Anesthetic Agents Are Not Harmful During Pregnancy—Reply

Abstract

COMMENT & RESPONSEIn Reply We thank Hunter and colleagues for their thoughtful letter and affording us the opportunity to clarify.As identified, a major hurdle in creating policies for pregnant surgeons has always been balancing protection and paternalism. Certain nonnegotiable safeguards need to be implemented; these are the basis of the policy outlined in Table 1. 1 Other recommendations listed in Table 2, including those regarding anesthetic gases, require shared decision-making and autonomy on the surgeon's part after they have been educated about the risks. 1 By separating a nonnegotiable policy that can be operationalized to protect pregnant individuals from items that require autonomous decision-making, we aimed to create a better solution to the problem of providing protection without exclusion or paternalism.Regarding the risk of anesthetic gases, clarity could have been offered in differentiating typical volatile anesthetics from nitrous oxide. For volatile agents, such as sevoflurane and desflurane, we agree that the risk to pregnant surgeons is low. This safety is accentuated due to modern scavenging. Nonetheless, scavenging is imperfect, and points of failure can occur at the system, anesthetist, or patient level, particularly in challenging mask inductions, emergencies, or airway surgeries. 2 Compliance with the US National Institute for Occupational Safety and Health Administration (OSHA) standards is mandatory, and best practices (ie, minimizing leaks and checking the scavenging system) should be performed at all times. 2 Nitrous oxide, however, is unique in that it has not been found by the US Food and Drug Administration (FDA) to be safe and effective and has been, in fact, grandfathered into exemption from FDA labeling requirements that address hazards, contraindications, side effects, and precautions. 3 OSHA specifically addresses limiting nitrous oxide exposure to less than 3 hours, citing risk of fetal loss. 4 While there will remain a paucity of institutional review board-approved, prospective, randomized clinical trials on the risks of nitrous oxide exposure to pregnant surgeons and fetuses, what is known is that exposure to nitrous oxide carries unique risks related to medical, genetic, and environmental histories, many of which are unscreened for or present asymptomatically. These include vitamin B 12 deficiency, aberrances in methionine synthase pathways, and more. 5 Furthermore, an abundance of biologic data