Pregnancy Testing in Gynaecology patients (316)

NICE suggest that on the day of the procedure or at time of presentation, all women of childbearing potential should have a sensitive discussion as to whether there is any possibility they could be pregnant.  The healthcare professional, should make the patient aware of the risks that both the anaesthetic and the procedure itself can have on the developing pregnancy.

Permission should be sought from the patient to perform the test.  Covert pregnancy testing should not be undertaken as it can be viewed as an infringement of human rights.  Discussions regarding pregnancy testing should be documented in notes.

There are two possible options for ascertaining pregnancy status in female patients; consented urine pregnancy testing or Enquiry Based Assessment.

The urine pregnancy test should be considered as first line approach and can be used in conjunction with enquiry based approach.  In cases when urine testing is not possible, practical or feasible, e.g. adults with incapacity, enquiry based assessment alone should be performed and documented.

Information for Enquiry Based assessment includes

• First day of Last Menstrual Period (LMP)
• Current contraception and usage
• Date of last episode of unprotected Sexual Intercourse (UPSI)

The criteria for excluding pregnancy used by the Faculty of Sexual and Reproductive Health is outlined below.

• Patient who present to emergency gynaecology services
• Patients attending for radiological investigations excluding ultrasound
• Patients undergoing general anaesthetic, including non-gynaecological procedures
• In the outpatient gynaecology setting, when undertaking procedures where there is instrumentation of the uterus pregnancy status should be determined.  This would include hysteroscopy, pipelle endometrial biopsy, insertion or removal of intrauterine contraceptive devices and LLETZ procedures.
• Consideration should be given to pregnancy testing prior to administration of hormonal therapies such as contraception or GnRH analogues.

The only patients who can be excluded are as follows:

• Previous total hysterectomy
• Patients attending for procedure where pregnancy already confirmed e.g. TOP patients, patients management of a miscarriage including MVA and patients undergoing management of ectopic pregnancy

In women where there is contraception use, HRT use and women who are post-menopausal and <55years of age, testing should still be considered and carried out.

Testing should be carried out on the day of the procedure, using a sample collected on admission for the procedure.  High sensitivity urine pregnancy tests should be used which will identify HCG >25iu/l.

The result of the pregnancy test must be recorded in the peri-operative care plan or in the patient notes.  It should include the test kit lot number.

In the theatre setting, the operating surgeon and theatre staff must be informed of any positive result prior to theatre transfer.  The test result, positive or negative, must be included in the surgical pause.

It should be acknowledged that the Urine Pregnancy Test adds weight to exclusion of pregnancy, but only if ≥ 3 weeks since UPSI.

Clinicians should consider the risk of becoming pregnant if UPSI < 7 days.  In these cases an assessment should be made with regard to continuing with the planned procedure or rearranging.

This guidance is mandatory – every eligible patient must be assessed, every time.