Pre anesthesia pregnancy screening: an imperative or a bubbe meise? Ethical considerations part two
Lynne G. Maxwell MD, Myron Yaster MD
Mandatory preoperative pregnancy screening/testing of adolescent and indeed of all potentially pregnant patients, is a source of frequent anxiety and sometimes awkwardness for patients, families, preop nurses, surgeon/proceduralists, and anesthesiologists. Most health systems have strict mandatory requirements for preoperative pregnancy testing for all females (and perhaps transgender males) beginning at menarche or age 12. While this is well-established practice in many institutions, including pediatric hospitals, the scientific, medico-legal and ethical basis for such policies is not so clearcut. Today’s PAAD by Jackson et al.1 is part 2 because we simply couldn’t do it the justice in a single PAAD. In part one we discussed the ethical concerns of mandatory and often non-consensual testing and the traditional concerns addressed by preanesthesia pregnancy testing: preventing fetal harm, mitigating medicolegal claims due to pregnancy loss and fetal malformations, and the supposed standard of care. Today we will discuss problems with the accuracy of testing, informed consent in adolescents, and conscientious objections to participation.
Original article
Jackson S, Hunter J, Van Norman GA. Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review. Anesth Analg. 2024 May 1;138(5):980-991. doi: 10.1213/ANE.0000000000006669. Epub 2023 Oct 6. PMID: 37801601.
Scientific issues of accuracy of pregnancy testing
Pregnancy testing relies on measuring the level of human chorionic gonadotropin (hCG) in urine or blood. hCG levels can reflect current pregnancy, recent pregnancy, various cancers, trophoblastic disease, and other conditions. There are several variants, the most important of which hyperglycosylated hCG (hCG-H), which controls pregnancy implantation and placental growth, and is dominant in early pregnancy (weeks 3–6). hCG testing may have both false positives and false negatives, especially in early pregnancy. As the case I (LGM) described in yesterday’s PAAD illustrates a patient who has had a recent early pregnancy loss, whether spontaneous or induced, may have a persistently positive hCG test . "Point-of-care (POC) urine hCG tests commonly used in the perioperative setting vary widely in sensitivity, and performed poorly in detecting hCG-H.2”1
“A positive early test (within 3 days of missed menses) can indicate actual elevated hCG levels for a number of reasons: (1) the patient is pregnant; (2) there was a successful implantation, followed by early, clinically inapparent pregnancy loss, and hCG levels remain high enough to be detected; (3) there is a “biochemical pregnancy,” that is, implantation ultimately failed, but hCG levels briefly rose into detectable range; and (4) there is a medical condition other than pregnancy causing elevated hCG. A negative early pregnancy test can reflect actual low hCG levels for a number of reasons: (1) the patient is not pregnant; (2) the patient is pregnant with normal early implantation but at the time of testing hCG levels are too low to detect; and (3) the patient is pregnant but has had a late implantation.
Informed consent and adolescent pregnancy testing
“Preanesthesia pregnancy testing in adolescents introduces further considerations in which traditional bioethical principles meet the complexities of human development, behavior, and biology, as well as an ambiguous, shifting, and sometimes conflicting legal landscape.” Further, “adolescents are likely to be reticent to reveal a history of underage and/or premarital sexual activity, especially in the presence of their parents.” Finally, “Anesthesiologists are ethically obligated to respect the autonomy of their minor patients by including them in medical decision-making appropriate to their decisional capacity and the issues involved.3 Additional complexities are the consideration of the rights of parents, and also legal as well as ethical issues of confidentiality.”1
Harms of pregnancy testing
A false positive test result (as described in yesterday’s PAAD) may result in cancelation of surgery, further testing, and psychological stress, and the authors state, the act of testing has “the potential for physical, psychological, and social harm. A positive pregnancy test (false or true), can have profoundly negative consequences for vulnerable patients who are in social situations that do not accept the pregnancy.” The ASA Task Force recommends informed consent for pregnancy testing. One father sued because a pregnancy test was performed on his daughter without his consent.4 Though the urine POC test may cost only $35, the cost of identifying a pregnancy may be much higher.
