In the 1990s, multiple studies demonstrated links between anesthesia exposure for pregnant patients and negative fetal outcomes. In response, hospitals around the country added pregnancy tests to the standard preoperative checklist for all female patients of childbearing age due to fears of fetal complications, patient problems, and legal actions. Recently, however, debate about preoperative pregnancy tests has resurfaced, with new questions about privacy and autonomy.
The main argument held by proponents of mandatory testing concerns the safety of the patient and the potential fetus. Typically consisting of patient interview questions and a urine test, this screening effectively prohibits or delays procedures for patients with previously unknown first-trimester pregnancies on the premise that anesthesia exposure in this stage threatens fetal development (1, 2). This rationale initially emerged from studies in the late 1900s that have since received scrutiny due to inappropriate design or the use of animal models (3). Modern studies, in contrast, have typically shown two key outcomes after anesthesia during first-trimester pregnancy. First, there is a lack of teratogenic effects of modern anesthetic agents at clinical dose and duration, resulting in zero increase in the risk of birth defects. Second, there is a minimal increase in the risk of birth complications and fetal loss, which certain anesthetics, prolonged surgery, abdominal or obstetric surgery, and multiple surgeries significantly elevate (3-5). Anesthesia exposure remains the most popular source of concern, yet numerous studies have also asserted that these negative outcomes may stem from physiological responses to surgery, other perioperative drugs, surgical indications, or high background rates of fetal complications (2, 4).
Overall, current consensus holds that surgery during first-trimester pregnancy should generally proceed, as long as the potential improvements in patient health outweigh the fetal hazards (1, 3, 4, 6). Therefore, preoperative pregnancy testing ideally allows patients to gain information about the potential risks to themselves and their previously unknown pregnancy (7, 8).
On the other side of the debate, opponents agree that informed consent is critical but argue that mandatory preoperative pregnancy testing does not achieve this goal. At around $30 per test, preoperative screening rarely identifies unknown pregnancies. In fact, studies have shown that roughly 97% to 99% of tested patients receive true negative results (2, 9). Some researchers have attributed this lower-than-average rate to the older age and poorer health of surgical patients, as well as patients’ ability to preemptively cancel procedures due to the widespread availability of at-home pregnancy tests (1, 2). Despite occasional detections of pregnancies, the typically negative results potentially deter medical staff from complying with other steps of the protocol before proceeding with surgery (10). In this way, despite its intentions, the test requirement may result in paradoxical decreases in safety, as well as legal issues and low utility.
Beyond safety, the debate over preoperative pregnancy tests also considers privacy (9). In the wake of recent anti-abortion legislation, many patients and providers alike have criticized mandatory screening, as results may be collected, recorded, or accessed, with or without patients’ informed consent (6, 11-13). Critically, family members, insurers or court orders may obtain test results, which likely deters many patients from seeking surgery, especially adolescents and residents of states with anti-abortion laws (9, 11, 12). Identifying pregnancies while upholding patient autonomy and considering legal consequences remains difficult in the current climate. However, evidence demonstrates that typical patient interview questions about pregnancy likelihood may parallel or even outperform urine tests in terms of accuracy, with a false-negative rate between 0.02% and 0.3%, although this standard protocol is rarely practiced in preoperative settings (9, 10, 14). Therefore, although required tests pose potential threats, pregnancy may be identified without compromising patient autonomy.
On an institutional level, experts generally recommend that hospital systems re-visit their protocols to enhance patient autonomy and privacy, consider opt-in or opt-out testing, provide clear information about legal implications to patients, and enhance patient interview question adherence (6, 15, 16). On a practitioner level, guidelines discourage universal preoperative pregnancy testing—instead, surgeons should strive to achieve patients’ consent and order pregnancy tests only in cases wherein the procedure would be rendered unnecessary by positive test results, involve significant radiation or manipulation of pelvic anatomy, or entail perioperative chemotherapy (6, 15, 16). As the debate persists, guidance for both levels will continue to evolve, with the goal of ensuring safety while protecting privacy.
