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

Physical and Medical Assessment

When MJ is brought into the examination room, she is tearful and states that she has a regular boyfriend and the condom broke "just one time" when they had sex. She has had some intermittent spotting and thus did not think that she could be pregnant.

For patients with a positive pregnancy test, a pelvic examination is strongly recommended, with speculum examination to visualize the cervix and a bimanual examination for sizing (Emans, Laufer, & Goldstein, 2007). The cervix is visualized to look for warts, lesions, bleeding, and Chadwick's sign, a bluish or purplish discoloration. The bimanual examination is essential to try to estimate gestational age, especially if there is uncertainty regarding dates provided in the history. An ultrasound may be necessary to confirm gestational age, especially if history and sizing is unclear or widely discrepant (Cox, 2008).

With recent availability of urine testing for gonorrhea and chlamydia, as well as recent revision of Papanicolaou test guidelines (ACOG, 2006), the newly pregnant adolescent may not have had a prior pelvic examination. Whether the pelvic examination can be completed at the initial visit or deferred to a follow-up visit in a week depends on the adolescent's readiness and the provider's schedule. It is important to stress the need for the pelvic examination, because the unprotected intercourse that led to pregnancy also places the adolescent at risk for STIs. If the adolescent is symptomatic for vaginosis, then a wet prep for trichomoniasis and bacterial vaginosis can be performed. The bimanual examination, in addition to estimating gestational size to correspond to dates on the history, allows assessment for adnexal mass or tenderness, which can be a sign of an ectopic pregnancy, as well as assessment for cervical motion and adnexal tenderness to rule out pelvic inflammatory disease. The Table summarizes the CDC's Sexually Transmitted Disease Treatment Guidelines During Pregnancy (2006). HIV counseling and testing also should be encouraged for all pregnant adolescents.

One of the most challenging issues to sort out in early pregnancy is bleeding. If there is vaginal bleeding, a provider must consider ectopic pregnancy, threatened abortion, or spontaneous abortion. Light bleeding might be due to implantation bleeding, but obtaining a thorough history and taking a conservative approach generally is recommended. Screening blood work may include complete blood cell count, blood type, Rh factor and antibody screen, quantitative HCG, and possibly a rapid plasmin reagin test to check for syphilis. RhoGAM would be indicated for Rh negative patients who have no antibodies (to prevent sensitization) and are bleeding because of an ectopic pregnancy or who have a spontaneous or elective abortion (Fortner et al., 2007).

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