Occasionally a preoperative pregnancy test is positive which could mean an ongoing pregnancy or a recent termination. The rules about when is it safe to perform a cosmetic elective procedure after a positive pregnancy test are quite blurry and misunderstood by the medical community and even the OB GYN community. This article discusses the literature, concepts, and planning necessary after a pregnancy termination in order to assure a safe elective procedure after a positive pregnancy test cancels an elective procedure.
Probably more often than we have known, women have had elective cosmetic surgery after having an elective or spontaneous recent abortion. If pregnancy testing has not been routinely performed, you may be missing an actual pregnancy or a recent abortion which would have tested positive for pregnancy. A woman may be pregnant, know it, and not tell you. Or, she may not even know she is pregnant, which is why pregnancy testing is advised and is a standard for any woman who could become pregnant. Many women who have had a recent abortion may never tell their surgeon about it for embarrassment reasons or to prevent it from being placed on her medical record. Within our own multi-clinic experience from 1 January 2013 through 31 October 2013, a 10 month period, we performed 8669 liposuction procedures. There were five procedures cancelled because of a positive pregnancy test.
Pregnancy or a recent history of pregnancy with abortion has raised the concern of many surgeons who have felt that there are associated risks to the mother and/or fetus whether there has been an abortion or not if contemplating an elective procedure. There is very little doubt that performing liposuction on a pregnant woman is ill advised and is not an appropriate standard of care. However after an abortion there is little agreement among physicians as to when it is safe to perform an elective surgical procedure such as liposuction. The intention of this paper is to review the literature to determine the prevailing opinions and discuss the physiologic changes that were the basis for those opinions.
The risks of performing cosmetic surgery after pregnancy has often centred on analysing the safety of combining procedures rather than discussing how long after the pregnancy to actually perform the procedure. W. Grant Stevens, for example, in his review of ‘the mommy makeover’ evaluated the outcome of 268 patients. There were 109 documented complications (34%) with a revision rate of 13%, and no incidence of death, deep vein thrombosis (DVT), pulmonary embolism (PE), or other life threatening complications1. There was no mention of how long postpartum any of the procedures was done.
Another similar study examining the results of liposuction and abdominoplasty performed individually or combined was presented by Eric Swanson, MD, in a prospective study of 551 cases. The complication rate for liposuction was 4.2% versus 50% for patients with abdominoplasty. There were no deaths, but one DVT. Most complications were minor. There was no mention of any relationship between the time between delivery and when either the liposuction or abdominoplasty was done2.
On the other hand, there has been more anecdotal and sidewalk consultative advices given on the topic of how soon after pregnancy and/or abortion should one safely have cosmetic surgery. The ‘Blog’ generation has taken as gospel beliefs preached without actual scientific studies to back them up. For example, when asked how soon after pregnancy can ladies have cosmetic surgery, advice without science is given freely. Considering plastic surgery after child birth, Dr Patrick Hudson blogs: ‘The most important thing is that your health is good and you are close to the level of emotional and physical well-being you had before the baby.’3
Through the internet, the following question was asked to a number of persons and credible organisations around the USA, ‘How long should a woman wait to have a surgical procedure like liposuction after having a recent abortion?’ Few definitive answers and mostly without scientific back up were obtained. Samples of those answers were:
- ‘I would know of no reasons to delay surgery after a first trimester abortion because there are really no changes to the anterior abdominal wall. In the second trimester there is stretching of the anterior abdominal wall and without any data what so ever I would think you would want to not do abdominal liposuction until the ant(erior) abd(ominal) wall has returned to normal which usually can take up to 2–4 weeks depending on how far into the second trimester. If the liposuction does not involve the ant abd wall then I don’t see any reason why the liposuction needs to be delayed any period of time after the woman has recovered from the abortion (1-2 days). This is the best judgment based on no facts.’ Arnold W. Cohen, MD, Past Chairman and Program Director, Department of Ob/Gyn, Albert Einstein Medical Center4
- ‘AAAHC standards do not speak to such requirements. It would be up to the organisation to be in compliance with their own policies and procedures. With additional questions I would recommend contacting the American Congress of Obstetrics and Gynecology (ACOG) or National Abortion Federation (NAF).’ Dorota (Dorothy) Rakowiecki, Manager, Accreditation Services, Accreditation Association for Ambulatory Health Care5
