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

Options Counseling

It is imperative for clinicians to utilize neutral, factual information and non-directive statements when discussing options. The following commentary can be helpful when initiating the conversation: "You have a decision to make about your pregnancy. Any pregnant adolescent has three options. Alphabetically, these options are: (a) abortion or pregnancy termination; (b) continuing the pregnancy and arranging for an adoption, infant care, or foster care; and (c) continuing the pregnancy, entering prenatal care, and becoming a parent. At this point, which option do you think you will choose?"

Before embarking on options counseling with pregnant adolescents, it is helpful for clinicians to examine their own values. Health professionals who feel strongly that they cannot offer unbiased, non-directive counseling regarding choices because of their religious or personal values should defer working with newly pregnant adolescents (Simmonds & Likis, 2005).

Choosing what to do about a pregnancy may be the biggest decision that an adolescent has ever had to make in her life. Ambivalence is normal. She will need time and energy to thoughtfully consider all of the options, along with their potential impact. For some teens, the choice may seem clear cut, and they reach a decision quickly. Others need more time to talk with people in their personal support network as they carefully weigh each option. They may vacillate between continuing and terminating the pregnancy. Some adolescents lack the cognitive skills to make decisions on their own and need extensive support and counseling, including mental health services. In some cases, the pregnant adolescent may feel pressured by her partner or parent to choose a certain option, and this situation requires careful exploration.

It is important to monitor pregnant adolescents at regular weekly intervals until they have made their decision and then to refer them accordingly. Appointments at the referral site should be confirmed by outreach calls to the site or to the adolescent. It is helpful for clinicians to inform their pregnant patients at the outset about their follow-up and outreach policies so that patients understand that providers will be calling them if they do not show for appointments and thus to encourage ongoing communication and cooperation.

Adolescents have legal rights regarding their ability to consent for reproductive health services, and these statutes are regulated by individual states. The clinician needs to be familiar with local and state laws about parental notification. Further resources are available from Physicians for Adolescent Reproductive Choice and Health (www.prch.org), Planned Parenthood (www.plannedparenthood.org), and the Center for Adolescent Health and the Law (www.cahl.org).

In this case, MJ returns to the clinic for follow-up in 1 week. She states that she has been unable to talk to her parents but has confided in an older cousin. When she informed her partner about the pregnancy, he denied the child could be his and they broke up.

Working with adolescents during early pregnancy involves monitoring both their physical and emotional status. In the case of MJ, the crisis of pregnancy is exacerbated by interpersonal strife with her partner and social isolation due to secrecy surrounding her pregnancy. When available, interdisciplinary care is optimal. A mental health provider can address the ongoing emotional needs as well as social support and safety issues. A health care provider can review laboratory test results and assess current physical status with particular attention to any signs or symptoms such as abdominal pain, bleeding, or elevated blood pressure. Follow-up visits or phone calls are an opportunity to inquire about nutrition, substance use, and any other mental health or medical concerns.

The pros and cons of each possible choice need to be discussed. It is not unusual for an adolescent to change from her initial choice during the decision-making process. It is imperative that the adolescent feels she has made her own decision and is not being forced into making one by others. In our experience, adolescents who express ambivalence yet are strongly urged to terminate their pregnancy by a parent or partner are more likely to experience a repeat pregnancy. No statistics regarding repeat adolescent pregnancy after termination are available, and thus more research is needed in this area. Similarly, prematurely choosing to continue a pregnancy without careful consideration of all the ramifications can have a great impact on the adolescent and her family. Although few adolescents choose adoptions, a variety of options are available, including temporary infant care placements, foster care, and placements with extended family, and it is helpful to have written materials available (Child Welfare Information Gateway, 2007).

MJ returns for a follow-up appointment the next week. She still is undecided about whether to continue or terminate the pregnancy. She is now 10 weeks pregnant and has missed several days of school because she felt nauseous in the morning.

