Introduction The influence of environmental exposures on the general status of health has been increasingly acknowledged for numerous disease outcomes. The connection between air pollution and acute respiratory disease, for example and, more recently, the observation linking poor indoor air quality to increases in the incidence of childhood asthma has been widely publicized. Such epidemiologic observations are often reported in the media and, when combined with the growing public interest in a clean and healthy environment, have translated into an increasingly sophisticated patient population that expects healthcare providers to be conversant with the environmental contribution to disease risk. Indeed, the lay public often has shown more interest in– and occasionally knowledge of– the relationship between health and the environment than has the medical community. 1 2 3 Sources of environmental exposure Organizing the environmental exposure history can be facilitated by using the definition referred to above and by eliciting information on aspects of the patient’s larger environment; this includes the specific community locale (workplace and her home environment) and infrastructure which relates to air quality and soil or water pollution, all of which the patient deals with on a regular basis. Community Surprisingly, a clinician would likely not know if a given patient in his/her practice was living in an area near by an environmentally polluted location, such as a National Priority Listed (NPL) waste site or a local toxic waste dump. In large metropolitan areas, many such sites are present and unknown to most citizens. Although clinically significant exposure to a toxic hazard present on the site would be unlikely to threaten the wider community, a risk may exist for some residents living very close to the site, possibly allowing for soil or drinking water contamination. In specific instances often covered by the news media, patients would likely be able to report knowledge of living in the vicinity of such a place. Such a ‘self-report’ response could be elicited by simply asking the question, “Do you live near or have contact with a waste site?” Probably the most potentially important exposure opportunity is via contaminated drinking water. Here the biggest risk is usually from a small private water source such as a well, not subject to municipal water treatment standards and testing. According to the EPA approximately 15% of the U.S. population has a private drinking water source. Workplace An intimate relationship exists between occupational and environmental health, because often the source of environmental contamination is a former (or present day) work site. The workplace is an important ‘special case’ in environmental history taking, because populations exposed at work tend to be exposed at higher concentrations than the larger community, regardless whether contamination is via air, water or soil. Thus, though the working population is smaller than the public at large, workers are exposed at higher ‘doses’. It is thus sometimes observed that workers are the ‘canaries’ or ‘sentinels’, exhibiting first the health effects which might be expected in a wider community exposure from an environmental pathway. 4 1 5 Table 1 Employment sectors and associated reproductive/develop-mental toxicants Sector Toxicant Examples Agriculture Pesticides/Herbicides Ethylene Dibromide Manufacturing Organic Solvents Glycol ethers, lead,  Heavy Metals Cadmium Dry Cleaning Solvents Perchloroethylene Printing Solvents/inks  Pharmaceutical Compounding/Manufacture Hazardous Drugs Antineoplastics, hormones, immunologic modifiers Health Care Biologics Rubella, CMV, Hepatitis virus  Physical Agents Ionizing Radiation/Heat  Chemicals Antineoplastics/Hazardous Drugs Anesthetic Gases Sterilants  Physical Exertion Lifting/Prolonged Standing Shift Work Note. Home Here, one must consider the exposure opportunities posed by the woman’s residential environment, such as those involved with household tasks, those related to her pursuit of hobbies and those related to her ‘micro-environment,’ including diet. Diet 6 7 8 9 Consumer advisory on methylmercury in fish In 2004, the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) issued a joint consumer advisory on methylmercury in fish and shellfish. The warning specifically targets women who may become pregnant, are pregnant or are nursing mothers, and also includes young children. The document emphasizes the health benefits of fish in the diet generally as a good source of protein, and also warns of several types of fish which contain comparatively higher concentrations of mercury and should be avoided. These include: shark, swordfish, King mackerel and Tilefish. Other types of fish may be consumed in up to two meals (6 oz each) per week, including: shrimp, canned light tuna (but not albacore, which has more mercury), salmon, pollock and catfish. The Advisory also warns about local fish advisories, which are generally posted for specific populations which supplement their diets with locally, caught fish. Appropriate discussion of relevant advisories should take place in the preconception visit and is especially important for non-meat eating patients whose total dietary intake of fish may be relatively greater than is the case for meat consumers. Also of note, the U.S. Department of Health’s Women’s Infants, and Children Program (WIC) sometimes gives canned tuna as a diet supplement. This practice should be weighed in light of the above concerns, however, at least in terms of the relative amount of tuna in a weekly diet. The complete consumer advisory can be found at: www.epa.gov/ost/fish. Hobbies and home-based work The hobbies of concern generally would include those involving similar types of chemical toxicants discussed in the occupational section above, including heavy metals (lead, cadmium, arsenic) and solvents (paints (other than latex based), furniture stripper, metal cleaners etc.) Hobbies to be discouraged include: painting, ceramics, stained-glass window making (lead solder), furniture re-finishing and the like. Leisure activities to be avoided include use of saunas and hot tubs. 10 11 Household exposures 12 13 Fig. 1 Example checklist for initial qualitative evaluation of reproductive hazards, (modified from Grajewski, 2005)  Fig. 2 Example of checklist for initial quantitative evaluation of reproductive hazards, (modified from Grajewski, 2005)  Many non-latex paints are solvent based and contain small amounts of metals to enhance wear, and as preservatives. This is especially true of exterior paint, such as that used on porches or building exteriors or even in the interiors of older buildings. Rehabbing older homes, which often involve paint stripping, either with a heat gun or a chemical stripper is particularly hazardous. Inhalation is a very efficient means of producing a clinically significant exposure to lead which was commonly used years ago in interiors of homes. Many commercial paint strippers contain methylene chloride (dichloromethane), which metabolizes to carbon monoxide, and is particularly toxic to the fetus. Guidance for clinician Certainly, awareness that occupational and environmental hazards encountered by patients may play a clinically significant role in a pregnancy outcome is the first step in effective patient management. Therefore, enlarging the standard health history form, completed by the patient on or before the first visit to obtain a more detailed environmental history is a necessary first step and is also often very informative. Whereas a number of preconception checklists exist, only some of which address fish consumption or residence near a waste site, most poorly capture, or even fail to query about occupation, despite this being the likely greatest ‘environmental’ risk the patient faces. ‘qualitative’ 1 quantitative 2 14 15 16 18 19 20 21 22 Conclusion The preconception office clinic visit presents a strategic opportunity to minimize the environmental and occupational sources of reproductive risk facing the preconception patient. This requires the two-way exchange of information between the patient and her clinician, clarifying misunderstandings and implementing reasonable strategies to minimize exposures from the wider community, in the workplace and at home. Taking an environmental and occupational history and tailoring recommendations based on that, enlarges the likelihood that preventable, adverse pregnancy outcomes can be avoided.