Monica da Silva, a critical care and cardiac anesthesiologist at the University of Alabama at Birmingham, was counseling a patient who had been in a car accident. She had suffered a broken bone and while it wasn’t an emergency, she needed urgent surgery.
Just before they headed to the operating room, however, the patient’s pregnancy test came back unexpectedly positive.
Such pre-procedure pregnancy tests are routine for patients of child-bearing age before everything from tooth extractions to ACL repairs, to guard against any potential risks to a developing fetus. Tens of thousands are done every year, with neither patients nor physicians giving it much thought — until now. The Supreme Court’s Dobbs decision has raised the stakes of a positive pregnancy test in the states where abortion is now banned or sharply restricted, making testing anything but routine.
Before the Dobbs ruling, when a patient of da Silva’s was tested, it was occasionally possible to delay finalizing a surgical plan if the patient wanted time to process and decide whether to continue or end the pregnancy. Da Silva and the surgeons could explore methods to decrease risks of harm to the fetus during the surgery if the mother decided to continue the pregnancy. For cases that were completely elective, da Silva would recommend postponing the procedure and assume the patient would make an appointment with an obstetrician. But the post-Roe implications of pre-procedure testing complicate the usual response by non-OB-GYN physicians.
Now it’s harder to punt the entire responsibility of positive results to a primary care physician or obstetrician, which the patient may not even have, when time could be of the essence. And many physicians and hospitals fear possible legal consequences of performing procedures associated with fetal risks, even when minimized, in the current climate. Da Silva wonders what her patient would have done today without the explicit option of pregnancy termination — and how she would have counseled her regarding next steps.
The American Society of Anesthesiologists recommends pre-procedure pregnancy testing for patients who can become pregnant if the result could affect their medical plan, meaning it’s an issue that mainly applies to non-emergency situations. After all, few would advocate waiting around for a pregnancy test to come back if a patient needs an immediate life-saving procedure regardless of testing. But for elective or urgent procedures, pre-op pregnancy testing is often the standard of care. Randall Clark, president of the American Society of Anesthesiologists, or the ASA, explains that routine testing avoids unnecessary risks to a potential fetus.
“The ASA has looked at this extensively over the years,” Clark said. “The reason we do pregnancy testing is for procedures where it may affect fetal development.” He added that certain procedures are associated with increased risk of preterm labor or fetal loss, particularly those involving the abdomen or pelvis. Radiation such as from fluoroscopy, a series of continuous X-rays sometimes used intra-operatively, is associated with organ malformation, intellectual impairment, and increased risk of later developing childhood cancer if given in sufficiently high doses. (Reassuringly, the dose of a single radiological study is typically well below the threshold for fetal harm.) Depending on circumstances, physicians may recommend waiting to do a surgery until the second trimester rather than the first to reduce those risks, or the medical team could explore alternatives that minimize radiation or other potentially harmful exposures, including certain antibiotics. In general, said Clark, the anesthetic agents themselves are safe for the fetus.
Nonetheless, to be cautious, pregnancy tests are recommended before multiple procedures. While most guidelines state such testing should not be mandatory, in practice, the level at which pregnancy tests are implied to be required varies by institution and specialty. Despite a favorable cost-benefit analysis, many patients, particularly those who feel confident they could not be pregnant, find them unnecessary and intrusive. When they’re positive, it’s usually a surprise.
What happens next is often up to the doctor who ordered it.
“This is an issue of huge importance across the country, and as you can imagine with 55,000 members, we have members that are on the full spectrum of opinion on these issues here,” said Clark.
Donald Herdt, an anesthesiologist at the University of Maryland School of Medicine, tries to deliver the news of positive tests in as straightforward a way as possible.
“There’s a whole range of emotions. Some patients say, ‘This can’t be possible.’ A lot of people are just taken aback,” he explained. “There’s usually been a lot of effort leading up to the procedure and you’re obviously not planning on a pregnancy in that moment. I see a lot of people upset, even if it’s not an unwanted pregnancy.”
Depending on the population, a positive pre-procedure pregnancy test can be relatively common. For example, 2.8% of women of childbearing age originally scheduled for molar extractions at Bellevue Hospital Center in New York City had a positive pregnancy test as part of a routine pre-procedure evaluation. Among premenopausal women undergoing elective surgery at Mayo Clinic Arizona, in contrast, positive tests occurred in around 1 in every 800 patients.
