Documentation of pregnancy status, gynaecological history, date of last menstrual period and contraception use in emergency surgical admissions: time for a change in practice?

OBJECTIVE: To determine whether pregnancy status, gynaecological history, date of last menstrual period and contraceptive use are documented in emergency female admissions of reproductive age admitted to general surgery.

DESIGN: This is a retrospective study.

SETTING: This study was conducted in the United Kingdom.

POPULATION: Females of reproductive age (12-50 years) admitted as an emergency to general surgery with abdominal pain were considered in this study.

METHODS: Retrospective analysis of medical notes of emergency female admissions with abdominal pain between January and September 2012. We recorded whether a pregnancy test result was documented (cycle 1). Results were analysed and a prompt added to the medical clerk-in document. We re-audited (cycle 2) between January and June 2013 looking for improvement.

MAIN OUTCOME MEASURES: Documented pregnancy status within 24 h of admission and prior to any surgical intervention.

RESULTS: 100 case notes were reviewed in stage 1. 30 patients (30 %) had a documented pregnancy status. 32 (32 %), 25 (25 %) and 29 (29 %) had a documented gynaecology history, contraceptive use and date of last menstrual period (LMP), respectively. 24 patients underwent emergency surgery, 6 (25 %) had a documented pregnancy status prior to surgery. Of 50 patients reviewed in stage 2, 37 (75.0 %) had a documented pregnancy status (p < 0.001), with 41 (82 %) having both gynaecological history (p < 0.0001) and contraceptive use (p < 0.0001) documented. 40 patients (80 % had a documented LMP (p < 0.0001). 7 patients required surgery, of whom 6 (85.7 %) had a documented pregnancy test prior to surgery (p = 0.001). All pregnancy tests were negative.

CONCLUSIONS: A simple prompt in the surgical admission document has significantly improved the documentation of pregnancy status and gynaecological history in our female patients, particularly in those who require surgical intervention. A number of patient safety concerns were addressed locally, but require a coordinated, interdisciplinary discussion and a national guideline. A minimum standard of care, in females of reproductive age, should include mandatory objective documentation of pregnancy status, whether or not they require surgical intervention.