preg testing

Started by gman33
Panacea Financial Contract Review
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
gman33

gman33

Full Member
Moderator Emeritus
Verified Member
Verified Expert
15+ Year Member
Advertisement - Members don't see this ad
Got into it a little with a nurse about getting a preg test in a teenage girl recently.
Wanted to know before giving a med which would be contraindicated if she was pregnant.

Never had someone give me a hard time about wanting a preg test.
Not sure where she was coming from.

I don't get preg tests on every female, but do get them if I think it will change management.
Some attendings just treat it like a VS and get them on everyone.

What are your practice patterns?
 
I don't get pregnancy tests on patients unless it would be related to their condition (Ex. chest pain, lac, ankle injury - prolly not). In the situation you described, I'd talk to the teenager in private and say "I'm planning to give you a medicine that could be harmful if you were pregnant. Are you sure you're not pregnant?" If she says she's sure, no test, briefly document conversation, give the medicine.

FWIW- I can imagine many situations where I might give a medicine without specifically asking about pregnancy - ex. motrin for ankle sprain.
 
Last edited:
Get them on every female between 5 and 55. Why ?

Because everybody lies.

"There's no WAY I could be pregnant!" really means - "I'd rather pretend like I didn't sleep with that guy six weeks ago, and if I repeat it enough to myself, it MUST be true."

Next thing you know, you've got to explain why you didn't get a ucg on a patient that you sprayed with an angel's whisper of radiation and she's now somehow trying to tie it to her jackpot lawsuit.

Tell nursie that she can make those decisions when she assumes that risk.
 
RustedFox said:
Next thing you know, you've got to explain why you didn't get a ucg on a patient that you sprayed with an angel's whisper of radiation and she's now somehow trying to tie it to her jackpot lawsuit.
Click to expand...
See, that's why practicing in a state with tort law is important. I mean, if they need the study, they need it regardless of pregnancy status. They should be shielding everyone anyway. Thus, you shouldn't have to get dragged to court for doing your job appropriately.

That being said, what drug is the OP talking about? Methotrexate? Accutane?
 
I was giving a prolonged course of steroids for something where there were other options.
Not asthma or anything like that where she might need them anyway.

For an intervention that I need to give immediately in the ER I might be okay with just asking the patient.
For a non-urgent intervention, I'd like it documented as non-pregnant in the chart.

It made me think a little more about my current style.
Not that I need less testing, maybe more testing.

If I know someone is pregnant and they have a HA, they usually get Tylenol and a pat on the back.
If they are female, not known to be pregnant, and come in with HA, I generally don't wait for a preg test before treating.
These patients might get Toradol or something I wouldn't give if I knew they were pregnant.
One dose probably wouldn't do much of anything.
Maybe I should be looking at this a little more closely.

For what it's worth, I work in an area with one of the worst malpractice environments.
I'll be staying there after residency, so I want to develop the proper style for the future.
 
A slightly different issue is the young female with belly pain and no preg test.
I wish they would just get this at triage and tell them they aren't coming back until they pee.
I'm only talking about the stable patients.

Would speed things up.
Plus the ones who only came because they wanted a preg test for free could just elope.
 
gman33 said:
I was giving a prolonged course of steroids for something where there were other options.
Not asthma or anything like that where she might need them anyway.
Click to expand...
Not sure there's anything emergent that needs a prolonged course of steroids, but whatever.

If I know someone is pregnant and they have a HA, they usually get Tylenol and a pat on the back.
If they are female, not known to be pregnant, and come in with HA, I generally don't wait for a preg test before treating.
These patients might get Toradol or something I wouldn't give if I knew they were pregnant.
One dose probably wouldn't do much of anything.
Click to expand...
You're right it probably won't do much. Including treating the headache. It might cause a GI bleed though. FWIW, NSAIDs are "ok" in the first and second trimesters.

I'll be staying there after residency, so I want to develop the proper style for the future.
Click to expand...
Those proper styles should be "leaving" or "enacting tort reform." If you're serious about learning bad medicine to avoid lawsuits, you're going to be frustrated at work.

gman33 said:
A slightly different issue is the young female with belly pain and no preg test.
I wish they would just get this at triage and tell them they aren't coming back until they pee.
I'm only talking about the stable patients.
Click to expand...
You can put a drop of blood on the urine pregnancy tests and it works just fine.
 
Dr.McNinja said:
Not sure there's anything emergent that needs a prolonged course of steroids, but whatever.


You're right it probably won't do much. Including treating the headache. It might cause a GI bleed though. FWIW, NSAIDs are "ok" in the first and second trimesters.


Those proper styles should be "leaving" or "enacting tort reform." If you're serious about learning bad medicine to avoid lawsuits, you're going to be frustrated at work.