While continuing to counsel an adolescent regarding her options, it is vital to provide non-biased, neutral support. Clinicians may find that the adolescent-friendly counseling techniques in the recently released Bright Futures Guidelines (Hagan et al., 2008) and Adolescent Health Care (Neinstein, Gordon, Katzman, Rosen, & Woods, 2008) are helpful. One currently popular technique, Motivational Interviewing (MI), can be used to help adolescents sort through their feelings of ambivalence so they can eventually take action steps in concert with their personal goals (Kokotailo and Gold, 2008, Miller and Rollnick, 2002). The spirit of MI includes: (a) respect for a person's own perspectives and autonomy; (b) optimism about a person's wisdom and capacity to change; (c) empathy and genuine interest in a person's experience and framework; and (d) the willingness to collaborate and suspend the expert role to work together to evoke the person's intrinsic motivation and commitment (Polaneeczky and O'Connor, 1999, Rollnick et al., 2007).

Many adolescents find it helpful to write down a list of all the pros or cons of being pregnant at this time. One should encourage the adolescent to seek family involvement if possible or to discuss her situation with a trusting adult. Referral to a mental health provider is very helpful, especially for adolescents who are "stuck" and having difficulty deciding on an option. Likewise, adolescents with a history of mental health issues benefit from mental health screening and crisis intervention. Mental health clinicians can assist with further processing of options and with sharing the information/diagnosis with the family if appropriate.

Whatever MJ decides, termination or continuation of the pregnancy, it will be important to maintain ongoing clinical contact to assist her with navigating through the complex health care system. Her case illustrates the importance of regular visits and contact until a decision is made and the referral appointment has been completed (and, optimally, there is verification that the referral appointment was kept). In the program we developed, the primary care provider, nurse coordinator, or mental health provider maintained weekly contact (in person or by phone) until the referral appointment was kept.

In the case of an adolescent who decides to continue her pregnancy, referral care is directed to an obstetrical provider, but because of the potential delay until their first prenatal visit, prenatal vitamins should be prescribed. Specifics of adolescent prenatal care are beyond the scope of this article. An overview of evaluation and management of the pregnant adolescent can be found in Cox (2008).

Adolescents who decide to terminate their pregnancy should be encouraged to do so as early as possible to minimize complications and costs. The time limits on the procedure and consent requirements are regulated by legal statutes (federal and state), as well as individual institutional policy. Planned Parenthood Federation maintains a Web site of current legislation and clinic availability based on zip codes (www.plannedparenthood.org). Most teens who choose to terminate have a first-trimester abortion, and depending on their gestational age, they may decide between a medical or surgical method (Cox, 2008). In addition to weekly visits prior to the procedure, we recommend seeing the adolescent 2 weeks after the procedure for follow-up. The purpose of this visit is to assess for medical complications, contraception needs, and emotional response.

In conclusion, we wish to acknowledge the efforts of all clinicians who care for adolescents during early pregnancy. The management of early pregnancy and counseling throughout the decision-making process takes time, energy, patience, and persistence. MJ's case illustrates the importance of consistent follow-up, outreach, and multidisciplinary team work. It is very easy for newly pregnant adolescents to become lost to follow-up, and there are still cases of adolescents delivering without any prenatal care (Aruda, 2007). Even when efforts are made to coordinate care, providing services to newly pregnant adolescents is still challenging. Pregnancy follow-up data for a 6-year period revealed that almost half of the adolescents who chose to continue their pregnancy did not enter prenatal care until 12 weeks' gestation or later (Aruda et al., 2008). Lack of early prenatal care for adolescents may contribute to their higher rates of perinatal and infant morbidity and is an area in need of further research study.

Clinicians who see adolescents for repeat pregnancies can easily become frustrated, but it is important not to give up hope. Adolescents do not think or act like adults, especially under stress, and they are in a unique developmental stage where curiosity, impulse control, and experimentation increase their risk for an unintended pregnancy. Supportive clinical relationships and connections can help adolescents through a pregnancy crisis as they navigate life's course to a safe and healthy adulthood.

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