To the Editor:
Several issues regarding the article by Kahn et al.1 describing their policy of routine pregnancy testing on all eligible female patients before elective orthopedic surgery deserve critical examination.
There is no scientific basis for the authors' statement characterizing exposure to anesthesia and surgery during early pregnancy as “highly controversial” with regard to whether it places the patient, her fetus, or her pregnancy at additional risk. Although some chronic exposures to common substances (alcohol, smoking) have documented negative effects on pregnancy or the fetus, a single exposure to modern anesthetics has not been shown to have an adverse effect on early human pregnancy.
The American Society of Anesthesiologists (ASA) has one official statement on preanesthesia testing, the ASA House of Delegates approved “Practice Advisory for Preanesthesia Testing.”2 This statement was amended by a special Task Force appointed to address issues associated with routine pregnancy testing. They determined that there are neither well-designed studies nor clear cut evidence supporting the contention that anesthesia is teratogenic or promotes miscarriage in early pregnancy of humans. Kahn et al. apparently missed the critical 2003 amendment which reads:
Preanesthesia Pregnancy Testing. The Task Force recognizes that patients may present for anesthesia with early undetected pregnancy. The Task Force believes that the literature is inadequate to inform patients or physicians on whether anesthesia causes harmful effects on early pregnancy. Pregnancy testing may be offered to female patients of childbearing age and for whom the result would alter the patient's management.
Kahn et al. do not address legal aspects of management of pregnancy tests, such as: 1) To whom were the results were revealed? 2) Were patients informed that the pregnancy test result is part of their permanent medical record, which is available to insurance companies, and perhaps to employers if her insurance is provided through her employment? 3) How did Kahn et al. observe minors' rights regarding consent to pregnancy testing and surgery? Some states require that a positive pregnancy test in a minor must be reported to proper authorities. Revealing or implying pregnancy test results to unauthorized persons (e.g., parents or partners) violates laws in many states regarding confidentiality, and may in some cases violate Health Insurance Portability and Accountability Act regulations.
Therefore, before undertaking or continuing pregnancy testing, policies should be in place to guarantee that informed consent is obtained for this test. Policies should also inform physicians how to record patient refusals for testing, to whom test results can or must be revealed, and how to manage test results for minors. A recent review of these issues at the University of Washington, for example, led risk managers to oppose routine preoperative pregnancy testing in the absence of appropriate patient consent.
We are sympathetic to physicians' motivation to avoid patient complaints following anesthesia and surgery when a pregnancy is later spontaneously aborted or the resulting fetus/newborn is imperfect. The ASA-approved amended advisory, which is based on a thorough literature review, does not require pregnancy testing, and it can defend anesthesiologists who offer, but do not require or routinely order pregnancy testing.
Finally, the ASA Committee on Ethics stated that pregnancy testing should be offered and that informed consent be obtained from competent patients. For nongynecologic surgery, a patient should be able to refuse the test without coercive consequences, such as automatic cancellation of scheduled surgery. Routine pregnancy testing of all females and/or testing in the absence of informed consent fails to recognize a woman's right to privacy with regard to these sensitive issues and fails to recognize a woman's autonomy in making decisions about her health care. We recommend that all anesthesiologists examine and revise, where needed, their preanesthesia testing policies.
Susan K. Palmer, MD
Oregon Anesthesiology Group
Gail A. Van Norman, MD
Professor of Anesthesiology
University of Washington
Stephen L. Jackson, MD
Department of Anesthesiology
Good Samaritan Hospital
San Jose, CA
1. Kahn KL, Stanton MA, Tong-Ngork S, Liguori GA, Edmonds CR, Levine DS. One-year experience with day-of-surgery pregnancy testing before elective orthopedic procedures. Anesth Analg 2008;106:1127–31
2. American Society of Anesthesiologists Task Force on Pre-Anesthesia Evaluation. Practice advisory for pre-anesthesia evaluation. Anesthesiology 2002;96:485–96 (Amended Advisory is available at: www.asahq.org/clinicalinfo.htm