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Implementation of the “Pregnancy Reasonably Excluded Guide” for Pregnancy Assessment

A Quality Initiative in Outpatient Gynecologic Surgery

Wyatt, Michelle A., MD; Ainsworth, Alessandra J., MD; DeJong, Stephanie R., MD; Cope, Adela G., MD; Long, Margaret E., MD

doi: 10.1097/AOG.0000000000002917
Contents: Gynecologic Surgery: Clinical Practice and Quality

OBJECTIVE: Preoperative evaluation for pregnancy at our institution lacked standardization among individual health care providers and surgical services. This pilot project aimed to improve assessment for pregnancy before scheduled outpatient gynecologic surgical procedures. The Pregnancy Reasonably Excluded Guide incorporates historic, evidence-based criteria to facilitate identification of patients with a higher chance of pregnancy.

METHODS: We retrospectively reviewed documentation for women undergoing gynecologic surgery at an outpatient surgical center from March through September 2016, before and after implementation of the pregnancy assessment protocol. After implementation, all eligible women (aged 18–50 years, not undergoing an emergent or pregnancy-related procedure) were assessed using the Pregnancy Reasonably Excluded Guide on arrival to the preoperative area. The Pregnancy Reasonably Excluded Guide checklist uses traditional and World Health Organization criteria for reasonable exclusion of pregnancy. Nursing staff reviewed responses with patients and pregnancy tests were completed as indicated by patient responses. Women who were unable to read, understand, or freely respond to the checklist received pregnancy testing. Pregnancy assessment, testing, results, and delays were recorded. This project was deemed exempt by the institutional review board.

RESULTS: Two hundred thirteen eligible patients underwent outpatient gynecologic procedures during the study period (excluding a 2-week washout period at implementation). In the preimplementation period, 93 of 136 patients (68%) had pregnancy risk documented; 73 of 77 (95%) had documentation in the postimplementation period (P≤.01). Pregnancy tests were completed in 45 preimplementation patients (33%) and 16 postimplementation patients (21%) (P=.06). No pregnancy test results were positive. No procedural delays were associated with pregnancy assessment.

CONCLUSION: Patient-centered assessment using the Pregnancy Reasonably Excluded Guide at presentation for outpatient gynecologic surgery significantly improved evaluation and documentation of pregnancy status before scheduled procedures without increasing the number of pregnancy tests or causing procedural delays.

A standardized, pregnancy-focused survey assessing potential for pregnancy improved pregnancy screening before outpatient gynecologic surgery without increasing testing or causing delays.

Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.

Corresponding author: Margaret E. Long, MD, Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; email:

Financial Disclosure Dr. Long is a noncompensated trainer for Nexplanon and receives Nexplanon research funding from Merck. The other authors did not report any potential conflicts of interest.

Presented at the American College of Obstetricians and Gynecologists' Annual Clinical and Scientific Meeting, May 6–9, 2017, San Diego, California; and at the Mayo Clinic Quality Conference, March 13–15, 2017, Rochester, Minnesota.

Mayo Clinic Scientific Publications, supported by Mayo Foundation for Medical Education and Research, provided editorial and submission assistance.

Each author has indicated that she has met the journal's requirements for authorship.

Received May 02, 2018

Received in revised form July 22, 2018

Accepted August 02, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.