Teen Pregnancy.

Pregnant teenagers may suspect that they are pregnant based on symptoms. These symptoms vary from person to person and also differ based on the gestational age of the pregnancy. Earliest signs of pregnancy can include a missed period, nausea with or without vomiting, breast tenderness, fatigue, cramping or lower backaches, and mood swings. Approximately one-third of pregnant women experience spotting referred to as “implantation bleeding.” ( 24 )( 25 ) Patients usually experience spotting or bleeding lighter than their period approximately 10 to 14 days after conception, as the zygote attaches to the uterine lining. Later in pregnancy, symptoms vary greatly but can include a decrease in nausea/vomiting, increased energy, a growing abdomen as the uterus expands with the appearance of stretch marks, increased urination, and swelling in the hands or feet. When diagnosing a pregnancy, it is important to confirm whether it is intrauterine, ectopic, or molar. Ectopic pregnancy can be challenging to diagnose ( 15 ) because classic symptoms such as pelvic or abdominal pain and vaginal bleeding can be nonspecific. Therefore, confirmation of the location of a pregnancy after a positive pregnancy test is necessary. Patients may find out that they are pregnant by taking a home pregnancy test before they seek medical care. Pregnancy tests, including home tests, detect the presence of hCG in urine or blood serum. Both tests rely on monoclonal antibodies ( 26 ) to the β subunit of hCG, a hormone secreted by syncytiotrophoblastic cells ( 28 ) of the placenta into the maternal circulation. Urine pregnancy tests report the result as a binary yes/no and rely on the test antibody reacting with fragments of the hCG molecule that are present in the urine. ( 26 ) In contrast, serum pregnancy tests give a quantitative result for hCG levels and rely on the antibody reacting with intact hCG in the serum. hCG is first detectable 8 to 10 days after ovulation, once implantation has occurred. Because the timing of ovulation varies from cycle to cycle, the number of days after the last menstrual period before hCG can be detected varies. Serum pregnancy tests can be positive as early as day 14 of the cycle, and urine pregnancy tests can be positive as early as day 16 ( 27 ) of the cycle, but it is more typical and likely for tests to be positive at the time menses is expected. hCG levels double every 24 to 48 hours in the first 30 days after implantation, peaking at 8 to 10 weeks of gestation. ( 28 ) A positive pregnancy test detects the presence of any type of pregnancy, including ectopic pregnancy, molar pregnancy, or intrauterine pregnancy (whether singleton gestation or multiple gestation). Manufacturers report that home urine pregnancy tests have 100% sensitivity and specificity when used correctly. Similarly, serum pregnancy tests are reported to have 97% to 99% sensitivity and 100% specificity. ( 29 ) Blood tests for hCG can detect levels of hCG as low as 1 to 2 mIU/mL (1–2 IU/L), whereas urine tests typically do not detect hCG levels lower than 20 mIU/mL (20 IU/L). ( 30 ) Trace levels of hCG can be detected in the urine or in the blood as early as 10 days after conception. False-positives are uncommon but can occur in the setting of ectopic production of hCGx due to malignancies, IgA deficiency, chronic renal failure, or rheumatoid factors (which can bind the antibodies in the test assay). ( 23 ) A false-negative pregnancy test can be due to early measurement after conception, so if pregnancy is still suspected, the test should be repeated in 1 week. Other causes of false-negatives include dilute urine (if urine sample) or the hook effect (if serum sample). ( 31 ) The hook effect is a rare cause of a false-negative serum pregnancy test. It can occur late in the first trimester or during the second trimester, when hCG levels are high and excess hCG antigens overwhelm and saturate the tracer and antibodies in the pregnancy test, hindering the formation of the tracer hCG antibody required for measurement, giving a false-negative result. The diagnosis of pregnancy is based on the presence of any of the following: detection of hCG in blood or urine, ultrasonography identifying a pregnancy, or Doppler ultrasonography identifying fetal cardiac activity, as early as the sixth week of gestation. ( 32 ) Transvaginal ultrasonography can identify a pregnancy by the presence of the gestational sac as early as 4.5 to 5 weeks’ gestational age. ( 32 ) Most commonly, a positive pregnancy test, whether from a urine sample or a blood sample, first confirms that a patient is pregnant. After that, first trimester ultrasonography ( 33 ) (up to and including 13 6/7 weeks of gestation) should be performed for dating and to confirm the location of the pregnancy. Ultrasonography can differentiate intrauterine, ectopic (ie, visualizing a gestational sac in a location outside of the uterus), and molar (ie, visualizing a hydatidiform mole) pregnancies.

