Original Article A multispecialty study of determining the possibility of pregnancy and the documentation of pregnancy status in surgical patients: a cause for concern? Ibrahim Ibrahim 1 , Bilal Ibrahim 2 , Guo Liang Yong 1 , Maria Coats 3 , Zorica Vujovic 4 and Michael SJ Wilson 3 ; on behalf of the NHS Tayside Junior Doctor Audit Group Abstract Background: Determining the possibility of pregnancy and the documentation of pregnancy status are important considerations in the assessment of females of reproductive age when admitted to hospital. Objectives: Our aim was to determine the adequacy of the documentation of pregnancy status and possibility of pregnancy across multiple surgical specialties. Materials and methods: A prospective audit of surgical specialties (general, orthopaedics, urology, vascular, maxillo- facial, ENT, gynaecology and neurosurgery) within NHS Tayside, in May 2015. Results: A total of 129 females of reproductive age were admitted; 69 (53.5%) elective and 60 (46.5%) emergencies. Eighty-four patients (65%) were asked ‘Is there any possibility of pregnancy?’ Pregnancy status was documented in 74% of patients. Eleven (8.5%) patients were not asked about possibility of pregnancy and did not have a documented pregnancy status. Documentation of the use of contraception, sexual activity and date of last menstrual period was noted in 53 (41.1%), 31 (24.0%) and 66 (51.2%) patients, respectively. Conclusions: There is a wide variation in the documentation of pregnancy status and possibility of pregnancy amongst surgical specialties. This was not an issue in gynaecology but is an issue in ENT, maxillofacial, neurosurgery, vascular and general surgery. The reasons are unclear. Documentation of pregnancy status using ßhCG assays should be the gold standard, and national guidelines are required. Keywords Pregnancy status, possibility of pregnancy, ßhCG, elective surgery, emergency surgery Introduction Females of reproductive age (FRA) present with a unique set of variables when admitted to hospital. In addition to the standard medical history, other fac- tors such as date of last menstrual period (LMP), use of contraception (UoC), pregnancy status (PS), sexual activity (SA) and possibility of pregnancy (PoP) should be considered. In emergency admissions with abdominal pain, ectopic pregnancy should be excluded. In the elective setting, PoP should be considered prior to procedures that require a general anaesthetic and exposure to ionising radiation. 1 1 Foundation Doctor, Department of General Surgery, Ninewells Hospital and Medical School, Scotland 2 Medical student, Department of General Surgery, Ninewells Hospital and Medical School, Scotland 3 Specialty Registrar, Department of General Surgery, Ninewells Hospital and Medical School, Scotland 4 Consultant Surgeon, Department of General Surgery, Ninewells Hospital and Medical School, Scotland Corresponding author: Michael SJ Wilson, Department of General Surgery, Ninewells Hospital, Dundee DD1 9SY 01382 660111, Scotland. Email: michaelwilson3@nhs.net Scottish Medical Journal 0(0) 1–5 ! The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0036933018801486 journals.sagepub.com/home/scm