1. Management of occupational exposure for pregnant workers in the medical field in Spain
Emilio Casal. Centro Nacional de Dosimetría. Valencia
Belén Fernández. Hospital General de Asturias. Oviedo
Mª Jesús Manzanas. Hospital 12 de Octubre. Madrid
Ignacio Amor, Ana Blanes, Gloria Martí, Mª Dolores Rueda. Consejo de Seguridad Nuclear. Madrid
Spain

2. Control of the occupational exposure of pregnant women
Measures for women who are not pregnant are the same as for men.
After pregnancy declaration, special protection for the unborn child has to be provided …
… comparable with that provided for members of the general public.
… not creating unnecessary discrimination against pregnant women.
But, ... how is this special protection put into practice?
Occupational exposure of pregnant workers

3. How has this special protection been implemented?
It has been established a cooperation among:
Nuclear Safety Council (CSN)
Spanish Medical Physics Society (SEFM)
Spanish Radiation Protection Society (SEPR)
…within the Radiological Protection Forum
… creating a specific working group to study the practical application of fetal protection
The main conclusions of this group are presented in this paper
Occupational exposure of pregnant workers

4. Main conclusions of the Working Group
Information on fetal risks and protection measures
… for physicians and pregnant workers
Introduction of practical dose limits
… related to dosemeter readings
Evaluation of working conditions
… to fulfil the adequate protection of the fetus
Supplementary individual monitoring
… to verify that dose limits have not been exceeded
Occupational exposure of pregnant workers

5. Information on fetal risks and protection measures
Physician´s guide
… intended to gynaecologists, obstetricians and medical professionals in charge of the medical surveillance of exposed workers
Pregnant worker guide
… main information to give to female exposed workers
Occupational exposure of pregnant workers

6. Occupational exposure of pregnant workers
Physician’s Guide 
Main ideas to be transmitted to physicians:
Specific biological effects of ionizing radiation to be considered during the pregnancy. 
Deterministic fetal effects appear only for doses exceeding the threshold of mSv. 
The increment of probabilistic effects due to radiation exposure for doses about 1 mSv is much smaller than the spontaneous incidence rate of fatal childhood cancers that is about 2-3 per 1000.
The fetal dose limit of 1 mSv for the remainder of the pregnancy, after it is declared, provides an adequate protection to the fetus: it has been established based on ethical rather than fetal risk considerations.   
Occupational exposure of pregnant workers

7. Pregnant Worker's Guide
Main information to give to female exposed workers:
You must notify your pregnancy to the employer
… in order to decide the best protection methods for the fetus 
You must follow the guidances on radiation protection
… in order to keep doses to the fetus to a minimum 
You must wear a dosemeter on your abdomen
... to check that doses to the surface of the abdomen do not exceed the practical limit of 2 mSv during the remainder of the pregnancy
Finally, if your working conditions are such that doses to the abdomen should keep lower than 2 mSv, you can feel safe enough in your position during the rest of your pregnancy.
Occupational exposure of pregnant workers

8. Declaration of Pregnancy
This is to inform you that I am currently pregnant, in order to guarantee that the additional protection measures, foreseen in the corresponding regulations, are applied
Name:...……………………….... National Identification Document: ....…..
I am currently working in the following area …… …...
I am ___ weeks pregnant. My expected delivery date is…….. …...
Date of the declaration …………………
Signature of the worker
Signature of the Radiation Protection Officer
Signature of the Physician in charge of the medical surveillance of exposed workers
Occupational exposure of pregnant workers

9. Occupational exposure of pregnant workers
Practical dose limits
A supplementary equivalent-dose limit to the surface of the woman´s abdomen (lower trunk) of 2 mSv for the remainder of the pregnancy has been proposed
Nuclide intakes SHOULD be limited to about 1/20 of the ALI
... as proposed by ICRP’60 but unfortunately not incorporated in the Directive 96/29 or in the Spanish Regulation
Occupational exposure of pregnant workers

10. Evaluation of working conditions from previous dose information
If equivalent-dose to the surface of the abdomen:
A: with certainty will be less than 2 mSv
... no change needs to be made
B: is likely to be less than 2 mSv
... initiatives to reduce the probabilty of possible exposures should be taken
C: is likely to be above 2 mSv
... Pregnant worker shall be transferred to other work (A or B)
Occupational exposure of pregnant workers

