and introduce our next speaker, who's become a real good friend of mine, Sean Marie Strain, MD. She was educated at the University of Texas Health Science Center and graduated from med school there. She also has a BA in biology from the University of Texas in Austin. She did her internship and OBGYN residency both at UT Health Science Center in San Antonio. She has been the program director for about 15 months at the OBGYN residency program in Oklahoma City. We just got a compliment increase to go from eight residents to 12. So we're very excited about that. I'll tell you one thing about Sean Strain. I love everything about her. She is a turnaround master in terms of improving the culture of a program. And she's a phenomenally competent teacher and coach of young residents. Yeah, and I'm brown nose a little bit. Yeah. So prior to academia, she has a long and distinguished career in OBGYN. She spent most of her previous career as an OB hospitalist. She has been an ACOG surveyor and she also did some ambulatory practice early in her career. And she is of course, boarded by the American Board of OBGYN. Her office and my office are right next to one another in the same suite of offices. So I'll often regale her with boring tales of my life as a young Cajun boy. So without further ado, Dr. Sean Strain. Yeah, what I'll do if you want, I've got a little remote, but I can hopefully advance them. If I get stuck, I'll just ask you to press one of these buttons, okay? Okay, that's fine. Yeah. Well, I'll tell you, I routinely go into Jeffrey's office and I'm not a very quiet person. So I walk to the door and I go, Jeffrey! And it scares him almost every time. It's awesome. So I feel like one of those progressive commercials right now because I like to use my paper. I don't like to use the computer. So we can go to, and sadly, I do have no disclosures. I wish I did. I don't have any disclosures. So we're gonna start first with the definition of hazards. So there are substances or agents that affect the reproductive health of females or males or couples, and that interfere with their ability to have healthy children. So we need to distinguish those things from teratogens and those that affect both the mother and or the fetus. So teratogens only affect the fetus, right? So if you give a mother a substance that doesn't affect her, but can affect the baby only, that's the definition of a teratogen. So our employees of concern, females of childbearing age, males of any age, pregnant women. So in this talk, I'm going to exclusively speak about women now. So first thing you need to know is pregnant women, they work outside the home, okay? 70% of all women with children under 18 work outside the home. 50%, 56% of women who are pregnant work full time. And 82% of women who are pregnant for their very first time work until the very last month of pregnancy. And 73% of those who worked in pregnancy will go back to work within six months, okay? On this, these are the employment issues for pregnant women and parents. And as y'all know, there's a lot of federal laws that go along with this. With pregnancy discrimination and then pregnancy accommodations, lactation accommodations, and then job protection. And the United States is one of the very few nations that doesn't provide paid maternity leave. But these are the things that concern y'all. And most of these have to do with 15 or more employees, but things like medical leave only affect those with 15 or more employees. Next one. So hazards can affect a woman's reproductive system in multiple ways. So it can affect them with fertility, conception, pregnancy itself, or delivery, or the development of the fetus, the embryo, the infant, or the child. So harmful environmental exposures, of course, y'all know this, they're widespread, but they're often disproportionate in the underserved, of course. So in the United States, patients of color are more likely to live in counties with high pollution, indoor and outdoor, and to be exposed to a variety of toxicants, like lead, allergens, and pesticides than the white population. Disparities. The effects of increased exposure can be exacerbated by injustice, poverty, racism, neighborhood and housing inequality, psychological factors, and things like nutritional status. In the workplace, immigrants are more likely to work at low-wage jobs and are more likely to work at jobs where they're exposed to toxicants than others. Go back one slide. The reproductive hazards definitely exist in the workplace. So it's critical that clinicians providing OB-GYN care. So not necessarily you, but those of us who provide OB-GYN care be knowledgeable about the environmental hazards, especially relevant in their area. You don't have to know everything about every toxic exposure, but you should know those that are important in your area. Like when I was in private practice for 26 years in Corpus Christi, Texas, I needed to know about fracking because fracking is so common there. Next slide. So some toxicants are really well-known like mercury from contaminated fish, lead from paint. Mercury, we first really started talking about that with the studies of Minamata City where those pregnant patients didn't become ill. They didn't have lead poisoning, but they found that they were diagnosing so much cerebral palsy for years after this toxic exposure in Minamata. And what they found was, is that the