To support patient autonomy, adolescents should be informed that a pregnancy test will be performed. ( 34 ) Clinicians can also prepare the adolescent to receive the result by asking questions such as “Do you have an idea of what the results of your pregnancy test might be?” and “What are you hoping the results will be?” Adolescents may have a variety of thoughts and feelings after hearing the result of a clinic-performed pregnancy test. Clinicians may navigate the conversation toward disclosure of the result by saying, “We’ll hope for the result you want, but if it’s different, we’ll work through a plan together.” Minor consent and confidentiality laws regarding diagnosis and management of pregnancy vary by state. The American Academy of Pediatrics maintains ( 35 ) that adolescents should have access to confidential reproductive health-care services, which includes providing nonjudgmental and comprehensive evaluation and counseling of patients regarding pregnancy options. In light of the Cures Act Final Rule in 2021, it is important to consider best practices for maintaining an adolescent’s confidentiality when ordering a pregnancy test for an adolescent patient, including confidential access to laboratory results in a patient portal, confidential note template creation in the electronic health record, and office policies to ensure that the adolescent can have a private conversation with their clinician about their options. ( 36 ) In addition, explanations of benefits may preclude true confidential care provision to young people up to age 25 years because the Affordable Care Act requires insurance plans to offer dependent child coverage until a child reaches age 26 years; therefore, clinicians should engage in confidential billing processes where possible. Specific guidance on how to do confidential billing are dependent on the insurance companies and their offered plans, state laws, health system policies, and clinic-level practices. ( 37 ) Therefore, clinicians are encouraged to discuss with clinic leadership the legal ways to confidentially mark sensitive services provided to minors when billing with insurance, streamline referral pathways to Title X clinics, or offer free or sliding scale services where possible. In the absence of a life-threatening emergency that must be addressed immediately, the clinician should provide confidential disclosure of a positive pregnancy test result as well as pregnancy options counseling. When disclosing a positive pregnancy test result to an adolescent, it is important to use clear language ( Fig ). We recommend saying, “Your pregnancy test is positive, which means that you are pregnant.” We also recommend pausing here and allowing silence so that the patient can process this information. Subsequent steps may include asking the patient how they are feeling and/or validating their emotions. ( 38 ) It is also important to note that a positive pregnancy test should be disclosed privately, initially to the patient alone. If the patient wants the clinician to share the result with someone else in the patient’s life, such as their parent or partner, it would be appropriate for the clinician to do so only after ensuring that doing so is both safe for the patient and congruent with the patient’s wishes. This can be done by asking the patient if they have discussed possible pregnancy with their parent or partner, and if not, how they think they will react. ( 39 ) It also provides an opportunity to assess for their safety at home and in their relationship. If there are concerns, the clinician should connect them to local intimate partner violence resources or make a referral to Child Protective Services, if appropriate. If there is concern for parental or partner coercion to continue or end the pregnancy, the clinician can reinforce the adolescent’s confidentiality and autonomy in making a decision for the pregnancy. ( 35 ) After disclosure of positive pregnancy test results, clinicians should offer pregnancy options counseling. There are no legal restrictions preventing clinicians from discussing all options, including abortion even if abortion is not available in their state; therefore, clinicians have an ethical responsibility to connect pregnant adolescents to their desired form of care. ( 40 ) Pregnancy options counseling is the process of discussing the possibilities of parenting, adoption, and abortion with a pregnant individual ( Table 1 ). ( 38 ) Ideally, pregnancy options counseling should be unbiased, nonjudgmental, supportive of all options, informative, and sensitive to the patient’s emotions and needs. The American Academy of Pediatrics recommends that pediatricians should either offer comprehensive and confidential options counseling to their