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

Diagnosing an Adolescent Pregnancy: The Presenting Complaint

MJ, a 16-year-old female adolescent, presents to the adolescent clinic for a sore throat. Behind closed doors, the clinical nursing assistant checks vital signs and asks a standard clinic intake question about MJ's last menstrual period (LMP). MJ reveals that her period is late and she would like a pregnancy test.

Adolescents present for pregnancy testing in a variety of ways. Amenorrhea may not be the presenting complaint, especially if the adolescent is hesitant to divulge sensitive information with the receptionist when scheduling an appointment or walking in for a visit. This reluctance to disclose sexual history underscores the importance of confidentiality for adolescent reproductive health visits, which is supported by law in all 50 states (English & Kenney, 2003). Busy clinicians anticipating a brief encounter with a patient complaining of something minor, such as a "sore throat," need to be prepared to ascertain the "hidden agenda." It should be standard practice to assess all adolescents for sexual risk behaviors. Many young women may be unaware of the possibility of being pregnant or reluctant to raise the question until a health care provider inquires about sexual activity. The focus on an adolescent's chronic medical condition, such as diabetes, renal disease, or cancer, should not deter from exploring common risk behaviors. Likewise, teens with complex mental health issues, such as depression, anxiety, or substance abuse, are at risk for engaging in unprotected sexual activity. According to the 2007 Youth Risk Behavior Survey (Centers for Disease Control and Prevention [CDC], 2008), 47.8% of all high school students indicated they had had sexual intercourse. Therefore, by assuming all female adolescent patients are potentially at risk, a provider is more apt to ask about sexual activity at each encounter.

Despite the availability of home pregnancy test kits, research has demonstrated that only approximately one third of adolescents presenting to clinics have already conducted a pregnancy test at home and thus were seeking confirmation and referral (Shew, Hellerstedt, Sieving, Smith, & Fee, 2000). For many adolescents, the cost of a home pregnancy test kit may be prohibitive or they may be reluctant to purchase a pregnancy test from their neighborhood pharmacy because of privacy concerns. Adolescents presenting for a routine physical or sick visit may refrain from disclosing their concern about a pregnancy unless they feel comfortable and trust the provider (Wildey, 1987). Perceptions that a clinical practice is not "adolescent friendly" and has limited hours, along with concerns about cost and confidentiality, all are potential barriers to care (McKee, Karasz, & Weber, 2004).

It is imperative for adolescent visits that the history be elicited in private, without a parent or guardian present, and that confidentiality be maintained. Protection of confidentiality is an essential component of health care for adolescents, and research has documented that without it, some adolescents will forgo care (Society of Adolescent Medicine, 2004). The presence of parents, siblings, or other adult authority figures may unduly pressure the adolescent, inviting partial truths or withholding of important information. Confidential care encourages adolescents to provide complete, timely, and sensitive information to their health care provider, who also works to facilitate communication between the adolescent and her family.

Clinicians have an array of contraceptive methods for pregnancy prevention. When working with adolescents, clinicians expend concerted effort to educate patients about risks of unprotected sex, the importance of consistent condom use, how to properly use a contraceptive method, and common side effects of hormonal contraception. Preventive interventions notwithstanding, pregnant adolescents often report that they "did not think it would happen to them." Some start and stop using a method, while others may blame the pregnancy on contraceptive failure. Teen risk behavior tends to be irrational in nature, which some researchers have attributed to lack of decision making rather than faulty decision making (Steinberg, 2002). Immature cognitive development, coupled with emotional influences, leads to sex "just happening," and contraception, which would have required preplanning, was therefore not implemented (Herman, 2007).

In this case, MJ reluctantly reveals that her last period was 2 months ago and it was lighter than usual.

Why do some teens wait so long for pregnancy testing after a missed period? That is a long-standing and perplexing question that has no definitive answer. It is helpful to remember that adolescents think differently than adults do (Weinberger, Elvevag, & Giedd, 2005). Their immature cognitive processing and egocentric thinking can lead to distortions in judgment and the belief that a pregnancy could not happen to them. Emotional factors, such as fear or shame, can perpetuate denial. For some adolescents, finding out that they are pregnant initially can be immobilizing, leading them to simply ignore it and hope that things will work out. Under stress, an adolescent may revert to concrete thinking and focus on daily routines, which can subvert abstract decision making and planning for the future.