placenta takes all of the lead or all of the mercury and concentrates it there, concentrates it in the placenta. So it didn't affect the pregnant mothers. It affected their offspring and they had cerebral palsy. So other things like anti-neoplastic drugs, cigarettes, smoke, BPAs, ethylene oxide, formaldehyde, flame retardants, things like that increase your risk of infertility and miscarriage. And then with preterm birth and low birth weight, there's a lot of them like air pollutants from fracking and then lead, mercury, all of those things do it also. I don't know why I did it, it's okay. Me and my paper, you know? Okay, so these are the other things that can cause preterm birth and low birth weight. And then neurodevelopmental delays, so many of them cause this, so many of them. And the problem is that neurodevelopmental impairment can occur anytime in pregnancy. It can occur in the first two weeks, in organogenesis and throughout their entire pregnancy. Okay, next slide. Okay, I'll do it. Oh, okay. So this next one talks to you about lead and it's talking to you about what we should really be asking them in their history. So for lead, you should be asking them about recent immigration. And you should ask them if they work with lead. Sometimes they don't even know that they do, but you need to ask them. Or if they know somebody that they live with that has been found to have a high lead content, because those things are mostly associated with neurodevelopmental problems. So other things are much less well-known. So let's consider this patient. This was a patient of mine in Corpus Christi, pregnant with her first pregnancy. She came in at 18 weeks and four days, and she had a temperature of 103, horrible body aches and debilitating headache. And this is what we found in her lab work. She had modestly elevated white blood cell count. She had LFTs that were about three times normal. Her platelets were decreased, I think they were 90,000. Her ESR was elevated. Her CPK was elevated. Chest X-ray was totally normal. We did a lumbar puncture, totally normal. Colter's normal. Fetal ultrasound, totally normal. And her spinal fluid was aseptic. So I tested her, oh, here, let's go. I tested her for typhus, because I truly thought she had typhus. In Corpus Christi, it wasn't common to see typhus, but we would see it. And I tested her for that. It didn't come back for eight days, because that's the problem with testing for typhus. It takes a long time to come back. But when it came back, it was totally negative. I did multiple blood, multiple urine cultures. All of them were negative. So the patient remained in the hospital for about 10 days, and she had recurrent high fevers, had the same myalgias, horrible headache. I gave her IV Zithromax. I did that because I thought she had typhus. And that's how you preempt pregnant patient with typhus. Otherwise, you give them doxycycline, but you can't give a pregnant patient doxycycline. That is a mistyping. I meant ampicillin and gentamicin. So I consulted the MFM. I consulted ID. Nobody could figure it out. But eventually, her fevers got her best, and she felt good. She went home. But a week later, she comes in, and she's so excited because she's going to have her ultrasound. And she tells me, I feel awesome. I'm so excited. And then we did her ultrasound, and the fetus was dead. So I induced her with Cytotec, and she delivered this beautiful baby girl, absolutely normal, and her autopsy was normal. So I referred this patient to one of my best friends, maternal and fetal medicine, Melinda McFarland in San Antonio, one of the smartest people I've ever known. And she calls me, and she said, I think this is coxiella burnetti. And I said to myself, I don't remember that, because I didn't remember anything about it. And sure enough, she was right. The uterine was positive, and it was quite high. So this patient's a lawyer, but the thing I didn't really talk to her about is the fact that she ranched. Almost every weekend, she would go out to her ranch. And not only did she go out to the ranch, unlike me who goes to a ranch and looks outside and says, oh, how beautiful. She actually goes out there and she works with the cattle. And that's what was important. She had Q fever. So this is a potential agent of bioterrorism. It wasn't for her, of course, but it could be used for that. It's a zoonotic infection. It's reportable in the United States. It's more common in males, much more than children and females. And most pregnant women aren't symptomatic. She happened to be horribly symptomatic, but it doesn't really matter because the same effects can happen if they're asymptomatic. So the symptoms can occur from nothing to severe. Next slide. So the way that you diagnose it is with immunofluorescence. Okay, the problem with that is they don't seroconvert until seven to 15 days, okay? So I couldn't have found it out for seven to 15 days with immunofluorescence. And they reached their maximum level by four to eight weeks. And that's important because she didn't get to see Dr. McFarland until four weeks after this infection. And then the titer stayed positive for about a year and they gradually decreased after about eight weeks. But we could have done PCR testing because it's positive up to seven to 10 days. So in that window where your immunofluorescence isn't positive, PCR testing can help. And you treat people who