Preoperative Pregnancy Testing Research Articles

Preoperative Pregnancy Testing in a Tertiary Care Childrenʼs Hospital: A Medico-Legal Conundrum

Department of Pediatric Anesthesiology, Children's Memorial Hospital and Department of Anesthesiology, Northwestern University Medical School, Chicago, Illinois

A guide to preoperative pregnancy testing for the nurse practitioner

A guide to preoperative pregnancy testing for the nurse practitioner

Preoperative Pregnancy Testing: A Survey of Current Practice

Preoperative Pregnancy Testing: A Survey of Current Practice

Preoperative pregnancy testing in a tertiary care Children’s Hospital: a medico-legal conundrum

Study Objectives: To track physician and nursing practice regarding preoperative pregnancy screening and testing in a setting where testing is the established policy. Design: Prospective study. Setting: University-affiliated, urban, tertiary care pediatric hospital. Patients: 261 menarcheal patients, aged 10 to 34 years, presenting for ambulatory surgery in a 15-month period. Interventions: None. Measurements and Main Results: Of 235 routine pregnancy tests performed, three were positive (1.3%). All patients denied the possibility of pregnancy; all reported last menstrual period less than 3 weeks prior to their scheduled surgery. Two of the three patients whose pregnancy tests were positive were adults. Only two study patients were unsure about the possibility of pregnancy; both patients tested negative. No patient younger than 15 years tested positive (0 of 107). History was an unreliable marker for pregnancy. Conclusions: Medical history alone may be an unreliable marker for ruling out pregnancy in patients presenting for outpatient surgery in an urban pediatric hospital. The policy for preoperative pregnancy screening adopted by a hospital or health care facility should be predicated on the principle of “best interest of the patient.” Considerations must include local law, ethical responsibility, and the balance between cost and risk based on the best and most current scientific information.

Preoperative Pregnancy Testing in Adolescent Patients

Preoperative Pregnancy Testing in Adolescent Patients

Preoperative pregnancy testing: A survey of current practice

Study Objective: To examine contemporary practices and opinions regarding preoperative testing requirements, with special emphasis on perioperative pregnancy recognition and consequences thereof. Design and Setting: Anonymous questionnaire survey distributed to 300 (almost exclusively American) physicians attending the 1996 Society of Obstetric Anesthesia and Perinatology meeting. Measurements and Main Results: Responses from 169 anesthesiologists indicated that approximately one-third mandated pregnancy testing via departmental policy. More anesthesiologists ( p = 0.02) mandated routine pregnancy testing of all elective (30%) versus all emergency (17%) surgical patients. Sixty-six percent versus 20% percent, respectively, would require rather than simply offer pregnancy testing when history indicated possible pregnancy; 20% and 15%, respectively, of those surveyed indicated elective surgery would be canceled by the anesthesiologist if the patient were pregnant or refused testing ( p = NS). Although 98% of respondents recognized a legal requirement to report child abuse, and 82% believed pregnancy in a juvenile ( i.e., the child's age is under local legal defined age for consent to sex) by definition constituted child abuse, fewer than 4% would report this information to the police, even if the impregnating male were known to be an adult. Conclusions: The desire to identify pregnancy using patient history was most prevalent among anesthesiologists, with less than one third using mandatory, departmentally imposed screening programs. Positive test results in minors are shared primarily with surgeons and patients, occasionally with parents and social services, but rarely with police, although a positive test almost universally signified child abuse, and mandatory reporting laws were acknowledged by anesthesiologists surveyed.

