Tiffany Tonismae and Eduardo Lara-Torre
History of present illness
A 13-year-old girl presents with her mother to discuss her irregular menses. Her menarche was at age 10 and her periods have been irregular since. Sometimes she bleeds every month and sometimes she skips a month or two. Her menses often last four to six days, or less. She has no dysmenorrhea. She reports that her last menstrual period started four weeks ago and consisted offive days of spotting.
Her mother is also concerned because her daughter has gained almost 15 lb over the past 3 months. Both deny changes in activity level or appetite. She is currently in the seventh grade and is very active with cheerleading. Her mom reports her daughter always watches what she eats, as she wants to be“thin”so she can be a better cheerleader.
She also complains of some nausea over the past two to three months but denies loss of appetite, diarrhea, or emesis.
With both the mother and the daughter present, you ask if she could be pregnant and the mother immediately dismisses the possibility. She states her daughter is always under her observation and is a“good girl.” Her mother denies that her daughter has a boyfriend.
She is otherwise healthy. She has no other known medical problems and has never had surgery. She takes no medications.
Physical examination
General appearance:No acute distress; healthy-appearing teenage girl
Vital signs:
Temperature: 36.9°C Pulse: 64 beats/min
Blood pressure: 110/65 mmHg Respiratory rate: 20 breaths/min BMI: 23.9 kg/m2
HEENT:Normal
Cardiovascular:Regular rate and rhythm without murmurs, rubs, or gallops
Lungs:Clear to auscultation bilaterally, no wheezing Abdomen:Soft, nontender, nondistended. An abdominal mass is palpated half way between umbilicus and pubic symphisis. It is nonmobile and nontender
Pelvic:Deferred at this point in the encounter
How would you manage this patient?
After the initial examination (as you do on all your adolescent patients), you ask the patient’s mother to step out of the room for private questions regarding teenage high-risk behaviors.
The mother agrees. In private, the patient denies any alcohol, tobacco, or drug use. She admits she has a boyfriend in the eighth grade. When you ask about sexual activity, she becomes very tearful and cannot answer the question. She nods her head in agreement when you ask if she is having sex. You ask her if you can run some tests to see if she could be pregnant. She agrees but does not want you to tell her mom the results.
Laboratory studies:
Urine pregnancy test: Positive
HIV testing and urine NAATs for gonorrhea and chlamydia sent
Imaging:Bedside transabdominal ultrasound shows a 16- week intrauterine pregnancy, fetal heart rate 145 beats/min
How would you manage this patient?
This is a case of a teen pregnancy. Pregnancy is always of concern when a sexually active patient presents with irregular bleeding or increased weight. Although a urine pregnancy test confirms pregnancy, it does not determine dates or location of the pregnancy. Both can be best determined with ultrasound.
Abdominal ultrasound is appropriate if the uterine fundus is palpable. Transvaginal ultrasound should be reserved for early gestations and pregnancies of undetermined location to min- imize discomfort and distress to the teenage patient. In our case, the confidential discussion with the teen allowed eliciting further information that was not available with the mother present, and to focus our diagnostic interventions towards pregnancy and further counseling and care.
Once the diagnosis of pregnancy was confirmed, thefind- ings were discussed with the patient. She was asked if she desired her mother to be present for further counseling on options. You discussed that you supported her privacy, but were available to assist in the disclosure as needed. She agreed to have her mother in the room and options were discussed as a group.
Once the patient’s mother was informed of the pregnancy, options were discussed for the management of pregnancy including obstetrical care and parenthood, adoption, or preg- nancy termination. The patient desired to continue the pregnancy and prenatal care was initiated.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Teen pregnancy
Teen pregnancy refers to pregnancies occurring in girls younger than age 20. Most data regarding teen pregnancy, complications, outcomes, and risk factors in the United States refers to girls aged 15–19, with limited data for pregnancies occurring in girls aged 10–14 [1]. Approximately 750 000 teens in the United States between the ages of 15 and 19 become pregnant each year, with a pregnancy rate of 42 per 1000 in teens between the ages of 15 and 17 years. Though this rate has declined over the past few decades (Fig. 77.1), the teen preg- nancy rate in the United States still remains one of the highest among industrialized nations, approximately twice that of Europe and Canada [2].
