Checking for pregnancy before surgery: summary of a safety report from the National Patient Safety AgencyBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3402 (Published 06 July 2010) Cite this as: BMJ 2010;341:c3402
- Tara Lamont, head of patient safety1,
- Tracy Coates, anaesthesia lead1,
- Dinah Mathew, research and evaluation lead1,
- John Scarpello, deputy medical director1,
- Andrew Slater, consultant anaesthetist2
- 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD
- 2East Sussex Hospitals Trust, Eastbourne BN21 2UD
- Correspondence to: T Lamont
Why read this summary?
Some surgical interventions carried out on pregnant women could harm the fetus. If a previously unknown pregnancy is detected before a procedure, such risks can be discussed with the patient. Where necessary, surgery can be postponed or anaesthetic and surgical approaches modified. At present, despite national guidelines,1 it seems that pregnancy status is not always being checked routinely before surgery.
Although robust processes have been established to check for pregnancy before gynaecological procedures and those involving ionising radiation,2 the same precautions seem not to be in place for general surgery. This is important given the scale of the problem—although no major study has been done in the United Kingdom, estimates from the United States suggest a 0.15-2.2% incidence of previously undiagnosed pregnancy at the point of surgery.3 4
Between October 2003 and November 2009, healthcare staff in England and Wales reported 42 serious incidents in which no documented pregnancy check was carried out before a planned procedure. Three of these cases resulted in spontaneous abortion.
A typical incident report reads: “Patient informed me that she had been admitted post-op with PV [vaginal] bleeding and a miscarriage diagnosed therefore pregnant during surgery. Subsequent complaint raised. No pre-op pregnancy test. No mention in notes re [question to patient about pregnancy].”
In addition, 12 claims were identified from litigation data where no pregnancy checks were carried out before surgery.
This summary is based on a new safety report (known as a “rapid response report” or “RRR”) from the National Patient Safety Agency (NPSA) on the need for pregnancy checks before surgery, with key actions for staff (NPSA/2010/RRR11; www.nrls.npsa.nhs.uk/checkingpregnancy).
Problems identified by the National Patient Safety Agency
The NPSA’s review of incidents and of several local policies on preoperative checklists suggests that current practice is inconsistent in terms of when and how pregnancy status is checked. In 2003 the National Institute for Health and Clinical Excellence (NICE) issued broad recommendations on preoperative testing, including a brief section on pregnancy checks.1 Hospitals have interpreted these in different ways. Some check women only at preoperative assessment, which may take place weeks before surgery, during which time pregnancy status may change. Many ask only for date of last menstrual period, which can be unreliable. Hospitals vary in their thresholds for testing women. In some places, there is no evidence even of the question being asked before women are taken into theatre.
What can we do?
In its 2010 RRR, the NPSA asked all organisations undertaking surgery to review preoperative assessment policies to ensure that pregnancy status is checked in the immediate preoperative period and recorded. It recommended the following key actions.
For individual clinicians
Always check whether a woman could be pregnant. Confirm this on admission—do not rely on the preoperative assessment if done several weeks earlier.
This is particularly important for any procedure in the pelvic or abdominal area and for any surgery where ionising radiation is used.
If there is any possibility that a woman could be pregnant, offer her a pregnancy test. This includes women with uncertain pregnancy history or irregular menstrual cycles, and those who have had recent unprotected intercourse.
If pregnancy is confirmed, refer the woman to antenatal services. Discuss the risks of continuing or postponing the procedure with your patient.
Record the patient’s pregnancy status on documents used for final preoperative clinical and identity checks. You could include this on your surgical site checklist5; in some hospitals, anaesthesia is not given without confirmation of this record.
In life threatening situations, confirmation of pregnancy should not delay treatment.
What else do we need to know?
During consultation on the draft guidance, several clinical and professional bodies advocated default urine testing with informed consent for all relevant women. Although the relatively high rates of undiagnosed pregnancy in US studies may support this, default urine testing has resource implications for the NHS.
Other problems raised during consultation related to the reliability of different tests available for confirming pregnancy,6 especially in the early stages, and problems in defining relevant female patients. Local policies vary, from all women who have started menstruating to those in certain age bands (normally 12-55 years). There are important ethical questions concerning informed consent,7 particularly for patients under 16.8 Current national guidance does not provide direction on how or when to check for pregnancy before surgery. These problems should be considered by NICE in its current review of guidelines on preoperative testing.
How will we know when practice has become safer?
Organisations were given until October 2010 to implement actions on this RRR and will be required to report compliance at that point. The NPSA will continue to monitor incidents reported by staff. This would be a useful area for local audit, to measure compliance with what should be a routine safety check.
Cite this as: BMJ 2010;341:c3402
This is one of a series of BMJ summaries of recommendations to improve patients’ safety, based on reports of safety concerns, incident analysis, and other evidence. The articles highlight the risks of incidents that have the potential for serious harm and are not well known, and for which clear preventive actions are available.
To report adverse events to the National Patient Safety Agency, go to www.nrls.npsa.nhs.uk/
Contributors: TL wrote the first draft, on the basis of work led by TC, DM, TL, and others at the National Patient Safety Agency. All authors reviewed the draft. TL is guarantor.
Funding: No special funding
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.”
Provenance and peer review: Commissioned; not externally peer reviewed.