severe pain radiating down the bilateral thighs. Other rare

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but severe conditions, such as femoral head osteonecrosis and transient osteoporosis of

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pregnancy, can also cause hip pain in pregnancy [31,40].

Knee and Foot Pain

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Ligamentous laxity in pregnancy also leads to relaxation of the peripheral joints and is likely a significant contributor to the development of knee and foot pain during pregnancy. The

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reduction in ligament rigidity is believed to weaken joint stability and increase demands on stabilizing muscles [41]. With regards to the knee, increased lateral movement of the patella can occur during normal flexion and extension of the joint [42]. This leads to increasing pain with repeated flexion and extension or prolonged standing. The forces absorbed across all joints in the lower extremities can increase up to 100% during pregnancy, which can cause cartilage breakdown and pain [43,44].

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Carpal Tunnel Syndrome Increased fluid retention in soft tissue structures is widespread throughout the body during pregnancy and is likely the result of changes in circulating hormones and increased fluid

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levels [45]. This fluid retention increases the risk for developing a cumulative trauma disorder such as tendinitis, tenosynovitis or carpal tunnel syndrome (CTS) when the pregnant woman engages in highly repetitive tasks involving the upper extremities [46,47]. CTS affects up to 10% of the working adult population and 34-62% of pregnant women [48,49]. It is second to LBP as

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the most common pregnancy-related musculoskeletal injury reported among pregnant women [36].

CTS classically presents with pain and numbness in the distribution of the median nerve, with more severe symptoms at night. Multiple factors may contribute to the development of CTS

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in pregnancy in addition to soft tissue edema, including hormonal changes which soften the ligament which forms the roof of the tunnel, body habitus, carpal tunnel size, gestation interval,

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weight gain and repetitive activities [50].

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DeQuervain’s Tenosynovitis

DeQuervain's tenosynovitis is a well-recognized cause of radial aspect wrist pain during

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late pregnancy and the post-partum period [51]. It is caused by inflammation in the first dorsal compartment of the wrist which contains the abductor pollicis longus and extensor pollicis brevis

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tendons. As with CTS, pregnancy-related fluid retention and repetitive movements are likely strong contributors to the development of deQuervain’s tenosynovitis [52].

Work-related pregnancy complications and injuries

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With regards to the workload of pregnant physicians, several studies have found that physicians often do not have any work-related schedule modifications prior to delivery, including to their night call schedules [53, 54]. This may have psychological and physical effects on the pregnant physician and may also affect fetal health [54]. Studies evaluating maternal and fetal

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complications among pregnant physicians have reported higher rates of stillbirth and premature delivery among medical residents compared to the general population despite no statistically significant difference in the mean age at the first delivery [53]. Additionally, a study comparing infants born to obstetricians before, during, or after residency found that infants born to mothers

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during residency were more often low birth weight [55]. However, a systematic review of studies addressing five occupational exposures (working hours, shift work, lifting, standing and physical workload) but not limited to physicians did not find a strong association between these exposures and several adverse birth outcomes (preterm delivery, low birth weight, small for

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gestational age) or to certain maternal complications (gestational hypertension, and preeclampsia) [56]. Another study, a meta-analysis of shift work on pregnancy outcomes among

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shift workers did find a significant increased risk, albeit small, for preterm delivery, low birth weight and small for gestational age. In a 2013 study by Bonde, night shift workers were found

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to have an increased risk for miscarriage [57,58]. Falls are the most common source of occupational injury and occur frequently in

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pregnant women due to joint laxity and shifts to the center of gravity [59]. They are a common cause of minor injury during pregnancy and are estimated to cause 17–39% of trauma

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associated with emergency department visits and hospital admissions [60]. Data on falls during pregnancy in the work-setting are not readily available, though environments with stairs, slippery floors, uneven or sloped ground, poor lighting and clutter may put pregnant workers at higher risk. Physically demanding work has been associated with a higher rate of adverse maternal and fetal health outcomes including growth restriction, small for gestational age, and pre-

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eclampsia [61-63]. In particular, occupational lifting has been found to be detrimental, carrying a consistent pattern of increased risk for miscarriage [64,65]. Other work requirements such as constrained postural demands (e.g. prolonged standing and stooping) may exacerbate mechanical compression, altered venous tone and poor venous return from the lower

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extremities and possibly induce fetal hypoxia [61]. Even sedentary work such as prolonged periods of time at a computer workstation may adversely affect the pregnant woman, increasing the risk for musculoskeletal disorders of the back due to flexed posture needed to reach past the growing abdomen, and of injuries to the shoulders and upper extremities if they are not

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supported [66].

