Article Text

Checking pregnancy status in adolescent girls before procedures under general anaesthesia
  1. J F Donaldson1,
  2. S J Napier2,
  3. M Ward-Jones2,
  4. R A Wheeler3,4,
  5. P M Spargo5
  1. 1Senior House Officer, Wessex Regional Centre for Paediatric Surgery, Southampton, Hampshire, UK
  2. 2Specialist Registrar, Anaesthetics Department, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
  3. 3Honorary Senior Lecturer in Clinical Law, Southampton University, Southampton, UK
  4. 4Consultant Paediatric Surgeon, Wessex Regional Centre for Paediatric Surgery, Southampton, Hampshire, UK
  5. 5Consultant Paediatric Anaesthetist, Anaesthetics Department, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
  1. Correspondence to Dr S J Napier, Anaesthetics Department, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD, UK; sarahjnapier{at}yahoo.co.uk

Abstract

Objective Surgery, ionising radiation and anaesthesia in the presence of an undetected pregnancy could be harmful. British guidelines state that female patients of 'childbearing age' should have their pregnancy status established before surgery. Approaching this topic with an adolescent girl can be challenging.

Design The authors conducted an observational study and a survey in their institution and a national survey of Association of Paediatric Anaesthetists (APA) linkmen.

Setting Local: Southampton. National: UK.

Results Both surveys demonstrate widespread concerns about inconsistent and informal practices. Only 45% of respondents in the authors' institution stated they ask adolescent girls if they could be pregnant. 40% of APA linkmen were unaware of national guidelines.

Conclusions This work illustrates the need for consistent national guidance. We propose that all girls who have reached menarche should be routinely offered a urine pregnancy test before any procedure under general anaesthesia.

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The UK has the highest rate of teenage pregnancy in Western Europe.1 In England and Wales, conception rates in 2009 were 38.3 per 1000 girls aged 15–17 years.2 Surgery, ionising radiation and anaesthesia in the presence of an undetected pregnancy can be harmful and could lead to costly litigation. However, establishing the possibility of pregnancy in adolescent girls undergoing procedures under general anaesthesia can be challenging.

In 2010, the National Patient Safety Agency (NPSA) published a rapid response report entitled ‘Checking pregnancy before surgery’ (see box 1).3 The National Reporting and Learning System reported 42 incidents where pregnancy status was not established between 2003 and 2009.3 Three cases involved spontaneous abortion. The NHS Litigation Authority reported a further 12 claims.3 The National Institute for Clinical Health and Excellence (NICE) issued guidelines on preoperative tests in 2003.4

Box 1 Summary of NICE and NPSA guidance

  1. NICE preoperative tests: the use of routine preoperative tests for elective surgery; 2003.4

    'Preoperative assessment policies should… ensure that pregnancy status is checked… in women of child-bearing age.'

    The need to test for pregnancy depends on the risk presented to the fetus by the anaesthetic and surgery.

    As a minimum, all women of ‘child-bearing age’ should be asked sensitively whether or not there is any chance that they may be pregnant.

    History of last menstrual period is ‘unsatisfactory’ as a marker of the likelihood of pregnancy.

    Pregnancy testing should be offered if patients say that it is possible they may be pregnant (with consent).

    12–16-year-olds who fear that they might be pregnant may say that it is not possible for them to be pregnant, especially if asked in consultation with their parents.

    Competent patients under 16 may consent without their parents' knowledge.

  2. NPSA rapid response report: checking pregnancy before surgery; April 2010.3

    Ensure pregnancy status is checked within the immediate preoperative period.

    Recorded in final clinical and identity checks before surgical intervention.

    Local audit and incident reporting systems when checks have not happened.

    Local organisations should consider:

    Inclusion of all 12–55-year-old women or all menstruating women.

    'Blanket testing'.

    Particular considerations are required in patients under 16 years.

NICE, National Institute for Clinical Health and Excellence; NPSA, National Patient Safety Agency.

Neither the NPSA nor NICE guidelines define what constitutes ‘childbearing age.’ In the UK, the onset of menarche ranges from 7 to 19 years (mean 12.7, SD 1.4).5 The aim of this study is to assess the current practice, opinion and awareness of NICE/NPSA guidance of staff caring for this age group.

Methods

All data were anonymised.

What is already known on this topic

  • Anaesthesia, surgery and ionising radiation during an undetected pregnancy could be harmful to both the patient and fetus: its discovery will change clinical practice.

  • The pregnancy status of girls of ‘childbearing age’ should be established and documented before procedures under general anaesthesia; this may include urine pregnancy testing.

