Originally published March 2018 / Revised August 2018
Two months after undergoing a breast augmentation, a 38-year-old woman discovers she is 3 months pregnant.
At the pre-operative visit, the plastic surgeon had obtained the patient’s history and conducted a physical examination, but did not ask about the possibility of pregnancy. The intake form also did not ask for this information.
The patient decides to continue the pregnancy. Despite the fact that the baby does not appear to have experienced any negative effects, the patient files a complaint to the medical regulatory authority (College). She alleges that the surgeon should have ordered a pregnancy test before surgery under general anaesthesia.
In this particular case, the College advises the surgeon that a pregnancy test should be routine before any surgical procedure, except emergent, on a woman of reproductive age.
CMPA members have contacted the Association describing cases like the example above, where treating physicians have been unaware that a patient was pregnant before they ordered an intervention or treatment. To get a better understanding of the factors that contribute to these cases, the Association conducted an analysis of its medical-legal files.
What the CMPA’s cases show
From its medical-legal cases that closed between 2011 and 2015, the CMPA identified 14 cases related to pregnancies that were unknown to the physician before investigations or treatments were ordered or performed. Of the 14 cases, 8 were legal actions and 6 were College complaints. Of the legal actions, 5 were settled, while the College was critical of the care provided in 5 cases.
The majority of physicians involved in these cases were obstetrician-gynecologists and family physicians. Patients ranged in age from 20 to 49 years.
Eight patients underwent surgical procedures including laparoscopy, hysterectomy, IUD insertion, endometrial biopsy, and breast augmentation; 5 were prescribed medications, such as hormonal therapy, antibiotics, or opioids. The remaining case was related to diagnostic imaging.
Peer experts who commented on the care in these cases involving undiagnosed pregnancies had the following observations:
- Physicians were not aware of the hospital's policies requiring testing for pregnancy before starting certain investigations and treatments.
- Healthcare providers did not communicate adequately among themselves about a patient's pregnancy status.
- The clinical evaluation, treatment options, and consent discussion were poorly documented.
- Before the surgical procedures, pregnancy should have been ruled out, by obtaining an adequate medical history (e.g. last menstrual period, contraception) and conducting a thorough assessment (e.g. serum chorionic gonadotropin level, abdominal or pelvic exam, or both).
- Before the surgical procedures, pregnancy should have been considered and ruled out, by obtaining an adequate medical history (e.g. last menstrual period, contraception) and/or conducting a thorough assessment (e.g. serum chorionic gonadotropin level, abdominal or pelvic exam, or both).
- If the fetus had been exposed to a potentially harmful investigation or treatment and the patient chose to proceed with the pregnancy, it may have been advisable to initiate appropriate investigations or access consultation to assess the fetus on an ongoing basis. Consultation with maternal fetal medicine is often necessary.
Risk management considerations
These cases illustrate what physicians should consider before a non-emergent surgery that might potentially affect pregnancy. When contemplating investigations, procedures, or treatments for a woman of reproductive age, physicians should consider taking the following actions:
- Ruling out pregnancy where and when appropriate, in accordance with professional, hospital, or other applicable protocols. Reviewing any outstanding test results with the patient.
- If the patient is pregnant and an investigation, procedure, or treatment is proposed, evaluating the maternal and fetal impact, including that of medications, and informing the patient of the risks and benefits.
- If the patient is pregnant and surgery is proposed, discussing the surgical risks and benefits, including risks to the fetus. Considering postponing elective surgery until after delivery, when appropriate.
- If the patient has undergone an investigation or treatment with the potential to harm the pregnancy and it is later discovered that she is pregnant, speaking with the patient to evaluate the risks, consequences, and available options.
- Talking with the patient about the importance of effective contraception to prevent pregnancy during a treatment that could be harmful to a fetus. Alerting patients to the importance of advising the treating physician as soon as she discovers she might be pregnant.
The bottom line
Certain investigations, medical treatments, procedures, and surgeries are potentially harmful to a fetus, pregnant patient, or both. If a pregnancy is detected before any of these are started, then the physician and patient can have a meaningful discussion about the possible physical risks to the fetus, and the possible physical and emotional risks to the woman.
Members should call the Association for advice if they have any medical-legal concerns with asking about or determining pregnancy.