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Heres one for all you boffins out there.

Just did a PNA (Partial nail avulsion) on a 3month pregnant lady and after consulting MIMS, local Pharmacist and the Google thingy. We (the patient and I) decided not to use cautery just in case there is some risk to the fetus.

Is there any evidence that Phenol (or any other cautery method for that matter) is contraindicated?

Cheers

Joe Wheeler

Hi Joe,

My COSHH Generic Assessment advises that pregnant women should not be exposed to Phenol at any time.

We do not use it on pregnant women or breastfeeding mothers and we do not allow pregnant staff to administer it. We also try to reduce exposure time by rotation of staff using Phenol.

Regards

Anne

COSH might also prohibit the storage and use of nail varnish remover !

The real issue, is the chemical toxic to the foetus and is there any evidence to support this?

Phenol is rapidly de-activated in vivo and it is probably unlikely this can be absorbed in its active form to harm the foetus, but I have not seen any literature evidence either way. But since it is such a hazardous material, and there is not an urgent need to do otherwise, I have always adopted the safest strategy ie. to do without.

Hi Dieter,

The advice given in my MSDS and my COSHH Assessment states that Phenol is embyrotoxic and foetotoxic in animals. I haven't looked for more evidence than that. It has been found to cause cancer in laboratory animals and may cause adverse mutagenic effects.

Like you, I'd rather play safe where there is the slightest chance that Phenol may cause reproductive fetal effects, so we do not expose any pregnant women, whether patients or staff to Phenol at any time.

Regards

Anne

Undoubtedly phenol is toxic but I am sure we do not actually know if any of it is absorbed when used in a chemical matricectomy....?

Hi Dieter,

We do know that Phenol can be harmful if inhaled or absorbed through the skin, resulting in severe respiratory and digestive tract irritation. When this is so, presumably it is also absorbed when used in a chemical matricectomy.

Regards

Anne

Hi Dieter
I had the knowledge for the university that the real contraindication for pregnant women is the administration of LA. The administration of phenol comes secondarily as a contraindication. And now i am really surprised that none of you lot not even mention it, and futhrmore that you proceded with the nail avuslion (obviously under LA) with no hesitation . I would like to know whether my knowledge is not reliable.
Thank you

I would agree with you totally. This is another reason why we don't touch pregnant women for nail surgery.

Regards

Anne

This is really a matter of clinical judgment.

It is true that Gordon (1968) noted foetal bradycardia following paracervical L.A. to ease pain in childbirth, and Rosefsy and Petersiel (1968), recorded death of the newborn due to the same cause (both quoted in Goodman and Gillman). However, the tiny amount of L.A. used in a digital block, the slow absorption from that area and the subsequent excretion of the drug suggests that such a block is unlikely to result in any problem. There is no record of any such adverse reaction. This being the case, a florid, serially infected onychocryptosis is likely to be more dangerous than the use of L.A. as outlined above, and the presenting complaint should therefore be treated.

The general advice not to use any uneccessary drug during the first trimester of pregnacy holds good, as does the advice on phenol outlined above (until evidence shows otherwise). If in doubt, simply refer to a colleague in a hospital setting where alternative methods of treatment are available and drugs for resuscitation and those with the skills to use them are available.

All the best

Bill Liggins

I was just reading these posts and was wondering the same thing as podomania. I would have stopped at the LA, I don't think I would have got as far as the phenol stage. Dentists also do not administer LA when pregnant. In college we were always told that the first question to ask in the pre op is if there is any chance of being pregnant. Then is so, Stop!
For the sake of 9 months, it is better to wait!!!

__________________
Tomorrow is promised to no man!
My location

some information from MIMS and the PP guide
so LA in pregnancy is OK

and for phenol

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

Tuckersm, you are quite right. I have just looked it up too in the Australian Medicines Handbook. I wonder why in uni they tell you otherwise? Is that just to make you err on the side of caution? Lignocaine is a ADEC category A.

__________________
Tomorrow is promised to no man!
My location

I would never advocate abandoning pregnant women with Onychocryptosis. I refer these patients to hospital where they have the necessary back up should things go ‘pear shaped’.

Sadly, this often means referring on to the medical profession, rather than Podiatry colleagues.

Whilst Mims may deem LA safe, the majority of us have been trained to avoid using it in pregnant women. Can you imagine the field day the legal eagles would have if a case came to court? It is acknowledged that Phenol causes foetal damage in animals; hence it could do likewise in humans. Until it is proven to be safe, I shall stick to my current protocols.

Regards

Anne

So what is the general concensus with breastfeeding mothers. I have a client at the the moment who badly needs a nail procedure, I have not used anything at present and am treating the case conservatively. Is there a time frame where we could consider the LA and phenol would in all likelhood be out of her system?
Paula

In the absence of hard evidence, best to play safe and keep the lawyers off your back. My wifes PCT stops female Pods undertaking Nail avulsions with phenolisation when pregnant.