Preoperative Pregnancy Testing in Adolescents

Preoperative Pregnancy Testing in Adolescents

Preoperative Pregnancy Testing in Ambulatory Surgery

Preoperative Pregnancy Testing in Ambulatory Surgery

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

In Response: The letter of Drs. Twersky and Singleton reminds us that the problem of unannounced pregnancy and anesthesia is not confined to the adolescent population. However, our ethical concern is raised by routine testing that is done by protocol, rather than with permission, and that is used to cancel rather than to counsel. We agree that the main "risk" involved in the debate is to the physicians' medical-legal status, but we argue that the enormous cost (monetary and otherwise) for routine testing cannot be justified. As suggested by the data in her letter, a simple preanesthetic question will suffice as a screen in the vast majority of instances. After a suggestive positive response, further testing and rational anesthetic decisions can follow, with the informed concurrence of the patient. Compliance with both legal standards and ethical principles is quite possible, but we must not allow concern for one to override respect for the other. P. G. Duncan, MD Department of Anaesthesia Queen's University Kingston, Ontario, Canada K7L 5G2 W. D. B. Pope, MD Department of Anaesthesia University of Manitoba Winnipeg, Manitoba, Canada R3G 3J4

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing

Preoperative Pregnancy Testing Revisited

Preoperative Pregnancy Testing Revisited

Preoperative Pregnancy Testing Revisited

In Response: The issue of preoperative testing for pregnancy clearly touches ethical, fiscal, legal, medical, and moral principles. Our editorial comments on the recommendations of Azzam et al. attempted to expand the debate to embrace all the elements requiring consideration, rather than restricting the issue to regional legal approval. Dr. Mesrobian suggests that diagnostic tests that either confirm a clinical diagnosis or quantitate functional impairment (the two indications for preoperative testing) are equivalent to routine screening for pregnancy in a normal population. We submit that the former are usually both explained and consented to upon presentation to most institutions and are done without specific consent only when perceived by reasonable persons to be self-evident with respect to purpose and to be without risk. When a diagnostic test significantly affects risk (for example, exercise stress testing or invasive organ imaging), specific informed consent, explained in terms of potential benefits and risks, is usually obtained, and the patient has the right to refuse. With respect to routine pregnancy testing, the benefits to the majority (97.5% in Azzam's study) are negligible, while the risks to those testing positive result more from the physician's subsequent response than from potential exposure to anesthetic drugs. In either event, all preoperative testing should be done with the patient's knowledge and with optimal use of health care resources in mind. Dr. Mesrobian may be correct in performing such a test in areas of high "disease prevalence," but should we not at least ask permission? Peter G. Duncan, MD Department of Anaesthesia Queen's University Kingston, Ontario, Canada K7L 3N6 W. D. B. Pope, MD Department of Anaesthesia University of Manitoba College of Physicians and Surgeons of Manitoba Winnipeg, Manitoba, Canada R3G 3J4

Preoperative Pregnancy Testing Revisited

Preoperative Pregnancy Testing Revisited

The Cost of Preoperative Pregnancy Testing

In Response: We recently reported the results of an institutional review board-approved retrospective review of urine pregnancy tests in adolescents presenting for surgery at a university-affiliated children's hospital [1]. This review has stirred an impassioned reaction. We appreciate the opportunity to respond to some of the issues that have been raised. Contrary to Dr. Battit's assumption, we did not design or conduct a prospective study, for which consent would have been required. We collected the information that was gathered routinely on patients according to our policy at the time. Although that initial policy was advised by our legal counsel, we have since changed our approach to ensure that all patients are informed. In an accompanying editorial, Duncan and Pope [2] also raised objections to our lack of obtaining consent. We submit that the very matter of asking for consent for a pregnancy test poses ethical dilemmas. A patient's refusal may be as telling as a positive test result, as she may suspect she is pregnant. Malviya et al. [3] did not find any positive results in adolescents who consented to the test but reported a 3.3% nonparticipation rate. This refusal rate is comparable to the incidence of positive pregnancy tests we found in adolescents aged 15 years and older (2.4%) and to that reported by Twersky and Singleton in adult patients (2.2%). Therefore, the request for consent places the adolescent patient in a situation whereby her acceptance or refusal of a pregnancy test carries definitive implications concerning her sexual activity. Additionally, the refusal of consent by the patient presents an ethical dilemma concerning the appropriate course of action. If a pregnancy test should not be performed without consent and if a request for consent is in itself a breach of patient privacy, then the alternative approach is the infamous "don't ask, don't tell" policy. Is it then ethical for us, as physicians, to ignore the possibility of a fetal life and to proceed with anesthesia and surgery? The cost of pregnancy testing as calculated by Kettler is over-stated. Hospital charges are different from actual expenses. A pregnancy test kit in our institution costs $2. Material costs for 42 tests therefore amount to $84. Overhead expenses are more difficult to estimate. Each physician must decide if this expense is warranted in his or her patient population. The ethical and financial questions associated with the determination of the reproductive status of patients are indeed complex. However, the main point of our article is that adolescent females presenting for surgery may be pregnant. We trust that no physician will willingly submit a fetus to the possible hazards of anesthetics, antibiotics, and radiographic and operative procedures without due consideration. Many of the drugs in our arsenal have specific warnings that the safety of their use in pregnancy is not demonstrated. In the United States, the medicolegal liability to the anesthesiologist must be weighed. Farid J. Azzam, MD Gurpreet S. Padda, MD James W. DeBoard, MD Jeremy L. Krock, DO Suzanne M. Kolterman, MD Department of Anesthesiology St. Louis University Health Sciences Center St. Louis, MO 63110