aren't pregnant with doxycycline for 14 days. But remember, you can't give a pregnant patient doxycycline. So how do you treat pregnant patients? You give them trimethoprim, cephalofoxazole until they're eight months pregnant. And all pregnant women, whether they are symptomatic or not, have to be treated because it gets to the placenta. So this long treatment decreases the risk of placentitis and obstetric complications, persistent Q fever. And then you have to discontinue it because when you get close to delivery, the fetus and or the infant can develop premicturus secondary to this. Next slide. So what did I learn? I learned that I better take a better history because if I had just really talked to her about her ranching, maybe I would have figured it out. And maybe the maternal fetal specialist could have figured it out. And maybe this baby wouldn't have died because we had put her on trimethoprim, cephalofoxazole. So I learned a big message there. So this was, uh-huh. So the cephalofoxazole is okay. I'm not going to be eight months, so I'm not going to be able to swallow that? You can. That is not our preferred antibiotic. It is not. But it is safe, especially when the risks outweigh it. And in this case, the risks outweigh it, okay? So yes, we don't generally use it. it's not our first line, but we will use it for UTIs when we have a UTI that's resistant to what we want to use, which is cephalosporins and nitroforantoin and phosphomycin. If it's resistant to that, then we go to BactrimDS or something like that. Very good question. So this was a huge study, and it was a study of lead, mercury, and PCB levels among childbearing age women. So 33% of women had two or more of these at equal to or higher than the median level for two of them. And then 23% had those same levels of three substances. So even though these were well below what's considered clinically significant, we don't know what the addition of all of these things together can do to a pregnancy or to a woman who is trying to get pregnant. So next slide. So our recent concerns are contaminants from plastics, okay, and consumer products like BPAs and phthalates. These agents act as endocrine disruptors. That's a big problem, okay, because these things can cause premature menopause, which some women say, oh, hey, that's great. I'd rather do that. Well, actually, you don't really wanna do that because once you go through menopause, you start losing bone, and your risk of heart disease goes way up. And the other thing it can do is cause precocious puberty, which is very dangerous because when you have an eight-year-old girl who's not going to get any taller because she has gone through puberty, or she starts having periods when she's eight years old, that's emotionally devastating to a young girl. So there's emerging evidence about the reproductive effects from these forever chemicals, the PFAs, because these have had life in the body for years, and they have no known agent that we know that can excrete them. So next one, the categories of reproductive hazards. So there's physical hazards, radiation. Radiation, generally very early, is an all-or-nothing phenomenon, meaning they miscarry or nothing happens. But at any other time after organogenesis, however, it can increase the risk of childhood cancers. Electrical shock, excessive vibration or heat, working conditions, working too long, working in too much heat, physical demands. And then the biological factors that we already talked about, that specific bacteria, viruses, parasites, and then toxic agents, like toxic exposure, whether that's prenatal or antenatal. Okay, so consider this patient. This is a 27-year-old, Ravita 2, para 1, morbidly obese. She was about 320 pounds. She was a patient of mine as a hospitalist in Houston. And she came in with cough, fever, fatigue, and no fetal movement. Her chest X-ray showed classic COVID pneumonia, her O2 sat started at 80%, and before we could get the oxygen on her, it was in the 70s. And her ultrasound revealed a fetal death again, okay? PCR was positive for COVID-19, okay? This was all before we had any COVID vaccines, of course. So the outcome was that I augmented her labor, because pregnant bodies are very smart. Women often go into labor themselves when there is a known problem. And so she was already laboring. She was having a regular contraction. She was three to four centimeters. So I just augmented her with oxytocin in the ICU, and she delivered spontaneously in the ICU without any problems. She was treated for COVID with all the normal agents that you normally use, and she got dramatically better after she delivered, because her respiratory problems got so much better with just delivery of the fetus. So COVID-19 is a biological factor. Pregnancy does not increase your susceptibility at all. It's just like the flu. The flu, you're not more susceptible to it when you're pregnant, but if you get the flu or you get COVID-19 when you're pregnant, you're more likely to die from it, or you're more likely to have severe disease. Vertical transmission, thank God, very rare. So if you have your baby and you have COVID-19, it's very unlikely that the infant will have COVID-19. But this really worries me for healthcare workers who are pregnant and those who want to become pregnant, because those who want to become pregnant, a lot of them are delaying pregnancy because they're scared