Hi Paula,

I totally agree with Peter. However there is no need for your patient to suffer until the baby arrives.

If you cannot manage the condition successfully until then, why not refer her to someone who can remove the offending nail without usng Phenol?

Phenol is not the only method of achieving ablation. There are alternative ways to manage this. Likewise, there are other local anaesthetics that can be used. Some anaesthetics have a longer duration of action than others and others have a slower onset of action, for example Bupivacaine, which is used for epidurals.

This is not usually ideal in the Podiatry setting as we want our local anaesthetics to work quickly. However, it can be a way around your patient’s problem.

I would not stop your patient from having a nail procedure, but would advise that it is carried out in a hospital setting which has these options and where back up is available.

Regards

Anne

In this case the baby has arrived! What I am concerned about is that she is breastfeeding. LA's are used in dentistry routinely with breastfeeding but I was concerned about the phenol. I would have thought that the amount we use in a normal nail procedure is so small that it would not leave any traceable amount in the breatmilk, and if you also avoid breastfeeding for a time after the procedure it would have been eliminated.
Any thoughts on this?
PJ

Hi Paula,

This makes no difference. The advice given in my MSDS and my COSHH assessment state that Phenol is not to be used on or by pregnant women or breastfeeding new mothers. Because of the organs it targets and the effects of ingestion, I would still rather avoid using Phenol.

Why not refer her to a colleague who performs nail surgery without using Phenol?

In this day and age when litigation is rife, I would try and avoid any grey areas such as this.

Regards

Anne

yes, I thought as much which is why I haven't advised her to go ahead with anything at this stage, unfortunately for us though, living in a remote area it is not always possible to refer to any one else easily and she has unfortunately also had a previous very bad experience with a failed wedge resection (with failure to adequately anaesthetize the toe during the procedure - local doctor).
Thanks,
Paula

Hi Paula,

Your main problem now seems to be the use of Phenol. Why don't you investigate using another method of nail ablation?

Several have been discussed on this site in previous postings.

Regards

Anne

The great majority of pregnant patients present with nail problems that need partial or complete avulsion to clear the infection even if only for a few months. The phenol can be used later, after delivery or after cessation of breast feeding. Not using an anesthetic is torture. The risk of patient reaction or fetal injury is miniscule. I think frank infection is more dangerous.

Mepivacaine (Carbocaine) is an excellent, although expensive local anesthetic. In a good percentage of toes, 1.5 to 2.0cc of a 2% solution is sufficient by using the technique where only dorsal to plantar injection on both sides of the toe are made. <1.0cc often is adequate for the lesser toes. No transverse injections used. This technique is adequate to acheive profound anesthesia in the vast majority of cases. If lidocaine is used, a little more might be necessary. A toe tourniquet is better than epinephrine to control hemorrhage. The tourniquet doesn't need to be extremely tight. Hold the leg up for a minute or so and apply. I don't recall any complications from the above procedures. I've veered off the thread a little, but the above works.

Tony Jagger DPM

Hi Tony

I'm not disputing the fact that a nail procedure can and frequently has been carried out without any ill effects, in both pregnant and breastfeeding Mums. My concern is that here in the UK our representative body has issued COSHH forms which categorically state that Phenol should not be used on or by pregnant or breastfeeding mothers.

So, assuming the worst and something does go wrong, even if it is only one case in several million, what chance do you think the poor Podiatrist would have in court when this evidence is produced? Going against the advice of one's Professional Body does not seem good or safe practice in my opinion.

Here in the UK we are also fast moving over to Phenol EZ swabs instead of using Phenol. In fact, Phenol is getting increasingly difficult to procure. The logic behind this is to reduce the amount of operator exposure and disposal hazards involved with this product. Podiatrists are buying into this on safety grounds despite the huge increase of cost involved.

As a Private Practitioner and a Scot, I would be delighted if someone can prove that Phenol is safe to use. I welcome any cuts in expenditure that can be achieved safely - not that I'm mean, just 'canny'.

Regards

Anne

I was under the impression that phenol was 'self limiting' i.e used up in its own activity, therefore, would there be any trace left once it has done it's job? I wouldn't 'write off' a pregnant patient for nail surg, because obviously, it may well be less of a risk to undertake the LA with the relatively small amounts of anaesthetic than for her to have continuous antbiotics and infection for the next 6 months! (our pregnant staff are not allowed to carry out n/s because of the phenol fumes as far as I undersand it.
However, our dept have just purchsed ourselves a lovely brand spanking new radiolase machine that promises to be a good alternative to phenol so perhaps this is the future?? (after all, phenol is pretty nasty stuff)