There are a number of clear risk factors for teen pregnancy (Table 77.1[1]). Certain racial and socioeconomic groups are
at higher risk of teen pregnancy. In the United States, African- American teens continue to have the highest teen pregnancy rate, followed by Hispanic teens [1]. Pregnancies are more common among those coming from lower levels of income or education. Having an older sibling who was a teen mother is also a risk factor [2]. Patients with these risk factors are more likely to seek prenatal care late, and have less access to reliable contraception services.
Most teen pregnancies are unintended, and teens often have presented to providers requesting information about their options in pregnancy prevention and contraception almost 12 months after initiation of sexual activity. Almost 26% of teens choose to have an elective abortion, with the increased incidence in unintended teen pregnancy in minority groups such as Hispanic and African Americans accounting for a larger amount of abortions performed in the United States [1]. Forty-four states require parental consent or notifi- cation to care for girls under the age of 18, and it is important for providers to know the requirements in their state when counseling teens. The Guttmacher Institute (www.guttmacher.
org) provides information regarding federal and state specific rules and regulations guiding the provision of reproductive services for teens including pregnancy care, abortion, and contraception [3,4]. Teens are also at risk as they may seek an unsafe abortion performed by someone lacking skills or sanitary conditions. It is estimated that 14% of all unsafe abortions are performed on teens. More than 90% of teens who give birth choose to raise the infants. Adoption is utilized by unmarried teens under age 17 as an option to manage pregnancy about 8% of the time [2].
86.1
69.2
48.5
34.935.8
11.5 23.6 22.120.1
100
80
60
40
20
0
21.4 38.6
Rates per 1000 women aged 15–17 in specified group 11.011.8
32.1
47.9 41.0
51.9
30.5 31.8 30.6
16.3
AIAN Hispanic
Non-Hispanic white Non-Hispanic black
All races API
8.2 8.2 7.1
1991 2005 2007 2009
Fig. 77.1 Birth rates for female teenagers aged 15-17 by race and ethnic origin: United States 1991, 2005, 2007, and 2009. Data for 2009 are preliminary. AIAN, American Indian or Alaska Native; API, Asian or Pacific Islander. (Source: CDC/NCHS, National Vital Statistics System.)
Table 77.1 Risk factors for adolescent pregnancy*
Lack of support
Living in disadvantaged/impoverished conditions Minority background
History of abuse
Lack of parental involvement Single-parent household Use of alcohol or drugs Early dating
Little perceived opportunity for success Child of an adolescent pregnancy School drop-out
* Modified from Kost and Henshaw [1].
Case 77: A 13-year-old girl with irregular menses and significant weight gain
Teen pregnancies are often associated with increased preg- nancy related complications, in part because adolescents often do not receive early prenatal care, placing them at higher risk for both preterm birth and low birth weight babies [2]. Teens are also at risk for poor nutritional status, low pre-pregnancy weight, poor pregnancy weight gain, poverty, unmarried status, low educational levels, smoking, and drug use, which are additional risk factors for adverse pregnancy outcomes [5].
Teen pregnancies have a higher rate of neonatal death with up to a three times increased risk of infant death in the first year of life compared to children born to older women (women aged 20 or older) [2]. Certain congenital anomalies are also more common including those affecting the central nervous system (anencephaly, spina bifida, hydrocephaly, and microcephaly), gastrointestinal anomalies (gastroschisis, omphalocele) and musculoskeletal anomalies (cleft lip/palate, polydactyly, syndactyly, adactyly) [2]. Infants born to teen mothers are also at increased risk of neonatal infection and abuse.