References
1: Xun, G. and Poterack, K. 2018. Retrospective review of universal preoperative pregnancy testing: results and perspectives. Anesthesia & Analgesia, vol. 127(2). DOI: 10.1213/ANE.0000000000002709.
2: Maher, J. and Mahabir, R. 2012. Preoperative pregnancy testing. Canadian Journal of Plastic Surgery, vol. 20(3). PMID: 23997593
3: Reitman, E. and Flood, P. 2011. Anaesthetic considerations for non-obstetric surgery during pregnancy. British Journal of Anaesthesia, vol. 107(1). DOI: 10.1093/bja/aer343
4: Cohen-Kerem, R., Railton, C., Oren, D., Lishner, M. and Koren, G. 2005. Pregnancy outcome following non-obstetric surgical intervention. American Journal of Surgery, vol. 190(3). DOI: 10.1016/j.amjsurg.2005.03.033
5: Upadya, M. and Saneesh, P. 2016. Anaesthesia for non-obstetric surgery during pregnancy. Indian Journal of Anaesthesia, vol. 60(4). DOI: 10.4103/0019-5049.179445
6: Palmer, S., Van Norman, G., and Jackson, Stephen. 2009. Routine pregnancy testing before elective anesthesia is not an American Society of Anesthesiologists standard. Anesthesia & Analgesia, vol. 108(5). DOI: 10.1213/ane.0b013e31819b34cf
7: Cheek, T. and Baird, E. 2009. Anesthesia for nonobstetric Surgery: maternal and fetal considerations. Clinical Obstetrics and Gynecology, vol. 52(4). DOI: 10.1097/GRF.0b013e3181c11f60
8: Webb, M., Helander, E., Meyn, A., Flynn, T., Urman, R. and Kaye, A. 2018. Preoperative assessment of the pregnant patient undergoing nonobstetric surgery. Anesthesiology Clinics, vol. 36(4). DOI: 10.1016/j.anclin.2018.07.010
9: Jackson, S., Hunter, J., and Van Norman, G. 2024. Ethical principles do not support mandatory preanesthesia pregnancy screening tests: a narrative review. Anesthesia and Analgesia, vol. 138(5). DOI: 10.1213/ANE.0000000000006669
10: Lamb, J., Allen, D., Franklin, J., and Goode, V. 2019. Evaluation of a presurgical pregnancy testing protocol at an ambulatory surgery center. Journal of Perianesthesia Nursing, vol. 34(5). 10.1016/j.jopan.2019.03.010
11: Pasricha, T. 2022. “Pregnancy tests are routine before many surgical procedures. But Dobbs has raised the stakes of a positive result.” StatNews. URL: https://www.statnews.com/2022/08/16/pregnancy-tests-are-routine-before-many-surgical-procedures-but-dobbs-has-raised-the-stakes-of-a-positive-reslt/
12: Clayton, E., Embi, P. and Malin, B. 2022. Dobbs and the future of health data privacy for patients and healthcare organizations. Journal of the American Medical Informatics Association, vol. 30(1). DOI: 10.1093/jamia/ocac155
13: Spector-Bagdady, K. and Mello, M. 2022. Protecting the privacy of reproductive health information after the fall of Roe v Wade. JAMA Health Forum, vol. 3(6). DOI: doi:10.1001/jamahealthforum.2022.2656
14: Wyatt, M., Ainsworth, A., DeJong, S., Cope, A. and Long, M. 2018. Implementation of the “Pregnancy Reasonably Excluded Guide” for pregnancy assessment. Obstetrics & Gynecology, vol. 132(5). DOI: 10.1097/AOG.0000000000002917
15: American Society of Anesthesiologists (ASA). 2021. “Statement on pregnancy testing prior to anesthesia and surgery.” ASA Committee on Quality Management and Departmental Administration. URL: https://www.asahq.org/standards-and-practice-parameters/statement-on-pregnancy-testing-prior-to-anesthesia-and-surgery.
16: Fairlie, R. and McConnell, P. 2025. Ethics of pregnancy testing in patients undergoing anaesthesia and surgery. Anaesthesia and Intensive Care Medicine, vol. 26(1). DOI: 0.1016/j.mpaic.2024.10.002