  • The last menstrual period is unreliable as a marker of the likelihood of pregnancy: early pregnancy bleeding is commonly mistaken for menstrual blood.

What this study adds

  • Inconsistent and informal processes including ‘social intuition’ are currently used to establish the pregnancy status of adolescent girls before procedures under general anaesthesia.

  • Awareness of the potential risks to the patient and fetus of anaesthesia in the presence of an undetected pregnancy is poor.

  • NICE guidelines are not being followed: suitable information and procedures should be implemented to address this. Routine urine pregnancy testing may be the best option.

Study of current practice in our institution

The nursing and medical notes (including consent forms) of girls aged 12–18 years undergoing procedures under general anaesthesia during a 4-week period were reviewed contemporaneously. Approval was not deemed necessary by the local ethics committee's chairperson.

Local survey

We distributed a questionnaire (supplementary online Appendix 1) to doctors and nurses who regularly admit, clerk or consent children undergoing procedures under general anaesthesia at our institution.

National survey of APA linkmen

All UK Association of Paediatric Anaesthetists (APA) linkmen (159) were invited (via email) to complete an online questionnaire (supplementary online Appendix 2).

Results

Study of current practice in our institution

Pregnancy status (the denial of the possibility of pregnancy) was recorded in 36 (68%) of 53 patients' notes.

Local survey

Completed questionnaires were received from 143 healthcare professionals (95 nurses, 48 doctors); see table 1 (65% of nurses and 55% of doctors surveyed). Only 45% of respondents (49% of doctors, 44% of nurses) stated that they ask girls whether they could be pregnant preoperatively. Only 50% use a lower age limit to determine which girls to ask (see figure 1). Forty-three per cent ask about last menstrual period (LMP). Other indicators cited by respondents are listed in figure 2.

Figure 1

Age used by respondents to determine which girls to ask about the possibility of pregnancy by respondents in our institution; supplementary online Appendix 2: survey B.

Figure 2

Other indicators used to determine which girls to ask about the possibility of pregnancy by respondents in our institution: Question 2; local survey (not mutually exclusive) (supplementary online Appendix 2: survey B). Responses included: if the patient has reached menarche, if physical signs of sexual development are noted, if the patient admits to being sexually active, only when ‘clinically relevant’ (eg, if admitted with abdominal pain), depending on the patient's behaviour, dress, smoking and alcohol habits and if taking the contraceptive pill (CP).

Table 1

Grade of respondents to our local survey: who regularly admit, clerk or consent children undergoing procedures under general anaesthesia

Most respondents (80%) think that the responsibility to ask these questions lies with the nursing staff (see figure 3). Nurses (81%) were more likely than doctors (41%) to ask girls these questions without their parents present. The majority (77%) of respondents (84% of doctors, 63% of nurses) find asking adolescent girls questions about pregnancy status embarrassing. Thirty-seven per cent of respondents thought girls of childbearing age should have a urinary pregnancy test routinely. Ninety-four per cent of respondents think clear guidance on this topic would be helpful.

Figure 3

Responsibility: if girls of childbearing age must be asked whether they could be pregnant, in your opinion who should ask? (Not mutually exclusive.) Question 8a; local survey (supplementary online Appendix 2: survey B). ‘Surgeon’ refers to any healthcare professional taking consent for a procedure under general anaesthesia.

National survey of APA linkmen

Completed replies were received from 56 (35%) APA linkmen. Forty per cent of respondents were unaware of the NICE guideline. Thirty per cent commented there was no system for the documentation of pregnancy status in adolescent girls in their hospital (32% were unsure). Eleven per cent of respondents stated that girls under 18 years old were always asked whether they could be pregnant (occasionally; 41%, usually; 25%).

Nearly 60% of respondents did not know the age below which it had, in their hospital, been deemed unnecessary to ask. Five per cent of respondents stated that patients were always asked if their periods had started (occasionally; 34%, usually; 12%). The LMP was always recorded in 11% of respondents' institutions (occasionally; 41%, usually; 16%).

There was ambiguity about whose responsibility it is to check patients' pregnancy status (unsure; 40%, nursing staff; 31%, doctor taking consent; 4%). One respondent stated that universal pregnancy testing is performed in their hospital (with written consent).

Discussion

All elective procedures under general anaesthesia should be avoided during pregnancy and, where possible, procedures should be delayed until the second trimester to reduce the risks of teratogenicity and spontaneous abortion.6 If pregnancy is established but surgery cannot be deferred, anaesthetic techniques can be modified.4 Given the potential risks to the patient/fetus and the litigation that may ensue, potential pregnancies should be identified before procedures under general anaesthesia. This should include children of childbearing potential.