You can put a drop of blood on the urine pregnancy tests and it works just fine.
Click to expand...

Thanks for the worthless response.
Have a nice day.
 
gman33 said:
A slightly different issue is the young female with belly pain and no preg test.
I wish they would just get this at triage and tell them they aren't coming back until they pee.
I'm only talking about the stable patients.

Would speed things up.
Plus the ones who only came because they wanted a preg test for free could just elope.
Click to expand...

This sounds like something you might be able to get running at your program. Nurses ordering UPTs in triage ftw?
 
Advertisement - Members don't see this ad
RustedFox said:
Get them on every female between 5 and 55. Why ?

Because everybody lies.

"There's no WAY I could be pregnant!" really means - "I'd rather pretend like I didn't sleep with that guy six weeks ago, and if I repeat it enough to myself, it MUST be true."

Next thing you know, you've got to explain why you didn't get a ucg on a patient that you sprayed with an angel's whisper of radiation and she's now somehow trying to tie it to her jackpot lawsuit.

Tell nursie that she can make those decisions when she assumes that risk.
Click to expand...

Or they're stupid. I've had the following conversation multiple times in the last couple months (and I'm sure I'm not the only one):

"And is there any chance you could be pregnant?"
"Um... I don't know..."
"Well, are you sexually active?"
"Yes."
"And are you using any kind of contraception?"
"No."
"Then there's a chance you're pregnant."
"Huh. See, it's so simple when you put it like that!"

Can we blame this on the (lack of) Sex Ed in America? Because really, that seems really straightforward.
 
Rendar5 said:
Actually, it was a very worthwhile response, I thought. He's suggesting you may not need your current treatment paradigms.
Click to expand...

On a -5 to +5 scale, I give it a +1. It didn't really strike me as so strong.

However, maybe I'm just no good, because I can't recall the incidence of GI bleed from Toradol, but have anecdotes about renal colic and headache getting moderate to complete relief from it. As such, I don't know if I'm statistically supported for benefit and risk. Or maybe it's just the patient population.
 
Apollyon said:
However, maybe I'm just no good, because I can't recall the incidence of GI bleed from Toradol, but have anecdotes about renal colic and headache getting moderate to complete relief from it. As such, I don't know if I'm statistically supported for benefit and risk. Or maybe it's just the patient population.
Click to expand...
It's been discussed in this forum before. Both .pdfs in post 22 are worth reading.
http://forums.studentdoctor.net/index.php?threads/toradol-and-gi-bleed.940079/
A systematic review of observational studies revealed that risk of upper gastrointestinal bleeding or perforation was not increased by celecoxib. Risk was low with ibuprofen (RR 2.69), followed by diclofenac (RR 3.98), meloxicam (RR 4.15), indomethacin (RR 4.15), ketoprofen (RR 5.4), naproxen (RR 5.57), piroxicam (RR 9.94), and ketorolac (RR 14.54).2
Click to expand...

And, as I mentioned in that thread, it's a good drug to use in renal colic patients who can't tolerate PO. For the rest, the risks are worse than the benefits IMO.
gman33 said:
Thanks for the worthless response.
Have a nice day.
Click to expand...
I'm sorry that challenging your paradigms made you respond that way.
 
We did a big medico legal institutional review after a patient at my institution was CT'ed while pregnant. Adequate documentation is the patient denying pregnancy. If they are unsure, then do a test.

FWIW - steroids aren't harmful in pregnancy.
 
I'm all for minimizing waste but a pregnancy test is pretty low on my chopping block of useless or over utilized tests/treatments. Cost is negligible. Probably better off just having it as part of triage. The system as a whole may just benefit from 1/N fewer fetii exposed to intrauterine insults and it doesn't take a lot of reduction in extended inquiries into basic reproductive knowledge, dispositions delayed by a pending pregnancy test, or work-ups for people who just wanted a pregnancy test for the department itself to benefit.
 
DeadCactus said:
I'm all for minimizing waste but a pregnancy test is pretty low on my chopping block of useless or over utilized tests/treatments. Cost is negligible. Probably better off just having it as part of triage. The system as a whole may just benefit from 1/N fewer fetii exposed to intrauterine insults and it doesn't take a lot of reduction in extended inquiries into basic reproductive knowledge, dispositions delayed by a pending pregnancy test, or work-ups for people who just wanted a pregnancy test for the department itself to benefit.
Click to expand...
Not sure that this is the argument. Sure, it's cheap. Order them on everyone. But how long are you willing to wait when the 22 yr old gets to the back, doesn't have one resulted, and says she peed in the lobby? I can tell you it sometimes takes hours for that to come back, and it's a room taken up during that time.

BTW plural would be feti.
 
