-Guidelines for Preoperative Detection of Pregnant Patients

-Procedural Care of Pregnant Patients

2/17/2005 (Scott Springman, MD)

The UWHC policy on pregnant patients is that any pregnant patient with a fetus < 20 weeks gestation may be cared for at UWHC. If above that gestational age, the patient should be cared for at a hospital with obstetric and perinatal services unless, in the opinion of the patient's physicians or patient or family, specialized services can only be given at UWHC.

See UWHC Policy 8.55

Background:

The scientific literature does not show that short term exposure to anesthetic medications, by themselves, pose a significant risk to a developing fetus or reduce the probability of carrying the fetus to term. There is, however, no evidence that there is "zero" risk from anesthetics. Further, mechanical manipulation and the stress of surgery, X-Rays, and exposure to a whole host of other substances in the perioperative period may increase fetal risks. For these reasons, most truly elective surgery on pregnant patients should be deferred until after delivery. For known pregnancies: UWHC has limited resources to handle pregnant women who have reached a point in the pregnancy where, if pretem labor commences, fetal viability is possible. UWHC has set a limit of 20 weeks gestation for elective surgical/procedural care.

All patients should, of course, have a standard pre-surgical history and physical exam. At that time, questioning about possible pregnancy should be performed. During this exam and during the assessment on the day of surgery on female patients, we should ask:

1. "Could you possibly be pregnant?" and
2. "Do you wish to have a pregnancy test?"

Likewise, these are also the questions that the Outpatient Surgery Center and First Day Surgery nursing admission teams will ask female patients who are between menarche and menopause (those not S/P hysterectomy or S/P tubal ligation) on the day of surgery.

I suggest that you preface these questions with a statement that "we ask these questions of all females, regardless"..........(.of family or socioeconomic situations, for example).

Process: A preoperative urine pregnancy test* should be performed on presumed "at risk" females who:

1. are having abdominal/pelvic surgery; or
2. are physiologically capable of becoming pregnant and say that they may "possibly be pregnant."; or
3. ask to have a preoperative pregnancy test; or
4. based on our judgement, may be pregnant (the patient must, of course, allow the pregnancy test).

*Urine test reported as: Negative, Positive (<50 mIU/mL), or Positive(>50 mIU/mL)

• Alternatively, a serum beta HCG (Red/Grey SST tube) test may be performed if it appears that detection of a very early pregnancy is desired. This test may detect pregnancy a few days earlier than a urine test. Serum test is a quantitative test and is NOT reported as "positive" or "negative".
• The normal non-pregnant beta HCG is less than 5 mIU/mL. During pregnancy, at 3-4 weeks post LMP, it is in the 9-130 mIU/mL range.
• Both urine and serum tests may be affected if patient has developed anti-murine antibodies due to treatment or imaging with murine products.

GUIDELINES FOR PREOPERATIVE DETECTION OF PREGNANT PATIENTS

• All women between menarche and menopause need to be screened for pregnancy at the work up visit and the morning of surgery by asking certain questions.
• However, not every woman must have a pregnancy test.

Questions to be asked and documented include:

1. Are you pregnant?
2. Could you possibly be pregnant?
3. Have you had unprotected intercourse since your last menstrual period?

Action required:

1. A female patient who is having abdominal or GYN surgery and is between the ages of menarche and menopause who has not had a hysterectomy is considered ' at risk ' and should have a urine pregnancy test ordered for the morning of surgery.
2. A female patient who is having any other kind of surgery (NOT abdominal or GYN) and when asked says she could possibly be pregnant (unprotected intercourse since her LMP) should have a urine pregnancy test ordered the day of the work up. If the test is negative, you need to repeat the test the morning of surgery. When the work up is the day before surgery, you do not need to repeat the test the next day.
3. A female patient who is having any other kind of surgery (NOT abdominal or GYN), knows the date of her LMP (within 28-30 days), has had protected or no intercourse since her LMP, or S/P a tubal ligation, does not need to have a urine pregnancy test ordered.
4. A female patient who requests a urine pregnancy test should have one ordered the day of her work up. If the test is negative, you need to repeat the test the morning of surgery.

FAQs:

Q: What about patients having surgery under local
anesthesia?
A: That's up to the surgeon to decide about risk. If they aren't concerned,
and the patient isn't either, and no X-Rays will be done, then no test is necessary.

Q: Is the patient required (as in # 1 and # 2) to consent to a pregnancy test? Does it become our
responsibility to convince her that it is to her benefit?
A: Yes, the patient must consent. No, we don't have to convince the patient but the surgeon and
anesthesiologist must both agree to proceed without the test.

Q: Do women who have had a tubal ligation (self reported) need to have a pregnancy test?
A: No, unless the medical team doubts the validity of the report or clinical signs point towards a pregnancy.