Ergonomic Risk Factor Modification for the Pregnant Worker

Increased understanding of the risks which work-related tasks may pose to the pregnant

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worker has led to the development of guidelines to reduce occupational risks. The guidelines include provisional recommendations for weight limits for lifting at work during pregnancy from

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the National Institute for Occupational Safety and Health (NIOSH) and endorsed by the American College of Obstetrics and Gynecology [28-30]. Expert panels have also made

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recommendations to reduce other ergonomic risks posed by physical exertion, posture, work hours and shift work [67]. With regards to posture, pregnant workers whose jobs require

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prolonged standing should minimize static postures, awkward postures, and reaches over 40 cm (16 inches). Bed height should be adjusted to allow room for expanding abdomen. In our

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experience, resting the abdomen on the bed helps to relieve some of the increased weight of the abdomen while allowing the endoscopist to stand closer to the patient and avoid reaching and leaning forward. Additionally, this position will encourage the correct ergonomic alignment of the bed at elbow height or 10 cm below as recommended by the 2009 ASGE recommendations [68]. Standing should be limited to two hours, and pregnant workers should be provided with footrests and floor matting to reduce low back strain [45]. To prevent back

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strain due to the larger size of the abdomen preventing the physician from reaching her workstation and to help maintain neutral posture, the pregnant endoscopist should be provided a back rest to support the lower back while seated [69,70]. With regards to work hours and rotating shifts, it is recommended that work weeks be limited to 40 hours and that rapidly

Considerations for Performing ERCP while Pregnant

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rotating shifts and work at night be avoided unless undisturbed day sleep is possible.

Endoscopic retrograde cholangiopancreatography (ERCP) poses unique risks to

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the performing endoscopist. The most commonly reported musculoskeletal complaints among these providers includes back pain, neck pain and hand pain [71]. Procedure-related factors which increase the risk of injury include longer duration of cases, unusual positioning and the need for protective lead aprons [68]. Lead aprons, weighing up to 20 pounds, increase static

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load to the lower back [72]. Practitioners in other fields in medicine which require use of lead aprons, such as interventional cardiology and interventional radiology, also reports high rates of

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LBP [73-75]. Lightweight or two-piece lead aprons may help mitigate the LBP and disk disease

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by reducing pressure on the intervertebral disks [76-78].

The risks of radiation exposure to the developing fetus have been well established and include

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organ malformation, mental impairment and pediatric leukemias [79]. Several studies have addressed those risks in medical personnel exposed to ionizing radiation in the workplace [80].

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These studies have largely found fetal risk to be negligible when proper safety practices are followed [80, 81]. A study of vascular surgeons and trainees who wore standard (single) protective garments had average abdominal dosimeter readings below detectable levels [82]. As radiation transmission is affected by the lead equivalence of the apron and the criteria for the lead equivalent coverage varies from state to state, it is recommended that the pregnant operator be aware of the degree of apron protection (which typically ranges from 0.25 mm to

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0.75 mm) and consider additional coverage with use of 2 lead aprons (“double lead”) or a “maternity” lead apron, if the lead equivalence is low [83]. Maternity lead aprons that wrap around are commercially available and provide an additional 0.5- to 1.0-mm protection in the

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fetal area.

Thus, pregnancy should not preclude endoscopists from performing ERCP. However,

precautions should be taken given the unique risks of ERCP including radiation exposure and

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increased static load on the lumbar spine.

Ergonomic Risks to the Pregnant or Postpartum Endoscopist and Endoscopy Modifications Several common musculoskeletal injuries encountered during endoscopy overlap with those occurring during pregnancy. Specifically, LBP and CTS, the two most commonly reported

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musculoskeletal injuries during pregnancy, are frequently encountered among endoscopists as well [84]. Similarly, deQuervain’s tenosynovitis which is well described during pregnancy and

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post-partum commonly occurs frequently among endoscopists [85]. General risk factors for the development of LBP include female gender, abdominal

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obesity and occupational ergonomic risk factors [86, 87]. Health care specific physical factors that increase the risk of LBP and that are common while performing endoscopy, include patient

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handling, sustained awkward postures and twisting of the trunk. Treatment options for LBP in pregnancy include massage and myofascial therapy to reduce muscle tension in the paraspinal