11. Workers with annual doses exceeding
Distribution of annual doses exceeding levels of reference (Data from CND)
Year 2000
Exposed workers
Workers with annual doses exceeding
2 mSv
5 mSv
50 mSv
Women
20.095
337 (1,7%)
72 (0,36%)
Men & women
31.881
636 (2,0%)
146 (0,46%)
Occupational exposure of pregnant workers

12. Occupational exposure of pregnant workers
Distribution on categories and working types of cases exceeding the limit of 2 mSv (Data from CND)
Women. Year 2000
Physicians
Nurses
Technicians
Other
Radiology (General Practice)
1 (0,42%)
2 (0,40%)
9 (1,1%)
2 (0,24%)
Radiology (Hospital)
14 (1,3%)
7 (0,42%)
9 (0,33%)
6 (0,24%)
Vascular Radiology
8 (7,3%)
17 (5,1%)
1 (2,6%)
1 (0,58%)
Surgery
3 (0,56%)
25 (0,62%)
1 (3,6%)
8 (0,49%)
Radiotherapy
13 (4,5%)
4 (1,8%)
2 (0,62%)
Nuclear Medicine
15 (8,6%)
113 (57,4%)
37 (27,8%)
36 (13,6%)
1 (0,25%)
1 (0,34%)
Occupational exposure of pregnant workers

13. Working restrictions: Diagnostic Radiology
In general a pregnant worker CAN CONTINUE doing her job as long as she stays behind structural protection barriers
Pregnant workers SHOULD NOT work without structural protection barriers (fluoroscopy and mobile radiographic and fluoroscopic screening equipment)
Pregnant workers SHALL NOT participate in any emergency programme.
Occupational exposure of pregnant workers

14. Working restrictions: Nuclear Medicine
It will be necessary to avoid any significant risk of bodily radioactive contamination.
Pregnant workers SHALL NEITHER handle radiopharmaceuticals in controlled areas NOR participate in the care of patients under metabolic therapy.
Pregnant workers SHOULD NOT administer or inject radiopharmaceuticals to patients.
Pregnant workers SHALL NOT participate in any emergency programme  
Occupational exposure of pregnant workers

15. Working restrictions: Radiotherapy
In general a pregnant worker
CAN CONTINUE doing her job using linear accelerators and automatic after-loading brachytherapy 
SHALL NOT work in cobalt units due to the possibility of emergencies.
SHALL NOT handle radioactive sources in manual brachytherapy techniques.
SHOULD NOT participate in the care of patients being treated with manual brachytherapy techniques.
SHALL NOT participate in any emergency programme
Occupational exposure of pregnant workers

16. Working restrictions: Special situations
To avoid any working discrimination exceptionally pregnant women work could be allowed in the cases:
Mobile radiographic X-ray equipments,
Fixed and mobile fluoroscopic X-ray equipments,
Administration and injection of radiopharmaceuticals in NM
Nursing of patients under treatment with manual BT
with the following conditions:
pregnant worker voluntarily declares her decision of continuing
working conditions make it unlikely that the equivalent dose to the surface of the woman’s abdomen will exceed 2 mSv
a radiation protection service will verify those conditions, supervising it during the remainder of the pregnancy.
Occupational exposure of pregnant workers

17. Pregnant women’s external exposure monitoring
Doses to the abdomen of the pregnant woman will be estimated using an individual dosemeter:
placed on her abdomen
additional to the other dosemeter used to evaluate whole body doses
adequately identified (“abdomen dosemeter”)
Doses to the abdomen should be registered independently from whole body doses
But remember ... “The dose to the fetus is not directly comparable to the dose measured on a dosemeter placed on the abdomen”
Occupational exposure of pregnant workers

18. Pregnant women’s internal dosimetry
It is necessary to avoid any significant risk of radioactive intake by pregnant exposed workers.
If the intake probability would be negligible, there will be no need to implement any systematic assessment of internal doses to the fetus 
Individual monitoring for intakes of fetus is extremely complex and with a high level of uncertainty.
However, in case of internal contamination of a pregnant exposed worker, there are methods to estimate fetal doses (ICRP’88)
Occupational exposure of pregnant workers

19. Occupational exposure of pregnant workers: Conclusions
Information on actual risks to the fetus should be given to physicians and pregnant exposed workers.
Working conditions of pregnant worker shall be reviewed after pregnancy declaration.
Practical dose limit to the abdomen of 2 mSv during the remainder of the pregnancy has been proposed.
Additional dosemeter to be placed on the abdomen is required.
… in these conditions an exposed pregnant worker can feel safe enough in her job during the rest of the pregnancy.
Occupational exposure of pregnant workers