Advertisement - Members don't see this ad
Dr.McNinja said:
It's been discussed in this forum before. Both .pdfs in post 22 are worth reading.
http://forums.studentdoctor.net/index.php?threads/toradol-and-gi-bleed.940079/


And, as I mentioned in that thread, it's a good drug to use in renal colic patients who can't tolerate PO. For the rest, the risks are worse than the benefits IMO.

I'm sorry that challenging your paradigms made you respond that way.
Click to expand...

I guess I took it more that you didn't really answer my question, just attacked a bunch of minor points.
I am aware of the data regarding Toradol and using whole blood for POC preg tests.
You probably didn't mean it that way, but that's how I took it.

In this particular case, I had no problem getting urine, just a nurse who wouldn't do the test.

I would like more comments regarding my initial question.
When do you guys get preg tests?

Obviously, when preg is part of the differential, but when else?
Before imaging, before certain meds, etc.

Steroids are a class D medication. If I have other options, I'd avoid them in pregnancy.
The data on steroids and pregnancy is pretty weak.
It's not like anyone is going to do a RCT in this day and age.
For asthma, it's still recommended if needed. More risk in the first trimester.

When these is a clear benefit that outweighs any possible fetal risk, I'd give the medication anyway.
 
No worries.
I misunderstood your first post. I though you were the one that didn't want the test, and nursing did. Guess I need to brush up on my comprehension.
Now that I've gotten your line of reasoning, I will respond in kind.
I usually try to get them on everyone. Often it's done from triage anyway. If they don't have it by the time they get to me, I decide if I want it or not.

Which steroids are D? Prednisone/prednisolone/dex are C. I don't give much of the others.
 
Apollyon said:
If you get a period, you get a pregnancy test. If you have pain in your trunk, or will need an xray of anything that is not your hand or foot, and you have a period, you get the test.

As stated above, people lie. All the time. ALL THE TIME.
Click to expand...
How long do you wait on those patients?
I don't disagree that people lie, but I don't go around drug testing everyone that's going to get a beta blocker either.
gman33 said:
Prednisone is listed as class D in Epocrates.
Click to expand...
Hmm. Would you look at that. References with differing opinions. Not sure what to make of that.
Personally, I'm not a fan of Epocrates, and this of course makes me cement that.
 
I try to be judicious. Urine pregs for anyone that has a complaint potentially related to pregnancy, or needing a drug that doesn't play nice with pregnancy. My radiology colleagues want a preg test for anyone getting any xray... Once you add all this up, its a lot of pregnancy tests! My nurses tend to be very good at getting them up front. I've RARELY had an RN question my desire for a preg test... only in, say, a 55 yo where they think it is silly but I think it is still reasonable.

Last patient that needed a CT, and wouldn't / couldn't pee for a Urine preg... myself and RN both went (separate) and discussed with her. She PROMISED NO POSSIBILITY OF PREGNANCY. Refused to wait for serum results (multiple hours at my institution). So we both documented, and got the CT... and I diagnosed a late first trimester pregnancy on that CT. Radiologist actually missed it... that was a fun phone call. That aside, once confronted the patient was actually tearful and apologetic for lying to me and the RN. And we DID find real pathology in addition to the pregnancy. And she DID end up terminating said pregnancy (her desire).

Not sure the moral of that story. Take from it what you will.
 
Dr.McNinja said:
How long do you wait on those patients?
I don't disagree that people lie, but I don't go around drug testing everyone that's going to get a beta blocker either.

Hmm. Would you look at that. References with differing opinions. Not sure what to make of that.
Personally, I'm not a fan of Epocrates, and this of course makes me cement that.
Click to expand...

In the first trimester, there is a potentially increased risk of cleft palate in women exposed to corticosteroids.
http://www.ncbi.nlm.nih.gov/pubmed?term=11091360
http://www.ncbi.nlm.nih.gov/pubmed?term=10482873

It's not a huge risk and some studies don't show a correlation but there is some literature to support it.

It is technically used in severely refractory cases of hyperemesis but it is fairly rare for a patient to be that bad.
 
I'm in Internal Medicine. My policy is, for any woman of child bearing potential, I don't care what she says, I order HCG. I just don't consider the workup done without it. The ED at my shop is good about that; they always send them to the floor with that test already done. Even if its not an immediate issue, something may come up where it becomes and issue, and I want to know. Maybe from a medicolegal standpoint documenting that the patient denies the possibility could cover me, I still think that the cost is so low that it makes sense just to be thorough and not take the risk. Better to have all the cards on the table and know exactly what we're dealing with. Now if its something you guys give a one off tx for and send out without ever consulting us, I'll leave it to you to decide when/if appropriate. But if they're sick enough to get admitted, its well worth it to know for sure. Call my cynical, but patients lie and they don't listen and they're not always particularly smart. So, either they have had sex and could be pregnant, and are lying, or they didn't actually listen to the question, or they don't know how babies are made. These are all real possibilities, and even though I hate kids, I still don't want to harm one of them, and the only way to make sure is to know for sure if I'm treating one patient or two. Just get the test as part of your initial workup; it is the right thing to do.
 