of getting COVID-19 when they're pregnant. So the interesting thing about it is that pregnant women are not at increased risk of miscarriage from it or congenital anomalies. It seems to be the biggest problem in the third trimester. So there are increased risks of preterm birth, whether that's iatrogenic from us, because we deliver them so that they can breathe, or whether they go into labor because of COVID-19. There are increased risks of cesarean birth. The only problem with this is sometimes there's someone stable that we can't do a cesarean on them, okay? And then there are increased risk of intrauterine fetal demise, such as that patient. But the increased risk appears to be limited mostly to the third trimester and mostly in women with severe disease. So if they have mild disease, they seem to do very well in pregnancy. And they appear to be at increased risk of preeclampsia, but we're not entirely certain of this because severe preeclampsia can mimic things that are in COVID-19. COVID-19 can increase your LFTs, and it can decrease your platelets. And those are two signs of severe preeclampsia. And for us, it matters because with severe preeclampsia, what is the treatment? Delivery, right? Okay, so we're gonna deliver them if they're 28 weeks. So, and not all women with severe preeclampsia have elevated blood pressures. You have to remember that. So we may be delivering people that don't truly have it, that may just have COVID-19, but the problem is women can die from preeclampsia, severe preeclampsia, and babies can die because of placental abruption. So we do that. So adverse outcomes of toxicants. You can see there are tons of them, okay? So menstrual disorders, premature menopause, infertility, sub-infertility, all of these things can happen because of toxicants, okay? Next slide. So this is really challenging, okay? Because accurate data on baseline rates of specific adverse outcomes are difficult to assess, okay? And that's due to the absence of national monitoring systems in the United States. And lack of comparability among these studies, okay? And assessing risk is very difficult too because specific environmental agents have been associated with things. But as causal agents, it's hard to delineate that they are the cause. Next slide. So here is your background prevalence. So eight to 12% of couples are infertile. So how do you know that it was the toxicant exposure that caused that? Because eight to 12% are going to miscarry anyway. It's hard to determine. Same thing with all these other things like birth weight, preterm delivery, fetal birth. Was it because they were going to be one of these people in the first place? Or was it because they were exposed to a toxicant? And on chromosomal abnormalities in live births, that's very, very small. But if you remember, chromosomal abnormalities in humans are actually very high in pregnancy. The majority of them just don't result in live births. 70% of your miscarriages have chromosomal abnormalities, but chromosomal abnormalities in live births are actually very small. So it's hard to determine these things because you already have this underlying risk. Next slide. So limitations to these, I love that, these studies. There's the difficulty in assessing the dosing and the timing, when the mother was exposed to it or when the fetus was exposed to it. And then difficulty in accurate ascertainment of multiple co-exposures. There's always so many co-exposures that you don't know, was it this one thing or not? And then in most of these studies, there aren't controlled groups. So it's difficult to say, is this truly a causative agent? And then inadequate association of background prevalence, which is what we just talked about on the previous slide. And then difficulty with reliable ascertainment of outcomes. So a lot of women don't realize they're pregnant. They just think, God, my last period was so heavy. It was really painful. And oftentimes the OB-GYN is like, they might've had a miscarriage. So a lot of times women don't know that they were pregnant. And then incomplete ascertainment of multiple confounders. Again, so many confounders. So pathogenesis to these things. They can interfere with oogenesis. They can interfere with the menstrual cycle and fertility, and then they can interfere with fetal development. So let's talk about the first thing, oogenesis. All primary oocytes of the ovaries are formed by the fifth month of pregnancy. So when a woman is pregnant with a female fetus, that female fetus has all of the primary oocytes that they will ever have by the fifth month of pregnancy, okay? They never form anymore, they're done, okay? And the first myonic division occurs in utero. That's very important, okay? And then they're arrested like this until a woman ovulates for the first time. So in utero, exposure to toxicants can result in later problems with fertility, okay? And then toxic exposures during a woman's lifetime can result in genetic or cytotoxic harm to oocytes, okay? And then menstrual cycle and fertility. So toxicants can interfere with hormone synthesis and the secretion, and that usually causes problems with ovulation. That's the biggest one. And then menstrual disorders, oftentimes seen in athletes, agricultural workers, lead-exposed women, hairdressers, shift workers, anti-neoplastic nurses. You're gonna hear anti-neoplastic nurses a lot. And then reduced