Here are three common clinical scenarios where the possibility of adolescent pregnancy must be considered:
Sidney is a 17-year-old girl presenting for her annual sports preparticipation exam. Her last menstrual period (LMP) was seven weeks ago. She is unconcerned as she says it’s not unusual for her periods to be irregular.
Amelia is a 15-year-old whose mother is concerned about her behavior, including a change in friends and frequent alcohol use. Her LMP was five weeks ago.
Dana is a 16-year-old girl on isotretinoin who has not been reliably taking her birth control pills prescribed along with the acne medication. “I am not that sexually active,” she states.
Pediatricians need to ensure that they and their offices are prepared to address pregnancy — not only to make the diagnosis but also to counsel the patient and her family when test results are positive. The AAP Committee on Adolescence has updated its policy statement Options Counseling for the Pregnant Adolescent Patient and developed a new clinical report, Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient, to guide the pediatrician through the diagnosis of pregnancy, sharing the diagnosis with the patient and her family, reviewing her management options and making appropriate referrals.
The policy is available at https://doi.org/10.1542/peds.2017-2274 and the clinical report at https://doi.org/10.1542/peds.2017-2273. They will be published in the September issue of Pediatrics.
Include in differential diagnosis
Adolescent pregnancy can easily be overlooked and its diagnosis delayed. Patients frequently do not realize their risk for pregnancy and may not recognize its signs and symptoms. Pediatricians should record the LMP as a vital sign at each visit and routinely meet with patients confidentially to inquire about sexual activity.
Pregnancy needs to be in the differential diagnosis of complaints such as fatigue or nausea and in the case of a late menstrual period. Urine pregnancy tests should be available in all offices and performed whenever pregnancy enters the differential, even if the sexual history may not suggest it.
Confidentiality, support network
In many cases, it is beneficial to share the results of a positive pregnancy test with the adolescent alone. This may allow her to express her emotions, reactions and questions more freely. While cognizant of the legal rights of the adolescent to confidentiality, the pediatrician is encouraged to work with the teen to identify supportive adults who can assist her with the challenges ahead. In most cases, this will be her parent(s) but might be another relative or adult friend as well as the adolescent’s partner and family.
Presenting all options
With the adolescent and her identified support, the pediatrician should provide options counseling. Since its first policy statement on the subject in 1989, the Academy continues to affirm that pregnant adolescents should be counseled in a nonjudgmental, developmentally appropriate manner about all legal pregnancy options. These include:
- carrying her pregnancy to delivery and raising the baby;
- carrying her pregnancy to delivery and making an adoption or kinship care plan; or
- terminating her pregnancy.
No one may be better suited to provide this counseling than the patient’s pediatrician. He or she knows the patient and her family, and can lead the discussion in a compassionate manner that is tailored to the adolescent’s developmental and social needs. Pediatricians are not expected to know detailed information on all these options but should be able to offer each as a viable choice and provide reliable sources for more information or services, as requested by the patient.
The Academy recognizes that discussions regarding premarital sex, teen pregnancy and parenting, adoption and abortion can be difficult for some, and may evoke strong personal feelings or moral conflicts. Consequently, some pediatricians may feel limited in their ability to fully present all pregnancy options to an adolescent. While medical providers may decline to perform a service based on claims of conscience, they should be prepared to refer their patients promptly for that service. Pediatricians are encouraged to reflect on this issue and if necessary, investigate potential resources for such referrals. Caution is advised when referring to “pregnancy crisis centers” as these frequently do not offer unbiased, medically accurate information.
Although the U.S. teen pregnancy rate is falling to record lows, it remains among the highest of all developed countries. With more than half a million adolescents in the U.S. becoming pregnant each year, pediatricians are likely to encounter this diagnosis in their practice.
It is important that all pediatricians routinely discuss reproductive health with their adolescent patients, be alert to the possibility of pregnancy, and be prepared to provide balanced, accurate information on all management options if the diagnosis is made.
Dr. Hornberger, the lead author of the policy and clinical report, is the liaison from the AAP Section on Adolescent Health to the Committee on Adolescence.
