Early Pregnancy in Adolescents: Diagnosis, Assessment, Options Counseling, and Referral

Mary M. Aruda, PhD, RN, PNP-BC; Kathleen Waddicor, RN, BSN; Liesl Frese, MSW, LICSW; Joanna C.M. Cole, PhD; Pamela Burke, PhD, RN, FNP, PNP-BC

Disclosures

J Pediatr Health Care. 2010;24(1):4-13. 

In This Article

Abstract and Introduction

Abstract

Health care providers are faced with many challenges when working with adolescents. Vague symptoms, unreliable menstrual history, and adolescent reluctance to disclose sexual activity present challenges to early diagnosis. When pregnancy is suspected, clinicians need skills for accurate diagnosis, conducting comprehensive assessments, and providing options counseling. Complexities of providing confidential care while balancing the needs of the adolescent and family may deter some clinicians. A clinical case scenario illustrates important elements of care. Through sharing lessons learned from 10 years of working in a Pregnancy Follow-up Clinic, the authors hope to empower other clinicians as they care for adolescents during this critical time.

Introduction

The adolescent birth rate in the United States rose in 2006 for the first time in 14 years (Hamilton, Martin, & Ventura, 2007). Current estimates are that one third of teens become pregnant by age 20 years, producing rates in the United States that are still the highest among fully industrialized nations (The National Campaign, 2008). According to the latest American Academy of Pediatrics clinical report on adolescent pregnancy, by 2010 the population of female adolescents ages 15 to 19 years is expected to increase by 10%; thus, there will be increasing demand for adolescent reproductive health services (Klein, 2005). Clinicians will need the knowledge and skills to provide quality care to adolescents during the early phase of pregnancy.

This article will explore issues surrounding the diagnosis of an adolescent pregnancy, including psychosocial and physical assessment, options counseling, referral to termination or prenatal care, and follow up. We draw from our extensive clinical experience and use a typical case study of "MJ" to highlight challenges and opportunities for providing developmentally sensitive interventions and coordinated care to adolescents in early pregnancy. Clinicians often find it helpful to view adolescence in three psychosocial stages: early adolescence (11–14 years), middle adolescence (15–17 years), and late adolescence (18–21 years), similar to the way health visit guidelines have been organized in the current Bright Futures Guidelines (Hagan, Shaw, & Duncan, 2008).

Each clinical setting is unique. The authors are based in an inner-city adolescent clinic within a large pediatric tertiary care hospital in the Northeast. Based on a review of 6 years of quality improvement data for pregnant adolescent patients (N = 601) diagnosed with a pregnancy between January 2000 and December 2005, 45.8% decided to terminate the pregnancy, 48.2% opted to continue their pregnancy, and 6% had a miscarriage (Aruda, McCabe, Litty, & Burke, 2008). While percentages fluctuated slightly from year to year, overall there was a relatively even distribution of those who opted to continue the pregnancy and those who chose to terminate it. None of these pregnant patients who chose to continue their pregnancy were interested in exploring options for adoption at the time of pregnancy diagnosis.

This article includes forms that we developed, which clinicians are free to adapt for their own practice. The Confidential Pregnancy Intake Form (Figure 1) is an interview guide that is completed by the clinician who is assessing a newly diagnosed pregnant adolescent. The Guide—Pregnancy Quality Improvement Project (Figure 2) is a resource for clinic providers and student trainees.

Figure 1.

Confidential Pregnancy Intake Form. CBC, Complete blood cell count; HCG, human chorionic gonadotropin; ICON, brand of clinic pregnancy test;LMP, last menstrual period; PCP, primary care provider; SAB, spontaneous abortion; STI, sexually transmitted infection; TAB, therapeutic abortion; US, ultrasound.

Figure 2.

Guide—Pregnancy Quality Improvement Project. CBC, Complete blood cell count; GC, gonorrhea; HCG, human chorionic gonadotropin; MD, medical doctor; MVI, multivitamins with iron; NP, nurse practitioner; RN, registered nurse; SAB, spontaneous abortion; STD, sexually transmitted disease; TAB, therapeutic abortion; US, ultrasound.

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