fertility. People forget about this. You see this in dental assistants because of nitrous exposure, cleaners because of organic solvents, and then industrial workers. And we think about the industrial workers, we just don't always think about the others. So interference with fetal development. This is where a lot of them occur. So the dividing zygote reaches the uterus about three days after it's fertilized. And then about three days after that, it's implanted. So that takes about a week to complete that cycle. So here's the developing fetus. And what you wanna look at is the first two weeks, usually first two weeks after implantation, what you see is prenatal death or nothing. So after that, the worst time is weeks three to eight, organogenesis. And if you'll look on here, you'll see that the heart's developing in three through five. The eyes are four and five. And then the limbs are early, they're four and five. But notice this guy called the central nervous system. It's developing from week three until they're born. And then it, as pediatricians know, it develops after birth. That's the big guy. So next slide. So toxic exposures by time. So during the first two weeks, this is generally the all or nothing phenomenon. So either they miscarry, and some women think these are likenances, or nothing happens. So if a woman comes in and they're screaming, oh my God, Dr. Strain, I didn't know I was pregnant and I got an X-ray. If they're still pregnant, nothing probably happened because it's all or nothing phenomenon. They either miscarry or nothing happens from it. But the bad time is three to eight, okay? So in that first two weeks, there's very little structural damage that occurs because they're rapidly dividing. So generally nothing or everything happens. This is when they're the most sensitive is organogenesis, the third through eight weeks. And it's not just in how they form, but it's in how they function too, sadly. So the consequences can be fetal loss, intrauterine growth restriction, birth defects, or impaired neurologic function, which is one of the most common ones, okay? Dosing and timing, very, very important because exposures occurring at critical periods in development has specific effects. And you saw that on that previous slide. If it happened at weeks four and five, it could be the limbs, it could be the heart, okay? So it depends on when it happens. And you can have a toxic exposure that occurred at week three and it would cause a different damage than if it occurred at week eight, okay? So it can be confusing. You think you're gonna memorize everything and then you realize, oh, they had it at that time. Oh, now I have to worry about this, okay? So next slide. So the CNS is the most sensitive organ because it can get hurt at any time in gestation, any time. So the brain's especially sensitive because they have an incomplete brain-blood-brain barrier. So they're still myelinating their neurons. They're still pruning them, proliferating them. And then they're very sensitive to hypoxia. So neurotoxins can adversely affect both their structural and cognitive development. It's horrible. So lead, mercury, tobacco can exert these effects throughout the entire gestation, okay? So prenatal exposure to numerous low-level, like we talked about before, numerous low-level things. We're very scared that this is what may be causing our drive in autism, ADHD, and cognitive behavioral impairments, okay? Organic solvents, these are generally related to shortened gestation. So they're much more likely to cause preterm deliveries, but they also have a role in neurological and behavioral function. So we have to be careful of those. Next slide. So these are agents with potential adverse effects on fetal growth. So this is just specifically speaking about growth. So strong correlation with carbon monoxide, cocaine, ethanol, and tobacco smoke. There's moderate strength of evidence for air pollutants and herbicides, pesticides, solvents, but little, limited evidence of the phthalates and the PCEs and TCEs and dioxins. Next slide. Does tobacco smoke also extend to marijuana smoke? Yes, it does. It has the same effects on growth and preterm delivery. Next slide. He asked if marijuana could have the same effect as nicotine, and it does. So pregnancy changes. This also makes it confusing because they can alter the amount of toxins. So now taking you back to physiology, okay? So they have delayed gastric emptying. Any woman who's ever been pregnant will tell you that, and they have reduced intestinal motility. So this makes it bad. That increases their absorption of that toxic agent. And then because they have increased minute ventilation and tidal volume increasing, their absorption of respiratory toxins is higher, okay? This can be a good thing. They have increased blood flow, so it decreases the blood concentration, but it increases the fat storage of lipid points, okay? And then the only good one is increased renal blood flow can lead to increased renal excretion. So we have one good one, okay? So, and then maternal factors, okay? So if an exposure leads to direct toxicity of the mother, so the mother is toxic, it can directly or indirectly affect the baby, like with carbon monoxide. If the mother has poisoning from carbon monoxide, then the baby is not going to be directly poisoned, but the baby is going to have less oxygen and less blood flow, and