References

Preoperative tests: the use of routine preoperative tests for elective surgery.: NICE; 2003

Powell-Bowns M, Wilson MSJ, Mustafa A Documentation of pregnancy status, gynaecological history, date of last menstrual period and contraception use in emergency. World J Surg. 2015; 39:(12)2849-53

Women lost babies after surgery as doctors failed to check for pregnancy. 2010. http://tinyurl.com/y9mjbujy (accessed 5 July 2017)

Strote J, Chen G Patient self-assessment of pregnancy status in the emergency department. Emerg Med J. 2006; 23:554-7

Wilson MSJ Personal communication. 2017;

Wilson MSJ, Powell-Bowns M, Robertson AG, Luhmann A, Richards CH National multicentre audit of pregnancy status in general surgery admissions in Scotland. Postgrad Med J. 2017; 93:480-3

Pre-surgery pregnancy status

02 October 2017
Volume 25 · Issue 10

Abstract

After headlines reported that women had lost babies following surgery, George Winter investigates the ethical and medical conflicts that may arise when women undergo surgical procedures

In 2010, a national newspaper reported that the National Patient Safety Agency database recorded three women who lost their babies following surgery, saying that,

‘In a further 12 cases, the NHS has been sued by women who were not tested prior to their operation … It is thought this is just the tip of the iceberg.’

(Smith, 2010).

Yet it appears that this story did not prompt an investigation into how best to establish the pregnancy status of pre-surgical patients, as a recent study from the Scottish Surgical Research Group (SSRG) (Wilson et al, 2017) suggested that the standard assessment of pregnancy status before surgery was not fit for purpose.

Wilson et al (2017) noted that, in the developing world, abdominal pain was the main reason for admission to acute surgical units, and one-third of such admissions were women of reproductive age. In UK guidelines, the National Institute of Health and Care Excellence (NICE) (2003) recommend that pregnancy tests should be conducted before elective surgery only if a woman replies, after questioning, that she may be pregnant; and there are no guidelines on establishing pregnancy status in emergencies. The study's lead author, surgical registrar Dr Michael Wilson, said that this led to an unknowingly pregnant woman being exposed to ionising radiation via a computed tomography (CT) scan, where a diagnosis of pregnancy was made. Dr Wilson said that,

‘Although she delivered a healthy infant, this episode prompted the SSRG to undertake a 14-day audit of pregnancy status documentation for [women of reproductive age] having general surgery across Scotland.’

(Wilson, 2017)

Of 2743 admissions, 530 were women of reproductive age, with 169 (31.9%) having elective surgery and 222 (68.1%) having emergency surgery. Documented pregnancy status was achieved in only 274 (51.7%) cases. Dr Wilson said:

‘Objective evidence of a negative pregnancy test at the point of admission to hospital should be electronically stored on the hospital database in the same way as a blood test or X-ray result. This is the only means by which we can confidently obtain informed consent [before] surgery in this cohort. A change in mindset, reflected in a change to current clinical guidelines is warranted to ensure that we continue to provide the optimal care for our patients.’

Dr Wilson's belief that there should be no place for subjectivity in determining pregnancy in women of reproductive age contrasts with Strote and Chen (2006), who suggested that ‘patients could reliably predict that they were not pregnant.’ Despite acknowledging the risks of a missed pregnancy, and recommending testing in most instances, the authors concluded:

‘Sexual history and self-assessment can be used as a highly effective predictor of a patient not being pregnant.’

This is unhelpful, and midwives who care for women who are unnecessarily exposed to surgery without objective confirmation of her pregnancy status might agree with Wilson (2017).

In a retrospective analysis of the case notes of 100 women of reproductive age admitted for emergency surgery following abdominal pain, Powell-Bowns et al (2015) found that 30% had a documented pregnancy status, and of 24 patients who underwent emergency procedures, only 6 (25%) had a documented pregnancy status before surgery. The authors concluded that:

‘A minimum standard of care, in [women of reproductive age], should include mandatory objective documentation of pregnancy status, whether or not they require surgical intervention.’

(Powell-Bowns et al, 2015)

While accepting the need for informed consent before undertaking a formal pregnancy diagnosis, Powell-Bowns et al (2015) stressed that clinicians must also follow the General Medical Council's code of practice, which states:

‘Make the care of your patient your first concern, provide a good standard of practice and care and to take prompt action if you think that patient safety is compromised.’