Surgical Centers Urged to Nix Mandatory Pre-Op Pregnancy Tests

PHILADELPHIA -- Given the questionable legal status of abortion in many states, hospitals are urged to reconsider their mandatory perioperative pregnancy tests, speakers advised here at the American Society of Anesthesiologists (ASA) annual meeting.

Traditional thinking had been that operators should screen women for preoperative pregnancy to minimize the odds of fetal harm during or after elective surgery. Routine pregnancy testing is a controversial practice for legal and patient privacy reasons, however, especially since the Supreme Court struck down federal abortion protections in 2022.

"Institutional policies and protocols requiring preoperative pregnancy testing should be rewritten with informed consent and patient autonomy as the goals in order to truly achieve beneficence and nonmaleficence," said Audra Webber, MD, of the University of Pennsylvania's Children's Hospital of Philadelphia. "Most women want to know their pregnancy status prior to undergoing surgery or anesthesia -- some just don't want the e-record to know."

The ASA's official stance is that perioperative pregnancy testing should not be mandatory. Testing should be based on risk of fetal harm during or subsequent to surgery, the choice supported by shared decision-making with the patient, according to the association.

However, a quick show of hands in the room here suggested that the vast majority of ASA session attendees still had institutional mandates for pregnancy tests before surgery. Less common, by an informal count, were institutions allowing the patients to opt out of regular testing, while a tiny minority of centers were defaulting to no testing unless the patient opted in.

Webber advocated for the latter -- the opt-in approach. Even though the Health Insurance Portability and Accountability Act legally protects the privacy of one's pregnancy records, laws change, she cautioned. "Things that are safe now may not be safe in 2 or 3 months."

Having a trail of detailed pregnancy records also makes hospitals vulnerable to legal action for not checking test results and database breaches by external parties hoping to gain from sensitive patient information, Webber suggested.

She said that anesthesiologists could ultimately just take the patients' word for whether they are pregnant or not.

Unlike surgeries and procedures with known associations with fetal loss or harm (e.g., surgeries on the uterus, some abdominal surgeries, chemotherapy, and radiation), "anesthesia has no such association," Webber explained. "Any study that draws corollaries to fetal anesthesia exposure and miscarriage or developmental delay are retrospective."

On the other side of the debate, Atul Gupta, MBBS, MPH, of the University of Chicago, argued for opt-out testing, in which the institution routinely tests for pregnancy unless the patient opts out.

"Whatever default position providers present, patients are generally more likely to select that position," Gupta said. Leaving testing as the default would better align with the principle of self-constitution as healthcare providers should want to know their patients' pregnancy status, and most patients would probably want to know, he said.

He stressed that opt-out does not mean mandatory testing, and opt-in does not necessarily mean active choice.

Either way, "even though we have been so vocal that [perioperative pregnancy testing] shouldn't be mandatory, at most institutions, it is mandatory testing, which is sad," Gupta lamented. "Any improvement from mandatory testing would be good."

Webber suggested working on the education of the people talking to the patient before elective surgery. At places with mandatory testing, informed consent is probably "extremely inadequate," she surmised.

"True informed consent requires lead time prior to the day of surgery and supports patient autonomy," emphasized Webber. "The patient's informed consent is only as good as the person giving the patient that information, and that's something that all of us can do our best to improve on."

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