- ‘We are not aware of any research/evidence specifically on this question, though we found the following related evidence when we looked: Coagulation parameters return to normal 3–4 weeks postpartum6. Note that this is after pregnancy in general, presumably including women who have had a recent abortion.’ Laura Castleman MD, MPH, MBA, Medical Director, Ipas (International Conference on Family Planning)7
- ‘I feel this varies a great deal on the type of surgical procedure and whether the patient had a first or second trimester abortion. As you know, most facilities will do a very sensitive pregnancy test on women prior to a surgical procedure. In the first trimester most of the effects of the pregnancy will be gone in 2–3 weeks but once in a while the real sensitive pregnancy tests can remain positive 3 plus weeks even in the first trimester. They can remain positive longer after a second trimester abortion. We warn patients that are contemplating elective surgery after an abortion that their pregnancy test many still be positive during that time period and the hospital or outpatient centre may cancel your surgery because of that positive test. I do think waiting 2–3 weeks after a first trimester abortion is prudent and 4–6 weeks after a second trimester if it is any kind of ‘major’ surgery.’ Dr Melvin Frisch, Medical Director of Planned Parenthood Arizona8
- ‘Thank you for your recent request for information on the College’s guidelines on surgical procedures after an abortion. Unfortunately, we are not aware of specific guidelines on this topic.’ American College of Obstetricians and Gynecologists Resource Center, Washington, DC.9
The pregnancy test
A urine pregnancy test is given in most clinics before elective surgery. The test detects elevated levels of hCG (human chorionic gonadotropin) which is produced by the neo-placenta after the fertilised egg is implanted. A false negative can therefore result if the urine is tested before the fertilised egg is implanted not allowing the hCG to be produced and circulate to the kidneys and then excreted in the urine. A urine pregnancy test is 97% accurate. Alternatively qualitative and/or quantitative blood testing for hCG can also be done.
Abortion and a positive pregnancy test
After an abortion hCG, which reaches peak levels in the first 8–11 weeks of pregnancy, returns to a non-pregnant range about 4–6 weeks after a pregnancy loss has occurred. Pregnancy loss can occur from a variety of causes (spontaneous miscarriage, a D&C procedure, abortion, natural delivery). Quantitative blood testing will determine when the patient returns back to normal which is <5.0 mIU/mL10.
For the purpose of considering whether a patient who has had an abortion is an appropriate candidate for elective surgery like liposuction, grouping all abortions into one category is incorrect, unwise, and potentially dangerous. Consideration must be given, not only to the elapsed time since the abortion, but more importantly whether the pregnancy was terminated in the first or second trimester, the method chosen to complete the abortion, and post abortion sequellae that may have or continue to occur.
Approximately 88% of those who have abortions performed are less than 13 weeks pregnant. 97% of reported abortions have no complications and 2.5% have minor complications from a surgical abortion. The remaining 0.5% has complications that require management with an additional surgical procedure and/or hospitalisation. Medically induced abortions similarly have serious complications 0.5% of the time11.
Since almost 50% of pregnancies in the United States are unintended and almost half of those end by abortion12, we all should be mindful of the reasons for which the abortion was done in order to give the patient proper emotional support. Overlooking that may be a mistake to make sure the patient is prepared for the elective surgery she wishes to have done.
During the first trimester of pregnancy there are two approved methods to accomplish a termination of pregnancy (TOP). Using a combination of medications, mifepristone/ misoprostol or methotrexate, a natural miscarriage can be induced by causing the uterine lining to thin, the cervix to dilate, and uterine contractions to occur13. Surgery is usually avoided. Vaginal bleeding after a medically induced abortion may last longer than after a surgical abortion and blood clots and pregnancy tissue may be seen. The other alternative, vacuum aspiration is the second method for first trimester abortions. Similar to liposuction, a cannula is inserted into the uterus through the cervix and the contents of the uterus are emptied by suctioning. This method takes minutes to complete under anesthesia or sedation. Compared to the medical abortion, a vacuum aspiration, although more invasive, is associated with less post-treatment complication and less risk of an incomplete procedure. The medical abortion may require a follow-up suction procedure owing to continued pregnancy or prolonged excessive bleeding14. The farther the patient is along in the pregnancy the greater the risk for post abortion complications.
Therefore, it is the complications of the abortion that magnify the preoperative risks of a desired elective procedure like liposuction. Among the many complications of a TOP may include:15
- Excessive bleeding causing anaemia
- An unsuccessful procedure that doesn’t end the pregnancy
- Dizziness or fainting
- Foul smelling vaginal discharge
- Bleeding that is more than a heavy period or has large clots
- Depression after a TOP
- DVT or pulmonary embolism
- Retained intrauterine pregnancy tissue
- Uterine perforation with potential bowel injury.
