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he Committee on Practice Management recently considered
the issue of mandatory preanesthesia pregnancy
testing for all women patients of childbearing
age. The listserve discussion revealed some
basic similarities between the anesthesiology
groups represented and also some significant variations.
The need for testing even some patients who deny
any possibility that they might be pregnant is
clear. Most of the committee members who
participated in the e-mail exchange knew of recent
cases in their hospitals where a presurgical patient
was quite surprised to have a positive test result.
It must have been a huge surprise to the 51-year-old
woman who presented for a bunionectomy (which
was deferred).
How and When to Test
There also is a consensus on the timing and method
of testing. Results that are more than a few days
old are not considered completely reliable. Serum
human chorionic gonadotropin (HCG) is slightly
more sensitive than urine HCG testing, but urine
HCG is the method of choice on the day of surgery
and will often be checked in the operating room
if the serum HCG results come from earlier preanesthesia
testing (PAT) or are not available. One
health care system’s formal policy states
that “All females of menses age will undergo
a urine pregnancy test on the day of surgery ….
If a urine specimen cannot be obtained, a serum
B-HCG will be performed.”
Whom to Test
The major difference from one hospital to another
is the set of patients whose HCG will be tested.
Some of the committee members report that every
potentially pregnant patient is tested without
regard to the cost-benefit ratio. Others
practice in facilities where patients receive
information about the risks and benefits of certainty
but may decline the test. Objective criteria
for ruling out potential pregnancy include total
hysterectomy, bilateral tubal ligation or the
passage of at least one year without menses (menopause).
A number of the hospitals in question have adopted
an approach based on the patient’s informed
consent or, more specifically, on her informed
refusal of the test. Reaching internal agreement
on a selective process that depends on patient
cooperation may be a complex exercise, particularly
if a bad medicolegal experience is the driver.
One committee member told the listserve of an
instance in which the father of a young teenage
girl sued the hospital for conducting a pregnancy
test without his consent. The father discovered
the test when he read the hospital bill.
Ultimately he dropped the lawsuit but he had set
in motion a process that led to the use of a pregnancy
questionnaire developed by the chairs of the anesthesiology
and obstetrics departments and the hospital legal
staff.
This questionnaire asks patients to identify themselves
as 1) pregnant, 2) not sure or 3) definitely not
pregnant. The third option gives women who
are sure that they are not pregnant a way to respond
by checking a box on a form without feeling compelled
to offer an explanation such as “I haven’t
had a date in two years,” “I have
an alternative lifestyle” or other private
reasons. The form also lists the risks of
not answering honestly. The hospital tests all
women who choose the second answer, “not
sure,” as well as those scheduled for procedures
that would imperil an undiagnosed pregnancy, including
hysteroscopies and total abdominal hysterectomies.
Is Explicit Consent Necessary?
In some anesthesiology departments, the patient
is informed and consulted but may be tested whether
or not she consents. In the real world,
anesthesiologists often tend to be more concerned
with good clinical outcomes than with legal risk
management. If they feel that the situation is
unclear or that testing is medically indicated,
they may order a pregnancy test, and they may
or may not inform the patient of the result.
Thus in these institutions, testing is de facto
required. It would be sound practice to
inform the patient that consent to the surgery
or to the anesthesia includes consent to the HCG
test.
Another approach that protects the physicians
and the hospitals and respects the patient’s
autonomy relies on full disclosure and a signed
waiver of the right to sue over a denied and undetected
pregnancy. In such a system, the anesthesiologist
explains the test and the risks of anesthesia
relating to pregnancy, but if the patient refuses
to be tested, she must sign a waiver releasing
the providers from liability or be deferred (except
in case of medical emergency).
Generally the lack of informed consent should
be a bar to a medical intervention, and a patient
should not be asked to hold the physician harmless
for acting against medical judgment. Testing
a specimen, however, is not invasive and is not
likely to be subjected to the same standard as
performing surgery or providing anesthesia. For
further discussion of informed consent and its
documentation, please consult the series of special
articles on those subjects in this issue of the
NEWSLETTER.