Adolescent Pregnant Patients in the ED: Special Considerations
Authors: Sharon G. Humiston, MD, MPH, FAAP, Associate Professor of Emergency Medicine and Pediatrics, University of Rochester Medical Center, Rochester, NY; Cynthia Rand, MD, MPH, FAAP, Assistant Professor of Pediatrics, University of Rochester Medical Center, Rochester, NY; Sireesha Reddy, MD, Assistant Professor of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
Peer Reviewer: James E. Colletti, MD, Associate Residency Director, Emergency Medicine Program, Regions Hospital, St. Paul, MN
Few health concerns raise as many biopsychosocial issues as a pregnant teenager presenting to the emergency department (ED). Patients, family members, and health care providers must cope not only with the complexities arising from the pregnancy, but also with a host of practical and ethical decisions not faced in other circumstances. Acute and chronic health conditions can have a significant impact on pregnancy. The emergency medicine (EM) physician faced with providing health care to a pregnant teenager must remain cognizant of all of these factors to provide the best and most effective care.
Regardless of the factors that promote or prevent teenage sexual activity, its immediate consequences and a variety of co-morbidities continue to account for a large number of ED visits. This article addresses surveillance and diagnosis of pregnancy in the adolescent, management and referral of the newly diagnosed pregnant adolescent, early pregnancy complications, and common medical conditions affecting pregnancy as encountered by the EM physician. The article's focus is on young women living in industrialized nations or those with emerging economies, although data relevant to developing nations are included.
— The Editor
Epidemiology
In the past decade, rates of sexual activity and its consequences have declined—as has the induced abortion rate—while contraceptive use has increased concurrently.1 Nonetheless, the United States continues to lead the industrialized world in rates of teenage pregnancy and births.2 There are roughly 1 million pregnancies in adolescents annually, representing about 10% of females 15-19 years of age,3 and 13% of all births in the United States.4 Despite declines in adolescent pregnancy rates in the past decade, unplanned pregnancies among adolescents remain a significant problem in the United States; 85% of all teenage pregnancies are unintended.5 Health care providers can be certain of encountering an undiagnosed pregnancy in an adolescent patient sometime in their career.
Adolescents often utilize health care services of the ED, especially when they have no identified primary care source. Treatable illnesses seen routinely in outpatient care facilities can often be seen as 'emergencies.' These visits to the ED increase with increasing age. Adolescents who have Medicaid or who have no insurance (self-pay patients) are more likely than commercially insured peers to receive a diagnosis of a gynecological problem.6 The prevalence of unrecognized pregnancy in the ED setting is estimated to be between 6% and 22%.7,8
The diagnosis of pregnancy in the ED can be difficult, especially when the adolescent presents with complaints not suggestive of pregnancy. The most common complaint of the pregnant teenager presenting to the ED is gastrointestinal symptoms (77%), followed by genitourinary and breast symptoms.8 Historical information concerning menstrual history and sexual activity is often inaccurate. In a study of 100 teenagers whose pregnancy was diagnosed in the ED, 10% denied sexual activity, 36% revealed a concern about pregnancy when questioned specifically, and only 8% mentioned pregnancy as a chief complaint.9 There should be a high index of suspicion when it comes to a diagnosis of pregnancy so that appropriate care and immediate referrals can take place.
Scope of the Problem
Pregnancy in adolescence has an impact on health well beyond the duration of the pregnancy. Pre-existing health conditions strongly influence both the intrapartum and postpartum periods. Psychosocial and economic status also function as both antecedents and consequences of pregnancy; these effects may be more pronounced during adolescence, when the adolescent is often much more vulnerable than she otherwise might be at an older age.10 All of these factors converge when a pregnant teenager presents to the ED for any problem at all. In this section the psychosocial and behavioral factors associated with increased risk of becoming pregnant in adolescence, those associated with being pregnant in adolescence, and those that influence the outcomes of pregnancy in adolescence are discussed. We discuss the biological aspects of pregnancy in the section on physiology. All of these factors influence the clinician's approach to the pregnant teenager in the ED.