Conscientious objection
Although the ASA Statement amended in 2021 states “Anesthesiologists and surgeons/proceduralists should be able to recuse themselves without question or repercussion from an elective case if their values/beliefs are in conflict with provision of care. The physician should refer the patient to an alternative healthcare provider in a timely manner”, Jackson et al doubt that the concept of conscientious objection applies to this situation (if a patient with a positive pregnancy test wants to proceed with anesthesia, or a patient refuses a pregnancy test, after being informed of possible risks). They state “discomfort with anesthetizing a pregnant patient despite strong medical evidence that it is safe, and despite extensive professional society reviews, opinions, and guidelines stating that it is safe and does not violate professional standards of care, is entirely different from objecting to abortion because of a deeply held and well-documented personal religious belief regarding the sanctity of life.
The authors concluded that “any policy requiring nonconsented, routine/mandated/screening pregnancy testing in patients with the capacity to consent is not ethically acceptable because it fails to recognize patient autonomy, and such policies should be modified.”
Given these ethical and scientific arguments, should institutions abandon their policies for mandatory preanesthesia pregnancy screening? Doing so would be administratively complex and would not result in completely discarding concern about unknowingly anesthetizing pregnant patients. The authors (and the ASA) recommend “Preanesthetic educational materials should ideally be developed and given to patients to allow them to make an informed decision. This material should include information about false positives and negatives of pregnancy testing and that the scientific literature is inadequate to inform patients or physicians on whether exposure to anesthesia causes unknown harmful effects during early pregnancy.” The patient can then consent to or refuse pregnancy testing with documentation in the medical record. If a test is done and is positive, the authors recommend documenting “risks, benefits and alternatives regarding proceeding versus delaying anesthesia at this time were discussed, and the patient has declined to proceed (or has decided to proceed) at this time.”
Even if your health system/department moves to abandon preanesthesia pregnancy screening, does this mean that this issue will no longer be salient for you? Not if you anesthetize patients for radiology (interventional or diagnostic) procedure, as the American College of Radiology (ACR) and the Society for Pediatric Radiology (SPR) have their own pre radiation exposure policies for pregnancy screening which apply to females from menarche to age 50 and exclude the following procedures: chest radiography, extremity radiography, any diagnostic examination of the head or neck, mammography, any CT imaging outside of the abdomen or pelvis (with the possible exception of the hip). Although the ACR-SPR guideline describes flexibility which allows the patient to state whether they could be pregnant or not and provides some exceptions to testing, many institutions make such testing mandatory, including this language from a major academic health system: “All female inpatients, outpatients and ED patients who have started their menses or are between the ages of 10 and 55 undergoing a non-emergent radiology exam listed in Appendix A (which may impart >50 mGy to the embryo/fetus, involves intravenous contrast for MRI or involves radiopharmaceuticals) must have pregnancy testing. A urine hCG or serum hCG pregnancy test are both valid, including Point of Care (POC) Pregnancy testing where available.”6 The policy states that patients who are > 18 may refuse testing and sign a waiver, but testing is mandatory in those under 18. So you may be still presented with an adolescent patient with a positive pregnancy test but the radiologist is the one who will cancel the procedure.
A final thought: Today’s PAAD was probably written before the recent maelstrom of lawsuits in the U.S. defining when life begins, fetal personhood, and when and if abortion is legal. How or if this will affect your decisions is unclear to us. Send your thoughts about all of these issues to Myron who will post in a Friday reader response.
References
1. Jackson S, Hunter J, Van Norman GA. Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review. Anesthesia and analgesia 2024;138(5):980-991. (In eng). DOI: 10.1213/ane.0000000000006669.
2. Cole LA. The hCG assay or pregnancy test. Clinical chemistry and laboratory medicine 2012;50(4):617-30. (In eng). DOI: 10.1515/cclm.2011.808.