Year: 2024
Type: article
Abstract: The American Academy of Pediatrics recently affirmed that clinicians must provide confidential and comprehensive pregnancy options counseling to teens. Therefore, it is important that clinicians be familiar with when and how to diagnose pregnancy, the psychosocial and physical changes that occur in pregnancy, and how to provide timely and comprehensive pregnancy options counseling.After completing this article, readers should be able to:Describe when and how to screen for pregnancy and how to communicate results in a patient-centered way.Identify concrete techniques for evaluating one’s values, thoughts, and attitudes about teen pregnancy and its outcomes (such as parenting, adoption, abortion), and understand how cognitive biases might impact the quality of care provided to a pregnant teen.Explain how to perform pregnancy options counseling, including comprehensive discussion of all options, using patient-centered communication strategies, and connecting pregnant teens to care confidently and appropriately.The Centers for Disease Control and Prevention defines teen pregnancy as pregnancy in individuals aged 15 to 19 years. (1) In 2017, the teen pregnancy rates were 13.6 and 56.9 per 1,000 females aged 15 to 17 years and 18 to 19 years, respectively, a decrease from 1991 rates. (2) In 2017, approximately 60% of teen pregnancies ended in births, 27% in abortions, and the remainder in miscarriages. Although increased contraception use and delayed sexual initiation have contributed to this decline, (3) non-Hispanic Black and Hispanic youths have twice the teen birth rate as non-Hispanic white peers. (1) This disparity is reduced when controlling for socioeconomic factors, indicating that the racial and ethnic disparities may reflect systemic and structural inequities. (4)Teen pregnancy prevention remains a public health priority, with the Healthy People 2030 (5) goal to “reduce teenage pregnancies” and directed federal funding for the Teen Pregnancy Prevention program. (6) However, advocates of reproductive justice are shifting the discourse away from teen pregnancy prevention and toward adolescent reproductive autonomy. Policy and practice efforts must include person-centered contraceptive counseling and care while also augmenting logistical, financial, and interpersonal resources and support for pregnant teens who decide to pursue parenting, adoption, or abortion.Clinicians have an ethical obligation to provide confidential and comprehensive pregnancy options counseling to teens, (7) including discussion of parenting, adoption, or abortion. (8) Therefore, they must be familiar with when and how to diagnose pregnancy, the psychosocial and physical changes that occur in pregnancy, and how to perform timely and comprehensive pregnancy options counseling that respects adolescents’ autonomy.Adolescents’ desires for and intentions about pregnancy are varied. Some may engage in unprotected sex with the desired outcome of pregnancy, some may choose to use 1 of several contraceptive methods to prevent pregnancy, and some may be ambivalent about contraception and/or pregnancy. No method of pregnancy prevention, aside from abstaining from sexual intercourse, is 100% effective, and, therefore, pregnancy is still possible despite the perfect use of any contraceptive method. (9) It is important for clinicians to ask about partner or parental coercion to get or not get pregnant because that may also affect an adolescent’s own desire for pregnancy prevention or intention.Pregnancy may occur due to unprotected penile-vaginal intercourse or from contraceptive method failure. The American College of Obstetricians and Gynecologists defines pregnancy as beginning with implantation of the embryo in the uterine wall.After penile ejaculation of sperm into a vagina, a sperm may enter the uterus and fertilize an ovulating egg to create an embryo, which then may implant within the uterus (ie, intrauterine pregnancy) or outside the uterus (ie, ectopic pregnancy). Implantation typically begins 5 days after fertilization and is completed by day 10. In addition, instead of an embryo, a hydatidiform mole may result when a sperm fertilizes an egg without genetic material, (10) and this can result in either a complete (ie, no fetal tissue present) or partial (ie, some fetal tissue present) molar pregnancy.Ectopic pregnancy is when an embryo implants outside the uterus, with 95% implanting in the fallopian tube. Ectopic pregnancies can also occur in the abdominal cavity, uterine myometrium, ovary, cervix, or cesarean scar. (11) Although half of ectopic pregnancies have no known risk factors, some risk factors include previous fallopian tube, pelvic, or abdominal surgery; history of pelvic inflammatory disease; or endometriosis. (12) Using an intrauterine device (IUD) does not raise the likelihood of having an ectopic pregnancy, but if a pregnancy occurs while an IUD is in place, it is more likely to be ectopic compared with a pregnancy without an IUD. (13) Healthy adolescents (<20 years old) are generally less likely to have an ectopic pregnancy than adult women given fewer predisposing risk factors. (14) However, adolescents with ectopic pregnancy are 3 times more likely to have a concurrent sexually transmitted infection than adult women with ectopic pregnancy. Ectopic pregnancy can present similarly to intrauterine pregnancy, with amenorrhea followed by bleeding or spotting, which makes its diagnosis challenging. An ectopic pregnancy is suspected in pregnant patients who have an abnormal rise in human chorionic gonadotropin (hCG) level, abdominal pain, vaginal bleeding, or the visualization of either adnexal masses or intraperitoneal bleeding on transvaginal ultrasonography without visualization of an intrauterine pregnancy on transvaginal ultrasonography. A diagnosis of ectopic pregnancy