therefore can result in a fetal demise, okay? And then some agents, the PFAs, are associated with hypertensive disorders of pregnancy, which is one of the highest cause of death in pregnancy is from them. So the American Academy of Pediatrics, US Preventative Maternal Task Force, and the CDC promote breastfeeding as they should. Yes? Those are the polyfluorinated alkyls, yes. They're associated with hypertensive disorders. Yeah, that's what they're associated with, in addition to growth problems. They cause growth problems in addition. So yes, we want everybody to breastfeed. The problem is your breast milk can be contaminated. The good news is that there's very little problem with it, because even though lactation mobilizes those fat stores, so it increases the toxins that are fat stored, they can diffuse them into the breast milk. However, they rarely develop problems due to this, very rare, okay? So that's the great news. They did this study, it was actually a huge study, and they used a milk bank, and they made sure that these were in patients who did not have smoke in their homes, okay? So these infants averaged their daily dose of inhaled toxicants was 25 to 135 fold higher than anything that was in the breast milk. So you should feel good about saying, yes, promote breastfeeding, okay? So what should we do, okay? As OB-GYNs, we need to counsel patients about actions that they can take to minimize their risks, okay? That's something we should be doing, right? You need to be specific when you talk to them about their exposures, okay? So just don't say to them, do you have any problems at your house? Anything with your house? Anything at work you're scared about? You need to be specific with people, okay? And you need to say, do you work in an old building? Do you live in an old building that has old paint? You need to ask them specifically about fish. Do you eat predatory fish? And the things they need to worry about in pregnancy for mercury levels are things that are the highest in it. Shark, king mackerel, tilefish is the highest, tuna, swordfish, all of those things. You want them to not eat them at all in pregnancy. You don't want them to eat any raw seafood because of the risk of salmonella, okay? So you ask them specific things about that. And then we need to consider at their new OB visits about giving them a questionnaire that's written and ask specific questions because I think we've learned a lot more. And then for y'all, we need to be asking for copies of their safety data sheets because that will really help us. Um, so, and this is what y'all probably, probably beg us to do correctly and that we do incorrectly. OB-GYNs are notorious for saying, put them on light duty. Okay, does that help y'all? No, it doesn't help you at all because what happens is you can't, light duty is a legal term. And then y'all don't know what we mean. So we need to be specific and say, no heavy lifting after this many weeks. They can continue to do their normal work that they did before physically for up to 34 weeks, okay? So I need to give y'all these things from ACOG and if you'd like for them, I will include this, but ACOG has guidelines for job continuations, okay? So they say you can do light activities until 38 weeks, okay? You can do moderate activities until 32 weeks. You can do heavy activities until 26 weeks. Uh-huh. What's light, what's heavy, what's moderate? I'm gonna tell you, okay? And then very heavy activities can only be done until 20 weeks. And why do you think that is? So that uterus starts compressing the blood flow back, right? So here are the things that you can do. You can do repetitive stooping and bending up to 20 weeks. And repetitive to us means 10 times an hour. Intermittent stooping and bending up to 28 weeks. So I'll send you all of this if you would like this. And then climbing stairs. A lot of us, a lot of them ask me that. You know, how many stairs can I climb? So repetitive, four times in eight hours would be up to 20 weeks they can do that, okay? They don't always like to hear that because they always want to be told that they can't do it at all. And then intermittent, which is less than four times in eight hours, up to 28 weeks they can do that. So I can send you all that if you're interested in that. I think that'd probably be something that you would like to see and that I forgot to put in there. And another thing is long work hours, okay? So long work hours, over 40 hours, you really shouldn't do that as a pregnant woman. And doctors should be specific in giving that recommendation and say, don't do that because there is moderate, low to moderate evidence that this actually is true, okay? So, and then inconsistently it's associated with an increased risk of preeclampsia, right? So, uh-huh? Going back to the question, what about a 36 work hour a week? That's less than 40, but it's 12, 12, 12. That's actually okay. Okay. Yeah, that's actually okay. Okay, and Murray is really loud and he is a grandpa, but so, oh my gosh, we're very proud of him for not killing the teenagers, but what he asked is, can they work 12 hour shifts, three of those in a week? And yes, they can. So the 12 hours is fine. If they did it before, they can still do it. And that's the thing you have to remember. So, and then shift work and night work. Those have been shown to increase the risk of problems in pregnancy. And they aren't