Risks for Becoming Pregnant. One of the important developmental tasks of adolescents, analogous to that of toddlers, is to differentiate self from parent and to establish increasingly firm control over their immediate environment. Increasingly risky behaviors and their consequences are prevalent at this time. Educational programs aimed at changing risk-taking behaviors can often be simplistic and futile if they do not account for this developmental drive.11
Certain factors specifically increase a teenager's chances of becoming pregnant.12 Adolescent attitudes toward pregnancy are important determinants both of becoming pregnant and of pregnancy outcome. In contrast to prevailing adult and public health views, adolescents' perception of adolescent pregnancy is that it is not invariably seen as a negative, and in fact often has positive connotations.13 Acceptance of traditional sex roles also has been shown to increase the risk of teen pregnancy. Pregnant teenagers were more likely to assign activities to traditional sex-typing, have lower educational expectations (lower grades or dropped out of school altogether), and have diminished future occupational aspirations.
Most adolescents lack understanding of the menstrual cycle and its association with sexual intercourse—a fact that also plays a large role in teenage pregnancy. Although most adolescents know where to acquire contraception, there has been an overall decline in the use of effective contraception, such as the oral contraceptive pill.14
Researchers have found adolescent pregnancy was more likely in adolescents who were older, who had attempted substance use, or who had sex with older or non-steady partners — and this trend increased with each additional sexual partner and with each additional year of sexual activity.15 Dating violence and date rape are associated with increased rates of teen pregnancy16 as is homelessness.17
Teenagers with depression are known to be at significantly higher risk for early parenthood, as well as for depression later in life,18 an observation that has implications for both mother and child. Recent evidence suggests that depression among adolescents is significantly underdiagnosed.19, 20
Risks Caused by Pregnancy. Pregnant teenagers have a higher overall mortality rate than their nonpregnant age-matched peers.21 Notably, teenage pregnancy is associated with both maternal and paternal morbidity and mortality.22 A variety of morbidities, primarily behavioral (e.g., substance abuse and domestic partner violence) also are associated independently with pregnancy in adolescents.23 Although liberalization of abortion laws has generally reduced abortion-related morbidity and mortality, illegal abortions continue to pose independent and disproportionate risks to the health of pregnant adolescents worldwide.24 The risk of suicide attempts is increased in adolescents who are pregnant, although in a two-year study of 92 adolescents with suicide attempts by ingestion, pregnancy was not significantly associated with severity of the suicide attempts.25
Teenaged mothers have an increased risk of premature death later in life as well. In a 2004 study in Sweden, Otterblad reported that the most prominent biological causes of these deaths were ischemic heart disease and cancer of the lung and cervix. Suicide, inflicted violence, and chemical dependence led the list of behaviorally mediated causes of death in adolescent mothers.26 These findings were independent of socioeconomic status, although Sweden has a narrower range of socioeconomic status than does the United States.
Risks Factors Influencing Pregnancy and Outcomes. In a recent large prospective cohort study, 20% of adolescent mothers studied used marijuana throughout their pregnancy, and one-third of these used multiple drugs.27 Among the 80% who remained drug-free throughout pregnancy, half were former users who stopped using drugs before or very early in pregnancy. Cigarette and alcohol use, as well as social and psychiatric morbidities, were associated with illegal drug use. In the cohort of teenagers who had good antenatal care, no effects were found between illicit drug users and non-users on birth weight or preterm birth, after controlling for significant co-variates. The only significant difference in outcome was a trend toward an increase in threatened preterm labor. The authors concluded that good antenatal care might be effective in ameliorating adverse outcomes that are commonly associated with prenatal drug use.
