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Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic Radiological Exam (3.5.1)

Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic Radiological Exam (3.5.1) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Patient Assessment

3.5.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic
Radiological Exam
Policy Number: 3.5.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: March 24, 2017

I. PURPOSE

To exercise reasonable precautions to protect the conceptus of pregnant or possibly pregnant females from
unnecessary radiation resulting from diagnostic radiological examination.

II. POLICY ELEMENTS

A. Any female patient of childbearing age (age 12 or with onset of menses to 55 inclusive) who is to undergo
diagnostic radiological examination (x-ray or nuclear medicine examination) shall be interviewed by the
referring provider (patient's provider) to determine whether she could possibly be pregnant. As an additional
check, the Radiologic Technologist shall also ask the patient if she could be pregnant. One exception shall
be for emergency conditions in which this is not possible due to the patient’s condition. A second exception
shall be if the radiological examination is of a type that does not significantly irradiate the conceptus: the
examination can then be performed without further consultations.
B. Aside from the two exceptions noted above, in the event of pregnancy or possible pregnancy, the requesting
provider must review with the staff radiologist or authorized physician (e.g., imaging cardiologist,
proceduralist ((pulmonary, vascular surgeon or gastroenterologists)) any request for radiological
examination that may significantly irradiate the conceptus. This consultation shall also include a discussion
of means to minimize radiation exposure risk to the conceptus. The referring provider will discuss with the
patient the potential risks from radiation. If, in consultation with the referring provider, it is decided that the
examination will proceed, a HCG Qualitative, Urine test will be administered.
C. In emergency situations reasonable efforts should be exercised to determine the patient's pregnancy status
and reduce any radiation exposure to the conceptus, without delaying needed diagnostic examinations.

III. PROCEDURE

A. The provider who initiates the request for radiology services shall first determine whether the radiological
examination is of a type that does not significantly irradiate the conceptus. If so then no further action is
required. These examinations include the following x-ray examinations:
i. Chest, all extremity examinations (excluding the femur), skull, cervical spine, scapula, shoulder,
humerus, thoracic spine, ribs, breast, and CT exams (other than those of the lumbar sacral spine,
pelvis, hip or lower abdomen).
B. If the examination may significantly irradiate the conceptus then this provider shall determine if there is no
possibility of pregnancy (see III.C.i.a.). If the possibility of pregnancy cannot be eliminated in this way, then
the patient shall be given the Radiation Exposure during Pregnancy Health Facts For You #6354.
C. If the procedure is to be performed that same day or the next day:
i. The requesting provider shall interview the patient to determine if she could possibly be pregnant,
provided she is age 12 or with onset of menses to 55 years inclusive. If there is no possibility of
pregnancy, then this provider shall indicate "NO" to the question "Is patient pregnant?" on the
electronic order, and forward the order through normal channels to the department performing the
examination.
a. The determination that the patient is NOT possibly pregnant should be made only if at
least one the following circumstances is true:
1. The patient has had a tubal ligation.
2. The patient is premenarchal or postmenopausal. This includes hysterectomy or
bilateral oophorectomy.
3. The patient has a regular menstrual cycle and normal menstrual flow that began
less than 10 days ago.
4. The patient has had no sexual intercourse since the beginning of her last
menstrual period.
5. All sexual relations since the beginning of her last menstrual period are with a
partner who cannot impregnate the patient even without the use of birth control



UW HEALTH CLINICAL POLICY 2
Policy Title: Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic Radiological Exam
Policy Number: 3.5.1

measures.
ii. If the requesting provider determines the patient is possibly pregnant:
a. A urine sample shall be collected so that a urine pregnancy test (HCG Qualitative, Urine)
may be administered for the patient, provided such a test is determined to be effective.
b. If the requesting provider cannot indicate NO to the question "Is patient pregnant?" on the
electronic order, if the pregnancy test indicates that the patient is pregnant, if the
pregnancy test would not be effective in ruling out pregnancy, or if the patient refuses to
consent to a requested pregnancy test, then the requesting provider must review the
appropriateness of the request for the examination and determine whether alternative
testing is available. The referring provider may want to discuss this matter with a physician
specialist of the department performing the examination (e.g., radiologist, cardiologist,
pulmonologist or gastroenterologist). If, in consultation with the requesting provider, it is
decided that the examination is still needed and should not be delayed, then this
consultation shall additionally include a discussion of means to minimize the radiation
exposure risk to the conceptus with input from a medical physicist if available. The
requesting provider shall discuss the potential risks from radiation, versus the benefits
from the examination, along with any diagnostic alternatives with the patient. This
discussion with the patient shall also be documented on the electronic order in the area
provided for comments.
iii. The Radiologic Technologist or physician specialist of the department performing the examination
shall confirm the requesting provider’s determination of "NOT Possibly Pregnant" by consulting with
the patient prior to the examination.
a. If it is determined that the patient is possibly pregnant, then the procedure as outlined in
sections III.C.ii.a. and III.C.ii.b. above shall be followed.
D. If the procedure/examination is to be scheduled for a later time:
i. The referring provider should schedule the procedure/examination such that it can be performed in
the 10 day period after the start of the patient's period or when the pregnancy test would be reliable
at excluding pregnancy.
ii. If the referring provider believes a pregnancy test is appropriate, then he/she should order a HCG
Qual, Urine test to be administered on the morning of the procedure/examination.
iii. An extra hour should be allowed before the procedure/examination time to allow extra time for
interviewing the patient and reviewing the results of the pregnancy test.
iv. All procedures outlined above in sections III.C.i. and III.C. ii. shall then be performed at the site of
the procedure/examination on the day of the procedure/examination, before the
procedure/examination is performed. However, the interview of the patient on this day shall be
performed by a Radiologic Technologist or physician specialist of the department performing the
examination instead of the referring provider. The consultation discussed in section III.C.ii.b., if
required, will still be performed between the referring provider and the physician specialist, as
stated in this section.
E. In x-ray examinations of women under age 55, proper radiation shielding of the uterus and ovaries shall be
employed whenever possible. In emergency situations, the above procedures shall be followed to the extent
allowed by the condition of the patient, unless they would delay needed diagnostic examinations, thus
presenting possible harm to the patient. The presence of an emergency or life-threatening situation should
be stated on the electronic order. In such cases the Radiologic Technologist should proceed with the
examination.
F. If the electronic order is not appropriately completed, the examination will be deferred for both inpatients and
outpatients.
IV. FORMS

UW Health computer generated Order Form from the department performing the procedure.

V. COORDINATION

Author(s): Vice Chair Operations, Radiology; Director, Radiology Services
Senior Management Sponsor: VP, Professional and Support Services
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: January 23, 2017



UW HEALTH CLINICAL POLICY 3
Policy Title: Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic Radiological Exam
Policy Number: 3.5.1


UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

Radiation Exposure during Pregnancy Health Facts For You #6354

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: February 19, 2018
Formerly Known as: Hospital Administrative policy #8.45