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muscles. Physical therapy targeting the gluteal muscles and hip extensors and abductors can help with stabilization [39]. Supportive belts to decrease pressure to the pelvis and back can be helpful as well [39]. With regard to CTS, no studies have evaluated the incidence of CTS in pregnant endoscopists, but given the high baseline rate of CTS during pregnancy and the risk for CTS development posed by repetitive motions such as those used to perform endoscopy, it is likely

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to be even higher than in the general pregnant population. Treatment of this condition is generally non-invasive and starts with wearing wrist splints while sleeping. Women performing endoscopy may benefit from wearing splints while performing procedures to prevent wrist flexion which diminishes the area within the carpal tunnel, in turn increasing compression and

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symptoms. Fortunately, most cases of CTS (85%) resolves within 4 weeks of delivery [88]. However, it is not known if female endoscopists who develop CTS during pregnancy are at increased risk for persistent and/or refractory CTS following delivery due to their ongoing performance of repetitive movements.

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DeQuervain’s tenosynovitis which arises during pregnancy or the post-partum period is thought to arise from ligamentous laxity and the awkward positions that new mothers take including repetitive lifting of the newborn and hand position while breastfeeding [89]. Notably, deQuevain’s tenosynovitis has also been dubbed as “endoscopist’s thumb” or “colonoscopist’s

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thumb” in the endoscopy literature [85]. Endoscopy-related risk factors for deQuervain’s include repetitive extension of the left thumb while using the elevator during endoscopic retrograde

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cholangiopancreatography (ERCP), and during colonoscopy with knob manipulation. Alterations in practice to address the condition include decreasing procedure volume, modifying procedure

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scheduling, changing endoscopic technique, and altering endoscope design [85]. In breastfeeding endoscopists with wrist pain, schedule modifications with breaks may help

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decrease the frequency of this overuse injury. Furthermore, thumb spica splints, icing, nonsteroidal anti-inflammatory drug (NSAID) use in the post-partum patient and corticosteroid

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injections in the pregnant and/or post-partum patient can be considered [22].

Injury prevention often includes both workplace ergonomics interventions as well as

individual worker interventions. Workplace interventions include modifications to make the job itself fit the worker. In the endoscopy suite, this includes using adjustable beds and monitors, cushioned mats, and two-piece lead for procedures requiring fluoroscopy [68]. Additionally,

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many hospitals have dedicated physical or occupational therapists on staff who perform ergonomic evaluations for a provider and give individualized feedback on how to optimize one’s workplace environment. These resources should be utilized whenever available. The individual worker interventions include increasing physical exercise as primary prevention for overuse

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injuries. No studies have shown that efforts to improve an employees’ physical health decreases the rates of LBP although low back flexor strength has been shown as a risk factor for

development of pain [87]. During pregnancy at least 150 minutes per week of moderate intensity exercise is recommended for most women, although certain high-risk populations are excluded

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[90]. Pregnant endoscopists should also seek accommodations, when needed, to allow them to continue to work safely.

Given the above risk factors including prolonged standing time with frequently awkward and static postures required during endoscopy, we recommend decreasing the number of

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procedures performed by the pregnant endoscopist in the third trimester by at least 1 during a half day of scoping. The adjusted schedule should contain increased time between procedures

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to allow the pregnant endoscopist to sit down, stretch as needed and rehydrate. Women should discuss modifications with their scheduling staff early in pregnancy to adjust their schedules as

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delivery approaches and avoid cancelling patients. In between procedures, pregnant women should have foot rest available to prop up their legs while using the computer to avoid lower

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extremity swelling. Although not reaching significance, there was a trend toward reducing lower

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extremity swelling in the third trimester in pregnant women [91].

Future Directions With more women entering the field of gastroenterology, better understanding of the risk

for musculoskeletal injuries that they face when performing endoscopy is needed. It has now been shown in several studies that female endoscopists may be at higher risk for endoscopyrelated injury compared to their male counterparts [92]. Whether that risk is heightened during

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pregnancy or the post-partum period is not known, but of great interest. Furthermore, studies of the biomechanics when preforming routine endoscopic procedures while pregnant are needed to assess the impact of pregnancy-induced ligament laxity on muscle contraction and joint loading. Such studies should ideally lead to ergonomic modifications to reduce injury and allow

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endoscopists to remain productive and safe during pregnancy and long after delivery.

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Authors declare no conflicts of interest

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