Teen pregnancy has a large negative impact on the teens after childbirth. Teen mothers are less likely to receive a high school diploma, are more likely to require public assistance or welfare, and are more likely to live in poverty [2]. Teen moms are also at increased risk of having another pregnancy as a teen, with 25% of teen births having a subsequent teen preg- nancy [5]. The children of teen mothers have increased rates of substance abuse, depression, and early sexual activity, as well as developmental delay and difficulty with academics. Daugh- ters of teen mothers are also more likely to become teen mothers themselves, thus repeating this unfortunate cycle [2].
It is important to talk with teens about contraception before the first sexual encounter and even more so after the first teen pregnancy. Even with increasing use of contraception by teens at the time of first intercourse, almost 50% of teen pregnancies occur within the first 6 months of their initial sexual encounter [5]. All options for contraception should be discussed starting with long-acting reversible contraception (LARC), such as implants and intrauterine devices, as well as injectables, oral/vaginal contraception, barrier methods or abstinence. The American College of Obstetricians and Gyne- cologists advocates for the use of LARC and its safety in this
age group [6]. Teens should also be made aware of options for emergency contraception and how to access them.
Counseling is key when clinicians take care of pregnant teens. The importance of prenatal care should be reviewed for those deciding to continue with the pregnancy. A discussion of other options including abortion and adoption is necessary to allow for all alternatives to be considered before making a decision. Providers who do not perform abortions should provide information about local clinics and practitioners where this service is available, as well as review time con- straints for decision making. In teens who continue with obstetrical care and delivery, counseling during pregnancy should include a discussion and plan for postpartum contra- ception. LARC methods should be recommended to decrease the risk of subsequent teen pregnancy.
Key teaching points
Teen pregnancy is a common occurrence and should be always kept at the top of the differential diagnosis in sexually active teens with abnormal bleeding or amenorrhea.
A confidential discussion with the patient should always be undertaken to discuss issues the patient would be more comfortable discussing in private and to address high-risk behaviors and circumstances.
Laws about parental disclosure vary from state to state.
Providers caring for teens must be aware of the laws in their states including provision of confidential services, emancipation rules, and parental involvement
requirements.
Pregnant teens should be counseled on all options for the pregnancy including abortion, adoption, and pregnancy continuation and parenthood. Practitioners should be able to refer the patient for any desired option that they cannot provide themselves.
Contraception should be discussed with all teen patients.
Ideally this discussion should occur prior to thefirst sexual encounter. Plans for postpartum contraception should be developed during pregnancy, with a focus on long-acting reversible contraception methods.
References
1. Kost K, Henshaw S.US Teenage Pregnancies, Births and Abortions, 2008:
National Trends by Race and Ethnicity, 2012. Available athttp://www.
guttmacher.org/pubs/USTPtrends08.
pdf.
2. Black AY, Fleming NA, Rome ES.
Pregnancy in adolescents. In Fisher M, Lara-Torre E, eds.Adolescent Medicine:
State of the Art Reviews. Elk Grove
Village, IL, American Academy of Pediatrics, 2012, pp. 123–38.
3. Ventura SJ, Abma JC, Mosher WD, et al.National Vitals Statistics Reports.
Estimated Pregnancy Rates by Outcomes for the United States, 1990–2004.
Available athttp://www.cdc.gov/nchs/
data/nvsr/nvsr56/nvsr56_15.pdf.
4. National Abortion Federation.Threats to Abortion Rights: Parental
Involvement Bills. Available athttp://
www.prochoice.org/policy/states/
parental_involvement.html.
5. Klein JD. Adolescent pregnancy:
current trends and issues.Pediatrics 2005;116:281–6.
6. American College of Obstetricians and Gynecologists. Adolescents and long-acting reversible contraception:
implants and intrauterine devices.
Committee Opinion No. 539.Obstet Gynecol2012;120:983–8.