- Email: [email protected]
Teen Pregnancy Testing: Risk Documentation Versus Cancellation?
Letters to the Editor / J Pediatr Adolesc Gynecol 24 (2011) e43ee45
may have polycystic ovarian syndrome, with combinations of anovulation, infertility, and androgenicity. They may have “metabolic syndrome,” which may lead to later hypertension, cardiovascular problems, and diabetes in addition to early endometrial cancer. Management requires diet, exercise, avoiding obesity, and avoiding salt. This is long-term preventive medicine. Medical judgment, individual care: I still have a vivid memory of Dr. Alan F. Guttmacher, the first Director of Obstetrics and Gynecology at Mount Sinai Hospital in New York City when I was a resident. The patient was an obstetrically elderly African American woman with 6 children whose last pregnancy at another hospital was complicated by chronic hypertension. She first came to us when she was in labor and was found to have hypertension and severe superimposed preeclampsia. Despite good medical care, she died. At our review conference, there was a variety of suggestions of what additional treatment might have been given. Dr. Guttmacher said we did not make any error. The error was made by previous hospital staff for failure to recommend contraception or sterilization. Aside from the humanitarian and personal happiness of the individual, especially the young individual over many future years, Education for Life will have a strong positive effect on our local and national economy. The unwanted pregnancy of a teenager, especially without prenatal care and in combination with substance abuse, often results in premature birth. Such a case may cost a quarter of a million taxpayer dollars and may result in a disabled newborn. Avoiding diabetes may reduce later chronic care, which involves huge expense. Preventing or stopping smoking will reduce lung cancer. Avoiding illegal “recreational” drugs may reduce later crime. The adolescent stops routine well-child pediatric care and tends to discontinue annual good health visits. The adolescent usually does not see adolescent medicine physicians or primary care physicians. One method of encouraging routine visits is to emphasize the need for vaccinations, especially those not given previously (such as HPV, diphtheria, pertussis, rubella, tetanus, etc.) and meningitis. The latter is important if the patient goes to a large college or military unit away from home that is crowded with young people. Thus, the physician should play an active role in individual patient care, which will help the individual and the country. We should be aware of the horrors of school dropouts, unintended pregnancy, HIV and other sexual transmitted disease, runaways, kidnapping, and forced prostitution. Albert Altchek, MD Clinical Professor with Tenure of Obstetrics Gynecology and Reproductive Science Attending Obstetrician-Gynecologist Chief of Pediatric and Adolescent Gynecology The Mount Sinai School of Medicine and Hospital Attending Obstetrician-Gynecologist Lenox Hill Hospital doi:10.1016/j.jpag.2010.07.008
e45
Teen Pregnancy Testing: Risk Documentation Versus Cancellation? Accepted practice implicates the avoidance of surgery and anesthesia during pregnancy. Unfortunately, medical history alone may be an unreliable marker for ruling out pregnancy in adolescent patients presenting for outpatient surgery. For different reasons, such as subtlety of early symptoms and signs, misconceptions, embarrassment, or denial, history is often not helpful in determining early pregnancy in adolescents. In the case of departmentally instituted routine preoperative pregnancy testing, and especially when applied to “at risk” ambulatory adolescent patients; the refusal of the patient or the family to consent for preoperative urine pregnancy testing poses the dilemma of case cancellation versus risk related to documentation and anesthesia administration. Let us cite the example of a 14-year-old female patient with a recent history of drug overdose, requiring elective ear surgery under general anesthesia. Last menstruation was approximated at 5 weeks prior to scheduled date of the procedure. Mother states that the patient had irregular menstrual cycles, denied any risk of pregnancy, and declined to give consent for urine HCG testing. Review of the literature shows a lack of consensus about whether all female patients in childbearing age should undergo preoperative pregnancy testing. Although the teratogenic and abortive effects on the human fetus of the more commonly used anesthetics may be equivocal, anesthesia and surgery in the pregnant patient may expose the fetus to potentially harmful perioperative procedures. There is usually alteration in perioperative management after a positive pregnancy test, resulting in cancellation or postponement of an elective operative procedure, with the patient desire for cancellation as the main determining factor in each case.1 Ethical responsibility and balance between benefit and risk are important factors in the anesthesiologist’s decision-making of administering anesthesia for elective ambulatory surgery in “high risk” patients when pregnancy test is not consented. Practice guidelines and medico-legal implications are not well established. Claude Abdallah, MD, MSc Division of Anesthesiology Children's National Medical Center 111 Michigan Avenue, N.W. Washington, DC 20010 United States E-mail address: [email protected] (C. Abdallah) doi:10.1016/j.jpag.2010.07.009
Reference 1. Manley S, de Kelaita G, Joseph NJ, et al: Preoperative pregnancy testing in ambulatory surgery: Incidence and impact of positive results. Anesthesiology 1995; 83:690