The Cost of Preoperative Pregnancy Testing

The Cost of Preoperative Pregnancy Testing

The Cost of Preoperative Pregnancy Testing

The Cost of Preoperative Pregnancy Testing

The Cost of Preoperative Pregnancy Testing

In Response: We recently reported the results of an institutional review board-approved retrospective review of urine pregnancy tests in adolescents presenting for surgery at a university-affiliated children's hospital [1]. This review has stirred an impassioned reaction. We appreciate the opportunity to respond to some of the issues that have been raised. Contrary to Dr. Battit's assumption, we did not design or conduct a prospective study, for which consent would have been required. We collected the information that was gathered routinely on patients according to our policy at the time. Although that initial policy was advised by our legal counsel, we have since changed our approach to ensure that all patients are informed. In an accompanying editorial, Duncan and Pope [2] also raised objections to our lack of obtaining consent. We submit that the very matter of asking for consent for a pregnancy test poses ethical dilemmas. A patient's refusal may be as telling as a positive test result, as she may suspect she is pregnant. Malviya et al. [3] did not find any positive results in adolescents who consented to the test but reported a 3.3% nonparticipation rate. This refusal rate is comparable to the incidence of positive pregnancy tests we found in adolescents aged 15 years and older (2.4%) and to that reported by Twersky and Singleton in adult patients (2.2%). Therefore, the request for consent places the adolescent patient in a situation whereby her acceptance or refusal of a pregnancy test carries definitive implications concerning her sexual activity. Additionally, the refusal of consent by the patient presents an ethical dilemma concerning the appropriate course of action. If a pregnancy test should not be performed without consent and if a request for consent is in itself a breach of patient privacy, then the alternative approach is the infamous "don't ask, don't tell" policy. Is it then ethical for us, as physicians, to ignore the possibility of a fetal life and to proceed with anesthesia and surgery? The cost of pregnancy testing as calculated by Kettler is over-stated. Hospital charges are different from actual expenses. A pregnancy test kit in our institution costs $2. Material costs for 42 tests therefore amount to $84. Overhead expenses are more difficult to estimate. Each physician must decide if this expense is warranted in his or her patient population. The ethical and financial questions associated with the determination of the reproductive status of patients are indeed complex. However, the main point of our article is that adolescent females presenting for surgery may be pregnant. We trust that no physician will willingly submit a fetus to the possible hazards of anesthetics, antibiotics, and radiographic and operative procedures without due consideration. Many of the drugs in our arsenal have specific warnings that the safety of their use in pregnancy is not demonstrated. In the United States, the medicolegal liability to the anesthesiologist must be weighed. Farid J. Azzam, MD Gurpreet S. Padda, MD James W. DeBoard, MD Jeremy L. Krock, DO Suzanne M. Kolterman, MD Department of Anesthesiology St. Louis University Health Sciences Center St. Louis, MO 63110