specific about this. They just say adverse pregnancy outcomes, and there's low to moderate evidence for that. So if they can do a day shift rather than a night shift, they should. The only thing is I have a lot of night shift nurses and they never want to change. I mean, and I understand that they get paid a lot more money, so I understand it, but I put that in there that they will not change. And then prolonged standing, and that to us is over three hours, okay? In general, prolonged standing is fine because it shows only low to moderate risk, but I just tell most of them, if you can sit down for the majority of your shift, please do so, you know? It's not gonna harm you to do that. And then heavy and physical lifting. Overall, during the first 34 weeks, they can do most of that. And trunk bending, they can do most of that. And there's limited evidence that it causes anything with spontaneous abortions. So I'll give you all of that. So this last slide. Environmental health is important for healthy pregnancies, fetuses, and infants. And it would really be beneficial to integrate this into OB-GYN training, because I will tell you that 30 years ago, I didn't get any of this, none of it. But my first day at work, one of my first patients in private practice says, Dr. Shrain, I need to know what I can do at work. Oh, never got trained on it. And so we need to do that more in training now. We need to talk about this more. And then for those that have been in private practice for a long time, we need to advocate training them too. And then we need to advocate for policies that will decrease the risk of these exposures. So that is my talk. I'm sorry, it's not very long. I didn't want to bore you too much. And if y'all have any questions, yes, ma'am. Thank you. Let me repeat it. To make a point with COVID, you know, it was the last three months. And I wondered if during COVID, you know, we recommended masks, and we recommended everybody to kind of stay safe. But knowing that in patients that they could live their life like all of us, but the last three months was so difficult if they haven't together. Did you advise your patients anything different? Did you take them all to work? Did you tell them to exclude the last three months? So the question was, did we do anything different? Did we advise anything different in pregnancy during the last three months when we found out that the last trimester is what mattered? The sad thing is when it was so bad, we didn't have that information. We got it a little bit after when the peak was going down. And so mostly what we tried to do is private practitioners. I was an OB hospitalist by this time, but most of the private practitioners tried to do most of their visits by telehealth because they didn't want their pregnant patients coming in. And it was a very scary time. Most of them didn't get to have any of their psychological support, emotional support. At first, we didn't let them have any visitors. Remember that? And then it got to where they could have one. Now, most hospitals are back to having normal visitation for pregnant women, but that was really hard on them to not have people. And we would say, you need to pick one because that's the only one. So if their husband was out of town when they went into labor, when he got there, he didn't get to come in because they had already picked their mother. I mean, it was horrible things like that. After we learned that we probably shouldn't do that, we got better about it. But at first we had no idea and we tried to just do as much as we could. And so sadly, we didn't know as much when the pandemic was raging. I have a two-part question and either for Dr. Strain or some of the occupational medicine physicians. And it's just curious. Are there any particular workplaces or occupational exposures that make women more prone to gestational diabetes? And the second part is, if a woman develops gestational diabetes, does it make her more vulnerable to these toxicants that you mentioned? He said Hershey's. And yes, I would agree with that. The phthalates have been shown to increase the risk of gestational diabetes and diabetes mellitus. But having them, having already had preexisting diabetes, I don't know that that increases their risk from the toxic exposure. I don't know that. Any other questions? So there's a question. I'm not sure if it's directed to Dr. Walden, but to our next speaker. Are you interested in receiving the environmental health history that was written by the doctors at the Environmental Health Clinic at Women's College Hospital in Toronto? I don't see why not. She says yes. Because there's just very little really for us. Just a little bit. Little really for us to help patients. This is very understudied. And like you saw, there's so many problems with those studies, because there's just too many confounding variables and pregnancy causes so many changes that it's understudied. So, and pregnant women aren't studied enough. That's the other big problem. Thank you. Anything else? And would y'all like to receive what I was talking to you about from the American College? It's actually very specific and I think that y'all might like it. And so I will get that to Jeffrey. He will send it on to you. Okay. Thank you.

OBGYN

environmental hazards

reproductive health

toxic exposures

fetal development

health disparities

OB-GYN training

maternal health