is confirmed either with transvaginal ultrasonography visualizing an extrauterine gestational sac or with levels of serum hCG that are not rising as expected (although expected rate of rise is nuanced and depends on initial hCG level). Ectopic pregnancy can be a medical emergency, estimated to cause 5% to 10% of pregnancy-related deaths. (15) Management options for an ectopic pregnancy (16) are varied and depend on the patient’s hemodynamic stability, location of the ectopic pregnancy, risk of tubal rupture, and β-hCG levels. Options include surgical removal, medical management with methotrexate, or expectant management.Molar pregnancy is a rare entity with unknown incidence (estimated in the 1990s to be approximately 1 per 1,000 pregnancies). Individuals younger than 16 years have a 4 to 10 times higher risk of developing a hydatidiform mole than those aged 20 to 30 years. (17) In addition, adolescents younger than 16 years have a higher risk of complete molar pregnancy (ie, where no fetal tissue is present) compared with those aged 20 to 30 years. However, the incidence of partial molar pregnancy (ie, where some fetal tissue is present) is not significantly different. (18) Molar pregnancy typically presents with missed menses, a positive pregnancy test, and vaginal bleeding, pelvic discomfort, or hyperemesis gravidarum. Because these signs and symptoms can be similar to intrauterine or ectopic pregnancy, further testing with serum hCG level or ultrasonography is needed. Patients often have an unusually high serum hCG level (>100,000 mIU/mL [>100,000 IU/L]), and transvaginal ultrasonography demonstrates a hydatidiform mole. Preferred treatment for women who want to preserve fertility is suction curettage. (19)There are several possible complications that can happen during an intrauterine pregnancy, which may increase either the birthing person’s or fetus’s risk of adverse outcomes. In the following subsections, we describe the complications that occur at higher rates in pregnant adolescents.Teens are slightly more likely than adult women to experience hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, and are far more likely to experience eclampsia. (20) Preeclampsia is a multisystemic disorder that usually develops after 20 weeks’ gestation. People at risk for preeclampsia may experience sudden hypertension, edema, respiratory distress, proteinuria, blurred vision, and severe headaches. Preeclampsia may progress to the occurrence of new-onset seizures, which is referred to as eclampsia. The only cure is delivery, although doctors may try to manage the patient with medications if it is too early to safely deliver. (21)Operative vaginal delivery, episiotomy, postpartum hemorrhage, and endometritis are more common for individuals younger than 15 years compared with older ages. In addition, adolescents aged 10 to 19 years have a 40% prevalence of maternal anemia. (22) Young adolescents are also at increased risk for low birthweight, preterm delivery, and small-for–gestational age infants compared with adult women older than 20 years. The risks increase with decreasing maternal age, with highest prevalence seen in girls 15 years or younger. (22)Of note, across pregnancies in all age groups, 15- to 19-year-olds have the highest rates of chlamydial and gonorrheal infections in the United States. (20) Complications resulting from having a sexually transmitted infection during pregnancy can contribute to miscarriages, preterm birth, low birthweight, intrauterine fetal demise, and neonatal eye infections. (23)Pregnant teenagers may suspect that they are pregnant based on symptoms. These symptoms vary from person to person and also differ based on the gestational age of the pregnancy. Earliest signs of pregnancy can include a missed period, nausea with or without vomiting, breast tenderness, fatigue, cramping or lower backaches, and mood swings. Approximately one-third of pregnant women experience spotting referred to as “implantation bleeding.” (24)(25) Patients usually experience spotting or bleeding lighter than their period approximately 10 to 14 days after conception, as the zygote attaches to the uterine lining. Later in pregnancy, symptoms vary greatly but can include a decrease in nausea/vomiting, increased energy, a growing abdomen as the uterus expands with the appearance of stretch marks, increased urination, and swelling in the hands or feet.When diagnosing a pregnancy, it is important to confirm whether it is intrauterine, ectopic, or molar. Ectopic pregnancy can be challenging to diagnose (15) because classic symptoms such as pelvic or abdominal pain and vaginal bleeding can be nonspecific. Therefore, confirmation of the location of a pregnancy after a positive pregnancy test is necessary.Patients may find out that they are pregnant by taking a home pregnancy test before they seek medical care. Pregnancy tests, including home tests, detect the presence of hCG in urine or blood serum. Both tests rely on monoclonal antibodies (26) to the β subunit of hCG, a hormone secreted by syncytiotrophoblastic cells (28) of the placenta into the maternal circulation. Urine pregnancy tests report the result as a binary yes/no and rely on the test antibody reacting with fragments of the hCG molecule that are present in the urine. (26) In contrast, serum pregnancy tests give a quantitative result for hCG levels and rely on the antibody reacting with intact hCG in the serum.hCG is first detectable 8 to 10 days after ovulation, once implantation has occurred. Because the timing of ovulation varies from cycle to cycle, the number of days after the last menstrual period before hCG can be detected varies. Serum pregnancy tests can be positive as early as day 14 of the cycle, and urine pregnancy tests can be positive as early as day 16 (27) of the cycle, but it is more typical and likely for tests