patients or be prepared to refer to another clinician who is able to provide this counseling. ( 7 ) In a qualitative study of 50 individuals who experienced pregnancy during adolescence, participant recommendations for best practices in pregnancy options counseling with adolescents included ensuring that communication is compassionate and respectful, neutral and comprehensive with respect to pregnancy options, and confidential (within the limitations of any relevant local policies). ( 41 ) Participants also recommended that clinicians, as part of options counseling, inquire about patients’ feelings, choices, life plans, and social support. Participants in this study also recommended provision of informational materials about different pregnancy options and clinician facilitation of next steps, including warm handoffs to referrals. In discussing next steps, it is important for clinicians to emphasize that adolescents can take sufficient time to make a pregnancy decision with which they feel comfortable and also to emphasize the need to pursue care for pregnancy options in a timely manner. Encouragement of timeliness is particularly important for adolescents given that adolescents tend to present for both prenatal care and abortion later in pregnancy than older patients. Timeliness is also important given local/regional variability in gestational limits for abortion care. Provision of referrals and discussion of next steps should ideally also include universal education about relationship abuse with referrals to appropriate local and national resources. This aspect of options counseling should also ideally include discussion of mental health emergencies, which can be framed as an acknowledgment that life changes such as pregnancy can be stressful for some but not all people. Discussion of mental health emergencies should be accompanied by provision of referrals to crisis resources. Options counseling should be offered initially as part of a confidential portion of the health-care visit between the clinician and the patient only. If the patient desires inclusion of a support person such as a parent or partner in options counseling, it would be appropriate for the clinician to invite them into the conversation after a brief private discussion with the patient and again after ensuring that including the additional person is both safe and congruent with the patient’s wishes. During the private segment of the visit, the clinician should be clear about limitations to confidentiality, such as disclosure of risk of harm to self or others. The clinician should also be clear about whether any disclosures from the patient have triggered a legal requirement for mandatory reporting (eg, regarding the age of the patient’s partner). Clinicians may want to engage in a values clarification exercise about adolescent pregnancy to be prepared to offer neutral, unbiased options counseling. A values clarification exercise represents an opportunity for the clinician to reflect on their own perspectives, experiences, and biases around a certain topic to increase self-awareness and ideally allow the clinician to mitigate the impact of their biases on clinical care. An example of a values clarification for adolescent pregnancy is provided in Table 2 . Although not all adolescents will consider abortion, those who do will likely benefit from clinician guidance given the evolving US policy landscape. Resources exist to inform clinicians about the state-based legal restrictions in place. ( 42 )( 43 ) Abortion is a highly safe medical procedure for adolescents and young adults. ( 44 ) The safety of abortion is maximized when performed at earlier gestations, with a less than 0.5% risk of serious complications. ( 45 ) There are 2 primary methods of abortion: medical and surgical. Medical abortion, commonly referred to as the “abortion pill,” involves the administration of 2 medications: mifepristone and misoprostol. ( 46 ) This method has Food and Drug Administration (FDA) approval for pregnancies up to 10 weeks’ gestation and is 99.6% effective at terminating pregnancy. ( 47 ) The initial medication, mifepristone, functions by inhibiting the progression of the pregnancy. Subsequently, the second medication, misoprostol, induces uterine cramping and bleeding to expel the pregnancy tissue. The resultant symptoms are akin to those experienced during a miscarriage, characterized by heavy menstrual-like bleeding. Recently, the FDA requirement to dispense mifepristone in clinical settings was removed, allowing patients in many states to have telehealth counseling appointments, receive a prescription for both medications, and then pick up both medications at a pharmacy for self-administration at home, which is equally as safe