Advertisement - Members don't see this ad
I just want to point out as a queer woman who passes easily for straight the whole pregnancy test thing is extremely frustrating when my only sexual partner is female.

Coversation goes something like this:

Doc/nurse: is there any chance u could be pregnant?
Me: no
D: are you sexually active
M: yes
D: do you use contraception
M: no
D: well then you could be pregnant
M: 🙄
 
touchpause13 said:
I just want to point out as a queer woman who passes easily for straight the whole pregnancy test thing is extremely frustrating when my only sexual partner is female.

Coversation goes something like this:

Doc/nurse: is there any chance u could be pregnant?
Me: no
D: are you sexually active
M: yes
D: do you use contraception
M: no
D: well then you could be pregnant
M: 🙄
Click to expand...

As a counter, I have once diagnosed a pregnancy in a woman who self identified as lesbian, who showed up to the ED with her female partner, who laughed when I asked if there is any chance she could be pregnant.
 
gro2001 said:
As a counter, I have once diagnosed a pregnancy in a woman who self identified as lesbian, who showed up to the ED with her female partner, who laughed when I asked if there is any chance she could be pregnant.
Click to expand...

Yikes. People lie I guess. I wouldn't get pissy if the doc said I understand where you are coming from but I just want to double check. It's the assumptions that grind my gears (and the subsequent lecture on how I should start using condoms)
 
gro2001 said:
As a counter, I have once diagnosed a pregnancy in a woman who self identified as lesbian, who showed up to the ED with her female partner, who laughed when I asked if there is any chance she could be pregnant.
Click to expand...

Same thing for me, when I was a resident.

touchpause13 said:
I just want to point out as a queer woman who passes easily for straight
Click to expand...

First, from looking at the rest of SDN, I thought that you described yourself as "bisexual", but, and not to derail the whole thread - "queer woman who passes easily for straight" - what does that even mean? You look like every other woman, not wearing flannel and having a brush cut? Stereotypes, yes, but that is what you imply with "passes". My crazy, bisexual ex (not one because of the other - like Ed, "I am a lawyer, I own a bowling alley - two different things") "passed easily for straight" because she looked like a woman. However, she DID drive a Subaru (although I forget which model), and, when I said something about that, she was already aware.
 
Queer is a broad spectrum term that includes bisexual. I prefer queer as a label because it has a lot less nasty stereotypes.

And by passing I just mean most straight people assume I am straight based off of my appearance. I dress very feminine, although I still fit a lot of stereotypes, being a rugby player and all haha
 
I generally don't bother asking the pt if there's a chance they could be pregnant. I just order the damn test and save myself a 2 minute sex-ed conversation 🙂 I order it on all women of child-bearing years unless it's a straight-forward dischargable type of complaint unrelated to any abdominal or GU complaints.
 
gman33 said:
Got into it a little with a nurse about getting a preg test in a teenage girl recently.
Wanted to know before giving a med which would be contraindicated if she was pregnant.

Never had someone give me a hard time about wanting a preg test.
Not sure where she was coming from.

I don't get preg tests on every female, but do get them if I think it will change management.
Some attendings just treat it like a VS and get them on everyone.

What are your practice patterns?
Click to expand...


The preg test is a cheap test that can help you avoid a lot of expensive litigation later on. My threshold for ordering them is from about age 10 to 55. Conversations with the nurse about why the test has been ordered them do not need to last long. I would try to explain (briefly) my logic. If nurse is still balking then I'd simply mention to her that my re-evaluation note would reflect the time of the written order and the follow up verbal conversation with the nurse about the fact that the test was requested. In the place where I work, the nurses have to do the equivalent of an incident report if too much time goes by between the time that a medicine is ordered and the time that it is given.
 
You must log in or register to reply here.

Similar threads

DocEspana
Pregnant emergencies
Replies
18
Views
4K
RustedFox
RustedFox
Dred Pirate
COVID testing for travel for 2 year old?
Replies
15
Views
2K
Birdstrike
Birdstrike
W
"Emergency rooms refused to treat pregnant women, leaving one to miscarry in a lobby restroom"
Replies
30
Views
4K
CoolDoc1729
CoolDoc1729
han14tra
Options for Emergency Physicians during pregnancy
Replies
17
Views
4K
wareagle726
wareagle726
Dr Mantis Toboggan
People come to the ED for covid testing, get upset about the bill later.
Replies
24
Views
3K
emergentmd
E