to be positive at the time menses is expected. hCG levels double every 24 to 48 hours in the first 30 days after implantation, peaking at 8 to 10 weeks of gestation. (28) A positive pregnancy test detects the presence of any type of pregnancy, including ectopic pregnancy, molar pregnancy, or intrauterine pregnancy (whether singleton gestation or multiple gestation).Manufacturers report that home urine pregnancy tests have 100% sensitivity and specificity when used correctly. Similarly, serum pregnancy tests are reported to have 97% to 99% sensitivity and 100% specificity. (29) Blood tests for hCG can detect levels of hCG as low as 1 to 2 mIU/mL (1–2 IU/L), whereas urine tests typically do not detect hCG levels lower than 20 mIU/mL (20 IU/L). (30) Trace levels of hCG can be detected in the urine or in the blood as early as 10 days after conception.False-positives are uncommon but can occur in the setting of ectopic production of hCGx due to malignancies, IgA deficiency, chronic renal failure, or rheumatoid factors (which can bind the antibodies in the test assay). (23) A false-negative pregnancy test can be due to early measurement after conception, so if pregnancy is still suspected, the test should be repeated in 1 week. Other causes of false-negatives include dilute urine (if urine sample) or the hook effect (if serum sample). (31) The hook effect is a rare cause of a false-negative serum pregnancy test. It can occur late in the first trimester or during the second trimester, when hCG levels are high and excess hCG antigens overwhelm and saturate the tracer and antibodies in the pregnancy test, hindering the formation of the tracer hCG antibody required for measurement, giving a false-negative result.The diagnosis of pregnancy is based on the presence of any of the following: detection of hCG in blood or urine, ultrasonography identifying a pregnancy, or Doppler ultrasonography identifying fetal cardiac activity, as early as the sixth week of gestation. (32) Transvaginal ultrasonography can identify a pregnancy by the presence of the gestational sac as early as 4.5 to 5 weeks’ gestational age. (32)Most commonly, a positive pregnancy test, whether from a urine sample or a blood sample, first confirms that a patient is pregnant. After that, first trimester ultrasonography (33) (up to and including 13 6/7 weeks of gestation) should be performed for dating and to confirm the location of the pregnancy. Ultrasonography can differentiate intrauterine, ectopic (ie, visualizing a gestational sac in a location outside of the uterus), and molar (ie, visualizing a hydatidiform mole) pregnancies.To support patient autonomy, adolescents should be informed that a pregnancy test will be performed. (34) Clinicians can also prepare the adolescent to receive the result by asking questions such as “Do you have an idea of what the results of your pregnancy test might be?” and “What are you hoping the results will be?” Adolescents may have a variety of thoughts and feelings after hearing the result of a clinic-performed pregnancy test. Clinicians may navigate the conversation toward disclosure of the result by saying, “We’ll hope for the result you want, but if it’s different, we’ll work through a plan together.”Minor consent and confidentiality laws regarding diagnosis and management of pregnancy vary by state. The American Academy of Pediatrics maintains (35) that adolescents should have access to confidential reproductive health-care services, which includes providing nonjudgmental and comprehensive evaluation and counseling of patients regarding pregnancy options. In light of the Cures Act Final Rule in 2021, it is important to consider best practices for maintaining an adolescent’s confidentiality when ordering a pregnancy test for an adolescent patient, including confidential access to laboratory results in a patient portal, confidential note template creation in the electronic health record, and office policies to ensure that the adolescent can have a private conversation with their clinician about their options. (36) In addition, explanations of benefits may preclude true confidential care provision to young people up to age 25 years because the Affordable Care Act requires insurance plans to offer dependent child coverage until a child reaches age 26 years; therefore, clinicians should engage in confidential billing processes where on how to do confidential billing are dependent on the insurance and their health and Therefore, clinicians are to with the to provided to when billing with to or offer or where the of a that must be the clinician should provide confidential disclosure of a positive pregnancy test result as as pregnancy options a positive pregnancy test result to an it is important to use saying, pregnancy test is which that you are also and so that the patient can this may include asking the patient how they are and/or their is also important to note that a positive pregnancy test should be to the patient the patient the clinician to the result with in the patient’s such as their or it be for the clinician to do so only after that so is for the patient and with the patient’s This can be by asking the patient if they have possible pregnancy with their or and if how they they will It also an to for their at home and in their are the clinician should to partner resources or a to if is for parental or partner coercion to or the pregnancy, the clinician can the adolescent’s confidentiality and in a for the pregnancy. disclosure of positive pregnancy test clinicians should offer pregnancy options are no clinicians from all options, including if is not in their therefore, clinicians have an ethical to pregnant adolescents to their desired of care. 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Source: Pediatrics in Review
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W4404880207