What Are Some of the Complications of Teenage Pregnancy?

Patient Presentation
A 16-year-old female came to the emergency room with dysuria for 2 days.
She had increased urinary frequency and urgency, and complained of strong smelling urine. She had no fevers, chills, constipation, or other abdominal pain. She had minimal vaginal discharge that was unchanged.
The past medical history was non-contributory.
The social history was obtained without her mother present and showed that she was sexually active with her second lifetime male partner. She denied sexual activity with female partners.
She said they used condoms inconsistently and did not use a spermicide. Her last intercourse was 3 days prior and her last menstrual period was about 8-9 weeks ago. She denied previous pregnancies or sexually transmitted infections.
The review of systems also revealed general fatigue and breast tenderness for 6 weeks.
The pertinent physical exam had normal vital signs with a height of 75% and weight of 50% for age. HEENT was negative. Breasts showed no masses or skin changes. Abdomen had normal bowel sounds without hepatosplenomegaly or masses.
There was no costovertebral angle tenderness, but there was mild suprapubic tenderness. External genitourinary examination showed no vaginal discharge, with minor erythema of the skin around the urethral opening.

The laboratory evaluation showed a urinalysis with a specific gravity of 1.015, 1+ blood, 4+ white blood cells with + leukocyte esterase and nitrates. She had 1-2 red blood cells and too numerous to count white blood cells.
A urine pregnancy test was positive but she refused any testing for sexually transmitted infections.
The diagnosis of urinary tract infection in a pregnant adolescent was made. She was treated amoxicillin for the urinary tract infection.
The physician discussed the pregnacy and all the potential options with the patient and also offered to be with the patient when she told her mother or to tell her mother for her.
She agreed to this and after her mother calmed down from hearing the news, her mother was very supportive.
Her mother said she would contact her own obstetrician for an appointment for her daughter. As the patient’s primary care provider was a family physician, the emergency room physician recommended contacting the family physician who may provide pregnancy counseling and obstetrical care.
Additionally, the emergency room physician also gave them other pregnancy-related community services for pregnancy counseling and obstetrical care. The patient was also given a prescription for daily prenatal vitamins and given basic information on nutrition and avoiding alcohol and drugs.

Discussion
Adolescent sexual activity and pregnancy continues to be significant health problems in the United States.

Lifetime sexual activity for high school students

Grade	Female	Male	Sexual activity
			in past 3 months
9th  	33%	45%	27%
12th  	66%	63%	51%

Pregnancy related statistics in 2000

  • Pregnancies to females < 20 years = 841,450
  • Births to females < 20 years = 477,509
  • Legal abortions to females < 20 years = 244,030
  • Risk of becoming pregnant or fathering a pregnancy for teenagers ages 15-19 years = females > males by 2:1
  • Risk of a sexually active teen age 15-19 years becoming pregnant = 20%
  • Teenage mothers who have another child within 2 years = 25%

However, the rates of teen pregnancy, birth and abortions have decreased over the past decade because of decreased sexual activity (25%) and improved contraceptive methods (75%).

Common pregnancy clinical presentations include overdue menses (most common), abdominal pain, breast tenderness, fatigue, nausea and urinary frequency.
Gestation age can be estimated by last menstrual period and fundal height. At 8 weeks gestation the uterus can be palpated, at 12 weeks gestation the uterus is at the pubic symphysis, and at 20 weeks gestation, itshould be at the umbilicus.
Non-judgemental pregnancy counseling should be offered including giving birth and raising the child, adoption and/or abortion. Referral for prompt prenatal care should be given to help prevent complications, but health care providers can also give prescriptions for prenatal vitamins and offer information on nutrition and avoiding alcohol/drugs.

Learning Point
Teenage pregnancy complications include:

  • For the infant
    • Low birth weight
    • Preterm birth
    • Higher peri- and post-neonatal mortality including sudden infant death syndrome and congenital malformations
    • Poverty
  • For the mother
    • Anemia
    • Delayed prenatal care
    • Depression
    • Inadequate weight gain
    • Poverty – partly due to inadequate education (only 50% of adolescent mothers complete high school by age 18 and by 35-39 years only 70% have a high school degree)
    • Pregnancy induced hypertension and eclampsia
    • Second birth as a teen

Some of these problems may be more related to poor prenatal care, nutrition and poverty than the mother’s age.
In general, first pregnancies have more complications than subsequent pregnacies, including teenager pregnancies.

Questions for Further Discussion
1. What are the potential complications of abortion for teenagers?
2. What are the potential complications of contraception for teenagers?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Teenage Pregnancy.

To view current news articles on this topic check Google News.

MacKay AP, Fingerhut LA, Duran CR.
Adolescent Health Chartbook. Health,
United States, 2000. Hyattsville, Maryland: National
Center for Health Statistics. 2000.
Available from the Internet at http://www.cdc.gov/nchs/data/hus/hus00cht.pdf (rev. 2000, cited 3/5/07).

Smith GC, Pell JP. Teenage pregnancy and risk of adverse perinatal outcomes associated with first and second births: population based retrospective cohort study. BMJ 2001;323:476.