as previous inperson administration. ( 48 ) However, half of states in the United States have legal restrictions on medication abortion, approximately half of which have near-total bans on abortions, and the other half restrict access such as requiring physician prescribing, in-person clinic visit requirements, or banning the mailing of abortion pills. ( 49 ) Surgical abortion is a procedure by a medical provider within a clinical or hospital environment. States have laws about whether surgical abortion is allowable, and up until what gestational age. The specific surgical technique used is contingent on the gestational age. Generally, the procedure involves several steps: administration of analgesics to ensure patient comfort, and often, sedatives to induce relaxation or sleep. After sedation, the cervix is gently dilated, and the pregnancy tissue is removed using suction or a combination of suction and surgical instruments. Thirty-six states require parental involvement in a minor’s decision to have an abortion, although some states have exceptions where adolescents can obtain an abortion during a medical emergency or in cases of assault, abuse, incest, or neglect. ( 50 ) In addition, all the states that require parental involvement allow judicial bypass, whereby adolescents can obtain approval from courts to obtain their abortion. Therefore, for minor patients expressing interest in abortion, clinicians should discuss privately with adolescent patients the need for parental consent/notification for abortion in states where these laws apply and connect adolescents to resources for judicial bypass if desired by the patient ( Table 1 ). Notably, the American Academy of Pediatrics acknowledges the harm that mandatory parental involvement can cause on adolescents seeking confidential abortion care. ( 35 ) Nausea, fatigue, mood changes, constipation, and musculoskeletal pain may occur during pregnancy and can be managed conservatively. However, medical emergencies may also arise and require immediate clinical evaluation. Concerning symptoms include acute chest pain and/or shortness of breath that may indicate a pulmonary embolism or myocardial infarction. ( 51 ) Other concerning symptoms may be severe dehydration related to excessive vomiting. ( 51 ) Severe abdominal pain or heavy vaginal bleeding (ie, bleeding that soaks through at least 1 pad per hour) may be signs of an ectopic pregnancy or miscarriage. ( 51 ) Severe headache may indicate venous sinus thrombosis or, in the appropriate clinical context, a hypertensive disorder of pregnancy such as preeclampsia. ( 51 ) Other signs and symptoms of preeclampsia can include vision changes, swelling, or blood pressure higher than 160/110 mm Hg. ( 51 ) Signs of eclampsia can include seizures or loss of consciousness. ( 51 ) Psychiatric emergencies, such as suicidal ideation, should also be considered. ( 51 )

Adolescents’ desires for and intentions about pregnancy are varied. Some may engage in unprotected sex with the desired outcome of pregnancy, some may choose to use 1 of several contraceptive methods to prevent pregnancy, and some may be ambivalent about contraception and/or pregnancy. No method of pregnancy prevention, aside from abstaining from sexual intercourse, is 100% effective, and, therefore, pregnancy is still possible despite the perfect use of any contraceptive method. ( 9 ) It is important for clinicians to ask about partner or parental coercion to get or not get pregnant because that may also affect an adolescent’s own desire for pregnancy prevention or intention. Pregnancy may occur due to unprotected penile-vaginal intercourse or from contraceptive method failure. The American College of Obstetricians and Gynecologists defines pregnancy as beginning with implantation of the embryo in the uterine wall. After penile ejaculation of sperm into a vagina, a sperm may enter the uterus and fertilize an ovulating egg to create an embryo, which then may implant within the uterus (ie, intrauterine pregnancy) or outside the uterus (ie, ectopic pregnancy). Implantation typically begins 5 days after fertilization and is completed by day 10. In addition, instead of an embryo, a hydatidiform mole may result when a sperm fertilizes an egg without genetic material, ( 10 ) and this can result in either a complete (ie, no fetal tissue present) or partial (ie, some fetal tissue present) molar pregnancy. Ectopic pregnancy is when an embryo implants outside the uterus, with 95% implanting in the fallopian tube. Ectopic pregnancies can also occur in the abdominal cavity, uterine myometrium, ovary, cervix, or cesarean scar. ( 11 ) Although half of ectopic pregnancies have no known risk factors, some risk factors include previous fallopian