When a patient has a positive pregnancy test before an elective surgical procedure and the repeat test confirms it, it is necessary to cancel the procedure and refer her back to her primary care physician or ObGyn. If there has been a recent abortion, perhaps not even admitted to, the risks of post abortion complication may preclude any rescheduling until criteria have been met:
First, the hCG must return to the non-pregnant range which takes 4–6 weeks depending upon how the loss occurred. The hCG, if tested quantitatively should return to <5 mIU/mL. Secondly, if an abortion was performed either surgically or medically, complications may be on going and not clinically apparent or not patient reported. A repeat history and physical exam also including the blood pressure, pulse, and temperature is essential. If indicated the patient’s primary care physician or ObGyn should perform a pelvic exam to rule out residual sequellae of the abortion that may affect the proposed elective procedure such as persistent vaginal drainage, pelvic infection, or possible retained intrauterine tissue. Third, before proceeding with the post-abortive patient, a CBC and UA should be done to appraise the presence or absence of anemia, increased WBC, and blood or bacteria in the urine. If methotrexate had been part of the medical abortion regime haematologic side effects which may include myelosupression need to be evaluated16.
The patient’s lower extremities should be evaluated for the presence or signs of DVT which include pain, swelling, warmth and redness, although those symptoms may mimic an infection or cellulitis of the leg. An ultrasound may be necessary to confirm the diagnosis of a DVT. A complaint of shortness of breath after an abortion must be taken seriously and may be the presenting symptom of a pulmonary embolism. A standard pulse oximeter measurement may indicate the presence of a PE with hypoxemia but can be falsely negative. Those symptoms require emergency evaluation by chest X-ray, CT scan, VQ Scan, and/or ultrasound.
This is a 40 year old female who has a history of a C-section many years ago. She is healthy and takes medication for ADHD and depression. She is 5’2”, weighs 129 lbs and has a BMI of 23. On the day of surgery she was scheduled for liposuction of her abdomen, hips, waist, and outer thighs. A pre-op pregnancy test was positive and repeated positive. The patient then admitted to having an abortion one week ago and said, ‘I didn’t think I needed to tell you that.’ Her surgery was cancelled and schedule for 4 weeks later. No other advice was given. Further liposuction surgery was not done.
This is a 30 year old female with two older children who is very healthy except for taking clonazepam and bupropion for anxiety and depression. She is 5’2”, weighs 168 lbs, and has a BMI of 30. On the day of surgery she was scheduled for liposuction of her abdomen, inner thighs and medial knees. A pre-op pregnancy test was positive and repeated positive. Her surgery was cancelled and she immediately was seen on the same day by her ObGyn and an abortion was done 6 days later. The type of abortion was not noted in her record. A second pre-op exam was done 19 days after her TOP with a negative pregnancy test determined. Laboratory studies were not done. The patient said that her regular period returned 14 days after her abortion. Liposuction of her abdomen, inner thighs, and medial knees was completed successfully 24 days after her abortion. There were no postoperative sequellae.
Critique of patient management
These two patients represents normal practices that could get both the patient and the surgeon into serious problems. Most of the time both the doctor and patient are caught off guard and not given time to make appropriate decisions. As discussed in the text of this paper most patients do very well after an abortion. However there are a few who need guidance and advice to make sure that their future surgery proceeds without further complications. Both of these patients should have had a CBC, UA, and perhaps clotting studies done before the next procedure. A new pre-surgical physical exam is necessary. They also should be followed, even by phone, to make sure they do not develop post abortive complications mentioned above. Clearance from their PCP or ObGyn is advised. In the cases presented no mention was made of how the abortions were done, medical or surgical, methotrexate or not. Those were important facts for the records.
Although simply rescheduling a cancelled surgery because of an unexpected pregnancy or recent abortion may seem quite benign, the hidden risks can be quite costly. Complications as a result of the abortion should be considered and a normal pelvic exam may need to be confirmed by the patient’s primary care physician or ObGyn. Laboratory testing including CBC and Urinalysis must be done to rule out anemia and/or a urinary tract infection. A careful repeat recent history and physical exam should be done by the surgeon with careful notation of the lungs and lower extremity veins to rule out DVT and/or PE. Plastic surgeons can be blindsided by patients anxious to have their surgery done, often leaving out historical facts of a recent abortion or miscarriage. It is very important to keep our guard up to protect the patient and ourselves from errors of judgment that can be made.