Establishing the date of the LMP is very important in determining how far along in the pregnancy the adolescent is. Yet adolescents often have difficulty remembering their LMP. Some girls enter this information in their cell phones or mark it on their calendar at home, but many do not keep track of it. The clinician can use a calendar as a visual aid and link important events, such as a holiday, birthday, or school vacation, to help them with recall. Research in using event history calendars has shown promising results (Martyn, Reifsnider, & Murray, 2006). It also is important to establish whether their last period was a typical period. Early pregnancy implantation bleeding/staining may be mistaken for a light period. One should ask about timing and characteristics of any presumptive symptoms of pregnancy, such as breast soreness and enlargement, nausea, vomiting, abdominal cramping, urinary frequency, fatigue, appetite changes, or aversive smells. Adolescents and young adults also are at high risk for sexually transmitted infections (STIs). Pregnancy confirms unprotected sex, and thus symptoms such as vaginal discharge and dysuria may signal an STI (Ickovics, Niccolai, Lewis, Kershaw, & Ethier, 2003).

Any adolescent who has achieved menarche and who presents with amenorrhea requires a pregnancy test (Nicolletti, 2005). Any missed, lighter, shorter, or mistimed menses warrants pregnancy testing as well. Some patients will vehemently deny sexual activity or insist that they "always use protection"; however, the most likely cause of amenorrhea in adolescents is pregnancy, and thus arrangements should be made to offer confidential pregnancy testing, and the patient should be informed that testing is being done. Most clinicians are able to arrange for testing while ensuring that a billing notice or Explanation of Benefits is not sent to the home.

Sensitive urine pregnancy tests can detect human chorionic gonadotropin (HCG) levels by 10 to 14 days post conception. Serum HCG tests may be slightly more sensitive (7 days), but these tests are more costly and thus are used primarily for tracking possible spontaneous abortion (miscarriage) or ectopic pregnancy by checking quantitative levels every 48 hours (Fortner, Szymanski, Fox, & Wallach, 2007).

It is important to note that the majority of pregnancy tests done in clinical practice settings are negative, and there is a growing body of research regarding negative pregnancy testing in adolescents. A longitudinal study revealed that 58% of teens who had an initial negative pregnancy test became pregnant within 18 months of that index test (Zabin, Sedivy, & Emerson, 1994). A subsequent cross-sectional study of 2926 young women aged 17 years or younger who presented to clinics for pregnancy testing revealed 62.3% of the tests were negative and 36.4% were positive (Zabin, Emerson, Ringers, & Sedivy, 1996). Recent research indicated that pregnancy tests were negative 77% of the time within an urban setting and further reinforced pregnancy testing as an important and often missed opportunity for clinicians (Daley, Sadler, Leventhal, Cromwell, & Reynolds, 2005).

These studies have focused attention on adolescents presenting for pregnancy testing and identified a subgroup of teens who repeatedly requested pregnancy tests and received negative results. Even at a young age, adolescents may be worried about their fertility, especially if they have had multiple episodes of unprotected sex and have never become pregnant. An adolescent's curiosity about whether she can become pregnant does not necessarily mean that she wants to be pregnant. Adolescents with a negative pregnancy test who acknowledge unprotected sexual activity need screening for STIs, contraceptive counseling, and follow-up for a repeat urine pregnancy test.

The interim between when the test is being processed and when the results are made known presents an excellent opportunity to explore the adolescent's initial thinking. The clinician can pose such questions as, "What would you do if the pregnancy test was positive?" and "What if the pregnancy test was negative?" The latter question may spark a discussion about the teen's desire for pregnancy and create an opportunity for prevention counseling. It is important not to assume how an adolescent will feel about a pregnancy test result. Emotional reactions are complex, unique to the individual, and likely will change over time as the adolescent processes the news. Therefore, it is important for providers to remain neutral and nonjudgmental, while being aware of their personal feelings and reactions, so as not to introduce bias.

In this case, MJ has a positive pregnancy test.

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