Neinstein S, Farmer M. Teenage pregnancy in Adolescent Health Care A Practical Guide, Neinstein LS eds. Lippincott Williams &Wilkins. Philadelphia. 4th edition. 2002;810-833.

Klerman LV.
Risk of poor pregnancy outcomes: Is it higher among multiparous teenage mothers? Journal of Adolescent Health. 2006; 38(6):761-764.

Strasburger VC, et. al. Adolescent Medicine A Handbook for Primary Care. Lipincott Williams & Wilkins. Philadelphia. 2006;215-217.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Systems Based Practice

    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    April 9, 2007

  • Can You Help Me? I Don’t Remember All Those Brain Malformations?

    Patient Presentation
    An internist came by the general pediatric clinic to ask for help because he was seeing a young adult patient in his internal medicine clinic who had a history of an incidentally found Chiari I malformation that had been asymptomatic.
    The patient currently was complaining of some new headaches and he wondered if he should be worried about the malformation as a potential cause.
    The pediatrician reviewed with him that Chiari I malformations are considered congenital with caudal displacement of the cerebellar tonsils.
    Patients are often asymptomatic but if symptoms occur they generally occur in adolescence or early adulthood.
    The internist was going to evaluate the patient and possibly discuss his findings with one of the neurologists.


    Figure 47 – Sagittal FLAIR-weighted image of the brain reveals the tip of the cerebellar tonsils to be 12 mm below the level of the foramen magnum and therefore to be low lying in position. If the tip of the cerebellar tonsils is greater than 3-5 mm below the level of the foramen magnum, the patient is considered to have a Chiari I malformation. The Chiari I malformation is best visualized on a sagittal T1-weighted image of the cervical spine.

    Discussion
    Advances in radiology and neurosurgery have lead to improvements in the diagnosis and treatment of various congenital malformations of the nervous and skeletal system.
    Magnetic resonance imaging is the best imaging procedure to evaluate the brain, posterior fossa and spinal cord for congenital abnormalities, especially as it is non-invasive and can obtain images in multiple planes.
    Surgical treatment mainstays for Chiari malformation are decompression or shunting and possible laminectomy.

    Learning Point
    Historically, Hans van Chiari described 4 types of hindbrain anomalies in 1891 and 1895. Arnold described a different classification system.
    The Chiari II malformation is synonymous with the Arnold-Chiari malformation. Hans van Chiari also described Budd-Chairi syndrome which is an unrelated liver problem with cirrhosis and ascites due to an obstruction of the hepatic vein by a blood clot or tumor.

    Chiari I – caudal displacement of cerebellar tonsils with elongation of the 4th ventricle.
    It is associated with syringomyelia in up to 80% of patients. Syringomyelia is a cyst-like formation within the spinal cord that contains altered glial elements.
    This may be asymptomatic or have symptoms occurring from infancy to adulthood. Most patients present in the 3rd decade. Hydrocephalus may be present.

    Symptoms include:

      Associated with brain and cranial nerves:

    • Ataxia
    • Dysphagia
    • Headache
    • Neck Pain
    • Nystagmus
    • Sleep apnea
    • Torticollis
    • Vertigo
    • Vocal cord paralysis
      Associated with spinal cord dysfunction:

    • Dysesthesia
    • Bowel and/or bladder dysfunction
    • Extremity – weakness or spasticity
    • Sensory loss
    • Scoliosis

    Chiari II – caudal displacement of the vermis of the cerebellum, medulla and pons with elongation of the 4th ventricle.
    This is almost always associated with a lumbar meningomyelocoele. Hydrocephalus occurs because of aqueductal stenosis.
    Patients are usually diagnosed at birth. Chiari II is the most common Chiari malformation.
    Clinical symptoms are the same as Chiari I plus those associated with the meningomyelocoele and hydrocephalus.

    Chiari III – herniation of the cerebellum into an upper cervical or occipital meningocoele. It may also be associated with a Dandy-Walker malformation.
    Because of the extent of the malformation, patients present at birth and have more obvious and extensive symptoms.

    Chiari IV – severe hypoplasia of the cerebellum. Because of the extent of the malformation, patients present at birth and have more obvious and extensive symptoms.

    Questions for Further Discussion
    1. What other congenital abnormalities may be associated with Chiari malformations?
    2. What are indications for referral to a neurologist or neurosurgeon?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Neural Tube Defects.

    To view current news articles on this topic check Google News.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2180-2186..

    Incesu L, Khosla, A. Chiari II Malformation. eMedicine.
    Available from the Internet at http://www.emedicine.com/radio/topic150.htm (rev. 11/15/2002 cited 2/12/07).

    Siddiqui NH, Laine FJ. Chiari I Malformation. eMedicine.
    Available from the Internet at http://www.emedicine.com/radio/topic149.htm (rev.8/11/2005, cited 2/12/07).

    Chiari Malformation Type I. Online Mendelian Inheritance of Man.
    Available from the Internet at http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=118420 (rev.8/8/2006, cited 2/12/07).

    ACGME Competencies Highlighted by Case

  • Patient Care
    4. Patient management plans are developed and carried out.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Practice Based Learning and Improvement

    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    April 2, 2007