When counseling patients in that situation, Herdt focuses mainly on how the result could affect the upcoming procedure and risks. After they decide about the procedure, he tends to leave counseling about reproductive options to their primary care provider or obstetrician.
But Amiko Uchida, a gastroenterologist practicing at the University of Utah School of Medicine, feels an “urgency” to start those conversations with patients herself — now more than ever. She performs endoscopies, procedures for which pregnancy tests are routinely advised, in one of 13 states that have abortion trigger laws — bans of all or most abortions that went into effect when Dobbs overturned Roe v. Wade. Utah’s law is currently on hold as a legal challenge makes its way through the state’s court system.
“We don’t know what’s going to happen and some patients just don’t have time to wait,” she said.
She devised a care pathway for fellow non-OB-GYN providers to navigate managing a positive pregnancy test. These include anesthesiologists, surgeons, gastroenterologists, and interventional radiologists, none of whom may have had formal training in this type of counseling in the past.
“I think in many ways, the provider should be over-prepared for the conversation in this situation,” she said. Without ample guidance and a general script, improvising makes “room for a lot of fumbling, and awkwardness, and inadequate delivery of care.” Uchida likens it to other rare scenarios for which gastroenterologists are better equipped — for instance, placing a specialized tube to stop bleeding from a variceal, a dangerous venous rupture. Gastroenterologists might perform this procedure once or twice in their lifetimes — but because of how critical it is to execute correctly, there are instructional videos and how-to algorithms that providers use to quickly refresh themselves. Why, she asks, should counseling a patient on a new pregnancy be different?
“Yes, we need to make an immediate decision — are we going to proceed with this procedure or not?” she said. “But then it’s critical we talk about their reproductive options because time is really not on anyone’s side anymore.”
Uchida also has prepared handouts with resources on local obstetric care as well as community resources for access to abortion even if the Utah trigger law goes into effect. She hopes other institutions and providers adopt similar care pathways.
Notably, like many states, Utah law does not stipulate what providers can say to patients about abortion, regardless of the trigger law, and so such discussions are currently protected.
“It’s really important that we say abortion by name when we communicate with patients. An abortion is a medical procedure,” said Uchida. “This is not Harry Potter where we’re dealing with ‘He-who-cannot-be-named.’ The moment we, physicians, start tip-toeing around saying it aloud, we allow in a dangerous gas into our field, and it’s the patients who will suffer.”
Still some non-OB-GYN physicians might feel hesitant to bring up abortion for fear of stoking a politically charged reaction or even legal action. That discussion feels “outside the comfort zone” for da Silva, and patients like hers in the car accident are likely not to be discussing reproductive options in the immediate aftermath of finding out about a positive test. Today Alabama has one of the country’s most extreme abortion bans, without an exception for rape or incest.
State abortion laws have also created uncertainty over where “case law may be heading” regarding personhood status for the fetus, Herdt said. “There are known and theoretical risks to the fetus when pregnant women undergo surgery, and we currently prioritize the safety and autonomy of the mother.” In places where women’s bodily autonomy is increasingly threatened, he said, he worries that clinical judgement may be affected by unknown legal risk for both the medical teams and the women, who may even have waived a pregnancy test at the time of surgery.
“It’s a big question mark right now.”
Documenting positive pregnancy tests in the medical record could have its own consequences, a concern that has been raised by prospective patients who fear having a formal record of a pregnancy they may intend to terminate. Post-Roe, there is increasing alarm about digital trails of possible early pregnancies — including period tracking and messaging apps, and information collected in the medical record. Currently, despite patient privacy protections in HIPAA, there are situations, like a court order, when a clinic or hospital could be required to disclose a patient’s medical records.
For pregnancy tests before elective surgery, most patients presume it will be negative, or they wouldn’t have scheduled a procedure in the first place. At least so far, said Clark, he has not heard of patients declining pre-procedure pregnancy tests in rising numbers.
And da Silva points out that those hypothetical legal implications don’t change the “valid medical reason” pre-procedure pregnancy tests are done.
“There’s a lot of uncertainty right now,” said Clark. “At the present time, I don’t see that Dobbs is changing the issue of pre-procedure testing, but I think we are just going to have to keep our ears to the ground to see if this has any major impact.”
Uchida emphasizes non-OB-GYN physicians don’t need to become “world experts” on reproductive medicine in order to support their patients.
“We’re tasked to have a discussion that’s within the qualifications of our jobs as doctors,” she said. “No one is asking you to perform an abortion or deliver a baby here.”