tube, pelvic, or abdominal surgery; history of pelvic inflammatory disease; or endometriosis. ( 12 ) Using an intrauterine device (IUD) does not raise the likelihood of having an ectopic pregnancy, but if a pregnancy occurs while an IUD is in place, it is more likely to be ectopic compared with a pregnancy without an IUD. ( 13 ) Healthy adolescents (<20 years old) are generally less likely to have an ectopic pregnancy than adult women given fewer predisposing risk factors. ( 14 ) However, adolescents with ectopic pregnancy are 3 times more likely to have a concurrent sexually transmitted infection than adult women with ectopic pregnancy. Ectopic pregnancy can present similarly to intrauterine pregnancy, with amenorrhea followed by bleeding or spotting, which makes its diagnosis challenging. An ectopic pregnancy is suspected in pregnant patients who have an abnormal rise in human chorionic gonadotropin (hCG) level, abdominal pain, vaginal bleeding, or the visualization of either adnexal masses or intraperitoneal bleeding on transvaginal ultrasonography without visualization of an intrauterine pregnancy on transvaginal ultrasonography. A diagnosis of ectopic pregnancy is confirmed either with transvaginal ultrasonography visualizing an extrauterine gestational sac or with levels of serum hCG that are not rising as expected (although expected rate of rise is nuanced and depends on initial hCG level). Ectopic pregnancy can be a medical emergency, estimated to cause 5% to 10% of pregnancy related deaths. ( 15 ) Management options for an ectopic pregnancy ( 16 ) are varied and depend on the patient’s hemodynamic stability, location of the ectopic pregnancy, risk of tubal rupture, and β-hCG levels. Options include surgical removal, medical management with methotrexate, or expectant management. Molar pregnancy is a rare entity with unknown incidence (estimated in the 1990s to be approximately 1 per 1,000 pregnancies). Individuals younger than 16 years have a 4 to 10 times higher risk of developing a hydatidiform mole than those aged 20 to 30 years. ( 17 ) In addition, adolescents younger than 16 years have a higher risk of complete molar pregnancy (ie, where no fetal tissue is present) compared with those aged 20 to 30 years. However, the incidence of partial molar pregnancy (ie, where some fetal tissue is present) is not significantly different. ( 18 ) Molar pregnancy typically presents with missed menses, a positive pregnancy test, and vaginal bleeding, pelvic discomfort, or hyperemesis gravidarum. Because these signs and symptoms can be similar to intrauterine or ectopic pregnancy, further testing with serum hCG level or ultrasonography is needed. Patients often have an unusually high serum hCG level (>100,000 mIU/mL [>100,000 IU/L]), and transvaginal ultrasonography demonstrates a hydatidiform mole. Preferred treatment for women who want to preserve fertility is suction curettage. ( 19 ) There are several possible complications that can happen during an intrauterine pregnancy, which may increase either the birthing person’s or fetus’s risk of adverse outcomes. In the following subsections, we describe the complications that occur at higher rates in pregnant adolescents. Teens are slightly more likely than adult women to experience hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, and are far more likely to experience eclampsia. ( 20 ) Preeclampsia is a multisystemic disorder that usually develops after 20 weeks’ gestation. People at risk for preeclampsia may experience sudden hypertension, edema, respiratory distress, proteinuria, blurred vision, and severe headaches. Preeclampsia may progress to the occurrence of new-onset seizures, which is referred to as eclampsia. The only cure is delivery, although doctors may try to manage the patient with medications if it is too early to safely deliver. ( 21 ) Operative vaginal delivery, episiotomy, postpartum hemorrhage, and endometritis are more common for individuals younger than 15 years compared with older ages. In addition, adolescents aged 10 to 19 years have a 40% prevalence of maternal anemia. ( 22 ) Young adolescents are also at increased risk for low birthweight, preterm delivery, and small-for–gestational age infants compared with adult women older than 20 years. The risks increase with decreasing maternal age, with highest prevalence seen in girls 15 years or younger. ( 22 ) Of note, across pregnancies in all age groups, 15- to 19-year-olds have the highest rates of chlamydial and gonorrheal infections in the United States. ( 20 ) Complications resulting from having a sexually transmitted infection during pregnancy can contribute to miscarriages, preterm birth, low birthweight, intrauterine fetal demise, and neonatal eye infections. ( 23 )