Adolescent Pregnancy

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Chapter 112 Adolescent Pregnancy

Dianne S. Elfenbein, Marianne E. Felice

Epidemiology

In 2006, there were approximately 442,000 births in the USA to young women under the age of 20 yr. This figure represents a birthrate of 41.9 births per 1,000 young women ages 15-19 yr and is a 3% increase over the birthrate in 2005 (40.5). This is the 1st time in the last 15 yr that teen birthrates have increased in the USA.

Before 2006, adolescent birthrates in the USA had steadily decreased since the early 1990s for all ages, races, and ethnic groups (Table 112-1), with the most dramatic decreases noted in African-American teens. In spite of the 3% increase from 2005 to 2006, the 2006 birthrate for teens ages 15-19 yr is considerably lower than the 1991 rate of 61.8. Pregnancy rates, which include births, miscarriages, stillbirths, and induced abortions, also decreased during this time frame, indicating that the decline in birthrates was not due to an increase in pregnancy terminations. The improvement in U.S. teen birthrates is attributed to 3 factors: more teens are delaying the onset of sexual intercourse, more teens are using some form of contraception when they begin to have sexual intercourse, and there is increased use of the new, long-lasting hormonal contraceptives.

Table 112-1 TEEN BIRTH RATES (BIRTHS PER 1,000 FEMALES) IN THE USA

In spite of the decrease in teen births in the last decade, the USA has the highest teen birthrate among all industrialized countries. U.S. teen birthrates are twice the rates in Great Britain and Canada and nearly 4 times the rates in France and Sweden. Two thirds of teen births are to 18-19 yr old women who technically have reached the age of majority.

Etiology

In industrialized countries with policies supporting access to protection against pregnancy and sexually transmitted infections (STIs), older adolescents are more likely to use hormonal contraceptives and condoms, resulting in lowered risk of unplanned pregnancy. Younger teenagers are likely to be less deliberate and logical about their sexual decisions and their sexual activity is likely to be sporadic or even coercive, contributing to inconsistent contraceptive use and a greater risk of unplanned pregnancy. Better hopes for employment and higher educational goals are associated with lowered probability of childbearing. In nonindustrialized countries, laws permitting marriage of young and mid-adolescents, poverty, and limited female education are associated with increased adolescent pregnancy rates.

Clinical Manifestations

Adolescents may experience the traditional symptoms of pregnancy: morning sickness (vomiting, nausea that may also occur any time of the day), swollen tender breasts, weight gain, and amenorrhea. Often the presentation is less classic. Headache, fatigue, abdominal pain, dizziness, and scanty or irregular menses are common presenting complaints.

In the pediatric office, some teens are reluctant to divulge concerns of pregnancy. Denial of sexual activity and menstrual irregularity should not preclude the diagnosis in face of other clinical or historical information. An unanticipated request for a complete checkup or a visit for contraception may uncover a suspected pregnancy. Pregnancy is still the most common diagnosis when an adolescent presents with secondary amenorrhea.

Diagnosis (Table 112-2)

On physical examination, the findings of an enlarged uterus, cervical cyanosis (Chadwick sign), a soft uterus (Hegar sign), or a soft cervix (Goodell sign) are highly suggestive of an intrauterine pregnancy. A confirmatory pregnancy test is always recommended, either qualitative or quantitative. Modern qualitative urinary detection methods are efficient at detecting pregnancy, whether performed at home or in the office. These tests are based on detection of the beta subunit of human chorionic gonadotropin (HCG). While claims for over-the-counter home pregnancy tests may indicate 98% detection on the day of the 1st missed menstrual period, sensitivity and accuracy vary considerably. Office or point of care tests have increased standardization and generally have increased sensitivity, with the possibility of detecting a pregnancy within 3-4 days after implantation. However, in any menstrual cycle, ovulation may be delayed and in any pregnancy, the day of implantation may vary considerably as may rate of production of HCG. This variability, along with variation of urinary concentration, may affect test sensitivity. Therefore, each negative test should be repeated in 1-4 wk if there is a heightened suspicion of pregnancy. The most sensitive pregnancy detection test is a serum quantitative beta HCG radioimmunoassay in which results are reliable within 7 days after fertilization. This more expensive test is used primarily during evaluations for ectopic pregnancy, to detect retained placenta after pregnancy termination, or in the management of a molar pregnancy. It is generally used when serial measurements are necessary in clinical management.

Table 112-2 DIAGNOSIS OF PREGNANCY DATED FROM FIRST DAY OF LAST MENSTRUAL CYCLE

CLASSIC SYMPTOMS

Missed menses, breast tenderness, nipple sensitivity, nausea, vomiting, fatigue, abdominal and back pain, weight gain, urinary frequency

Teens may present with unrelated symptoms that enable them to visit the doctor and maintain confidentiality

LABORATORY DIAGNOSIS

Tests for human chorionic gonadotropin in urine or blood may be positive 7-10 days after fertilization, depending on sensitivity

Irregular menses make ovulation/fertilization difficult to predict. Home pregnancy tests have a high error rate.

PHYSICAL CHANGES

2-3 wk after implantation: cervical softening and cyanosis

8 wk: uterus size of orange

12 wk: uterus size of grapefruit and palpable suprapubically

20 wk: uterus at umbilicus

If physical findings are not consistent with dates, ultrasound will confirm

Though not generally used for primary diagnosis of pregnancy, pelvic or vaginal ultrasound can be used to detect and date a pregnancy. Pelvic ultrasound will detect a gestational sac at about 5-6 wk (dated from last menstrual period) and vaginal ultrasound at 4.5-5 wk. This tool may also be used to distinguish diagnostically between intrauterine and ectopic pregnancies.

Pregnancy Counseling and Initial Management

After the diagnosis of pregnancy is made, it is important to begin addressing the psychosocial, as well as the medical, aspects of the pregnancy. The patient’s response to the pregnancy should be assessed and her emotional issues addressed. It should not be assumed that the pregnancy was unintended. Discussion of the patient’s options should be initiated. These options include (1) releasing the child to an adoptive family, (2) electively terminating the pregnancy, or (3) raising the child herself with the help of family, father, friends, and/or other social resources. Options should be presented in a supportive, informative, nonjudgmental fashion; they may need to be discussed over several visits for some young women. Physicians who are uncomfortable in presenting options to their young patients should refer their patients to a provider who can provide this service expeditiously. Pregnancy terminations implemented early in the pregnancy are generally less risky and less expensive than those initiated later. Other issues that may need discussion are how to inform and involve the patient’s parents and the father of the infant; implementing strategies for insuring continuation of the young mother’s education; discontinuation of tobacco, alcohol, and illicit drug use; discontinuance and avoidance of any medications that may be considered teratogenic; starting folic acid, calcium, and iron supplements; proper nutrition, and testing for STIs. Especially in younger adolescents, the possibility of coercive sex

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