Our national survey found that 40% of APA linkmen are unaware of NICE guidelines. Despite a disappointing response rate (35%), our survey identified a significant number of institutions where confusion prevails regarding local policy. Our local survey also illustrates widespread multi-disciplinary concern about inconsistent and informal processes. Only two-thirds of adolescent girls had their pregnancy status documented before procedures under general anaesthesia. Over half of nurses and doctors do not ask about pregnancy status in our institution. Alarmingly, 35% of respondents admitted that they use what might be termed ‘social intuition’, relying on girls' appearance or behaviour.

Adolescent girls may be reluctant to admit that they might be pregnant, particularly if asked in consultation with their parents because of embarrassment or fear of social or legal recrimination. It could be argued that a Gillick competent child has as much right to confidentiality (from her parents) about these matters as she does for the planned procedure itself.7

NICE guidance advises pregnancy testing in patients who say that it is possible they may be pregnant. In England and Wales, consent for pregnancy testing in a patient under the age of 16 years may be obtained without the knowledge of their parent, if the patient is judged to be Gillick competent.8 A child may be considered to possess the legal capacity to consent providing they can ‘understand and appraise the nature and implications of the proposed treatment, including the risks and alternative courses of action.’9

If a clinician suspects that a child is involved in ‘abusive or seriously harmful sexual activity,’ relevant information must be shared with the appropriate agencies.10 If children under the age of 13 (who are considered by law in England and Wales as unable to consent)11 admit sexual activity, they must be carefully assessed and discussed with a ‘designated doctor for child protection.’10

The NPSA suggested an age range of 12–55 years or all menstruant female subjects be used to reflect those of ‘childbearing age’. However, over 21% of British girls have their first menstrual period before their 12th birthday and pregnancies have been reported below this age.12 ,13 It is well established that a patient's LMP is an unreliable marker of the likelihood of pregnancy.4 However, many patients and healthcare professionals are not aware of this.

An adolescent girl who knows or fears that she is pregnant but has not confided in her parents faces a dilemma. At a time of considerable anxiety prior to surgery, a girl may be confused by conflicting demands: a duty to her parents, her unborn child and the father in addition to fear of social or legal recrimination: paradoxically, a situation much more demanding than in the consenting adult.

A routine policy of universal urine human chorionic gonadotropin (uhCG) testing in the immediate preoperative period may therefore be worthy of consideration to minimise these uncertainties. This is currently employed by at least one centre nationally and was supported by over a third of respondents in our institution. However, there are logistical difficulties in performing same-day uhCG testing and this would require additional resources. Patients who forget to bring a sample, are unable to void or refuse testing will require counselling.

While uhCG testing has been claimed to be effectively 100% reliable,14 its sensitivity and specificity in the context of routine preoperative screening are unclear.15 False positive rates are likely to be extremely low in adolescents presenting for procedures under general anaesthesia; however, they may occur following bladder augmentation surgery, in end-stage renal failure, ovarian/germ cell tumours, gestational trophoblastic disease or osteosarcoma.16,,18

The incidence of previously unrecognised pregnancy in paediatric patients undergoing procedures under general anaesthesia is almost certainly very low. Furthermore, 60% of conceptions in girls aged 13–15 years lead to a legal abortion.2 Nevertheless, the consequences for both the mother and fetus of an elective procedure under anaesthesia in the presence of an undiagnosed pregnancy are potentially catastrophic. The vexed question is whether the benefit of introducing universal pregnancy testing to confirm the rare possibility of an undisclosed pregnancy is a proportionate step to take. Is it reasonable to risk harming relationships not just between carers and patients, but also within families, to protect the interests of a minority of teenage girls who are pregnant, a significant proportion of whom may request a termination in any case?

Conclusion

Our work demonstrates the need for consistent, children's specific national guidelines. We suggest that routine same day urine pregnancy testing should be offered to all female paediatric patients who have reached menarche before any procedure under general anaesthesia. It is essential that the patient, her parents and health-care professionals understand the importance of establishing pregnancy status before any procedure under general anaesthesia to improve compliance and reduce the potential for harm and costly litigation.

Acknowledgments

The authors would like to thank all respondents who took the time to complete our surveys.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • Competing interests RAW has provided advice concerning forthcoming national guidance on this topic. There are no other competing interests to declare.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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