may have polycystic ovarian syndrome, with combinations of anovulation, infertility, and androgenicity. They may have “metabolic syndrome,” which may lead to later hypertension, cardiovascular problems, and diabetes in addition to early endometrial cancer. Management requires diet, exercise, avoiding obesity, and avoiding salt. This is long-term preventive medicine. Medical judgment, individual care: I still have a vivid memory of Dr. Alan F. Guttmacher, the first Director of Obstetrics and Gynecology at Mount Sinai Hospital in New York City when I was a resident. The patient was an obstetrically elderly African American woman with 6 children whose last pregnancy at another hospital was complicated by chronic hypertension. She first came to us when she was in labor and was found to have hypertension and severe superimposed preeclampsia. Despite good medical care, she died. At our review conference, there was a variety of suggestions of what additional treatment might have been given. Dr. Guttmacher said we did not make any error. The error was made by previous hospital staff for failure to recommend contraception or sterilization. Aside from the humanitarian and personal happiness of the individual, especially the young individual over many future years, Education for Life will have a strong positive effect on our local and national economy. The unwanted pregnancy of a teenager, especially without prenatal care and in combination with substance abuse, often results in premature birth. Such a case may cost a quarter of a million taxpayer dollars and may result in a disabled newborn. Avoiding diabetes may reduce later chronic care, which involves huge expense. Preventing or stopping smoking will reduce lung cancer. Avoiding illegal “recreational” drugs may reduce later crime. The adolescent stops routine well-child pediatric care and tends to discontinue annual good health visits. The adolescent usually does not see adolescent medicine physicians or primary care physicians. One method of encouraging routine visits is to emphasize the need for vaccinations, especially those not given previously (such as HPV, diphtheria, pertussis, rubella, tetanus, etc.) and meningitis. The latter is important if the patient goes to a large college or military unit away from home that is crowded with young people. Thus, the physician should play an active role in individual patient care, which will help the individual and the country. We should be aware of the horrors of school dropouts, unintended pregnancy, HIV and other sexual transmitted disease, runaways, kidnapping, and forced prostitution. Albert Altchek, MD Clinical Professor with Tenure of Obstetrics Gynecology and Reproductive Science Attending Obstetrician-Gynecologist Chief of Pediatric and Adolescent Gynecology The Mount Sinai School of Medicine and Hospital Attending Obstetrician-Gynecologist Lenox Hill Hospital doi:10.1016/j.jpag.2010.07.008
e45
Teen Pregnancy Testing: Risk Documentation Versus Cancellation? Accepted practice implicates the avoidance of surgery and anesthesia during pregnancy. Unfortunately, medical history alone may be an unreliable marker for ruling out pregnancy in adolescent patients presenting for outpatient surgery. For different reasons, such as subtlety of early symptoms and signs, misconceptions, embarrassment, or denial, history is often not helpful in determining early pregnancy in adolescents. In the case of departmentally instituted routine preoperative pregnancy testing, and especially when applied to “at risk” ambulatory adolescent patients; the refusal of the patient or the family to consent for preoperative urine pregnancy testing poses the dilemma of case cancellation versus risk related to documentation and anesthesia administration. Let us cite the example of a 14-year-old female patient with a recent history of drug overdose, requiring elective ear surgery under general anesthesia. Last menstruation was approximated at 5 weeks prior to scheduled date of the procedure. Mother states that the patient had irregular menstrual cycles, denied any risk of pregnancy, and declined to give consent for urine HCG testing. Review of the literature shows a lack of consensus about whether all female patients in childbearing age should undergo preoperative pregnancy testing. Although the teratogenic and abortive effects on the human fetus of the more commonly used anesthetics may be equivocal, anesthesia and surgery in the pregnant patient may expose the fetus to potentially harmful perioperative procedures. There is usually alteration in perioperative management after a positive pregnancy test, resulting in cancellation or postponement of an elective operative procedure, with the patient desire for cancellation as the main determining factor in each case.1 Ethical responsibility and balance between benefit and risk are important factors in the anesthesiologist’s decision-making of administering anesthesia for elective ambulatory surgery in “high risk” patients when pregnancy test is not consented. Practice guidelines and medico-legal implications are not well established. Claude Abdallah, MD, MSc Division of Anesthesiology Children's National Medical Center 111 Michigan Avenue, N.W. Washington, DC 20010 United States E-mail address: [email protected] (C. Abdallah) doi:10.1016/j.jpag.2010.07.009
Reference 1. Manley S, de Kelaita G, Joseph NJ, et al: Preoperative pregnancy testing in ambulatory surgery: Incidence and impact of positive results. Anesthesiology 1995; 83:690