Homelessness places teenagers at very high risk for multiple morbidities, including pregnancy, drug use, trauma, and partner violence.17 The interactions of each of these factors can perpetuate the others, and can be compounded by depression and suicidal behavior. Homeless youth often choose not to receive medical care. EDs often provide the only source of medical care for this troubled population, and may be called upon at times to provide what might otherwise be considered routine prenatal screening and health care. Feldman has recently pointed out that EM physicians have the opportunity to be advocates for this population.17 The need for reproductive counseling or early entry to prenatal care should be stressed whenever adolescents come into contact with the health care system.
Pregnant women in general, including teenagers, are more likely to become victims of partner violence than their nonpregnant peers. Partner violence has many co-morbidities, including chemical dependency, psychiatric conditions, and family/social problems.28 The abusing partners also have higher rates of chemical dependency than do the partners of non-abused pregnant women. These observations mandate special consideration when planning the discharge of a pregnant woman from the ED or inpatient setting.
Physiologic Considerations
Despite being in overall better physical condition and having fewer chronic diseases than adults, teenaged mothers have higher rates of spontaneous miscarriage, preeclampsia, gestational diabetes, premature delivery, and low birthweight babies.29 Younger adolescents (15 years or younger) also have higher rates of maternal death, early neonatal death, and anemia compared with young adult women. Pregnant adolescents of all ages have higher rates of postpartum hemorrhage, puerperal endometritis, and operative vaginal delivery and episiotomy compared with older women.21
Because of greater variation in menstrual cycles compared with adults, teenagers are at higher risk of obtaining false-negative results on initial home pregnancy test kits. This factor may contribute to late entry into prenatal care programs and may have an effect on overall pregnancy outcomes.30
Adolescents have poor nutritional intake regardless of gender and parity. In a recent study, pregnant teenagers were found to have deficiencies in calcium, folate, vitamin E, magnesium, and iron31—all of which are particularly important in early pregnancy. Poor nutrition in pregnant adolescents has been ascribed, in part, to anxiety about body image changes.32
Certain pre-existing conditions are either exacerbated by pregnancy or cause elevated risks to both mother and fetus. These apply in adolescents as well as in adults and are summarized in Table 1.
Common Medical Conditions in Which Pregnancy is a Factor
Most ED visits made by pregnant adolescents are for conditions not directly related to the pregnancy, yet the pregnancy must be considered in every case. In this section general clinical considerations as they apply to the pregnant adolescent are discussed, and in the following section we discuss conditions specific to pregnancy.
Trauma. Trauma is the leading cause of maternal death during pregnancy in industrialized countries, and pregnancy in trauma patients is associated with high fetal mortality, with fetal death rates threefold higher than those of their mothers.33 A recent retrospective case-control study among women of childbearing age, comparing pregnant and nonpregnant trauma patients found that the pregnant patients were younger, had less severe injuries, and were more likely to be black or Latino.34 Approximately one-third of pregnant patients involved in motor vehicle trauma were not wearing seat belts at the time of injury.
Motor vehicle crashes (MVCs) are the leading cause of trauma hospitalization during pregnancy, and as many as 1% of all infants may have been involved in crashes while in utero.35 The national rate of MVCs in pregnancy was estimated at 13/1000 person-years based on data from police-reported crashes recorded in the National Automotive Sampling System Crashworthiness Data System.36 Although mean injury severity was lower for pregnant women, they were more likely to be transported or hospitalized, particularly during their third trimester.
Although overall the most common injuries in pregnant trauma victims are equivalent to those seen in the general population, unique injury, morbidity, and mortality patterns are discernable. In particular, placental injury, including abruption, is a significant risk in blunt abdominal trauma.36-38
A recent review of 34 cases found obstetric complications in 21% of pregnant trauma victims; these were mainly preterm labor (12%) but also included a placental abruption, one second trimester fetal loss, and one maternal fatality accompanied by loss of an 8-week-old fetus.39
In a large retrospective cohort study, women delivering at the time of their trauma hospitalization had worse outcomes at delivery than their nontraumatized controls, regardless of injury severity; odds ratios (OR) were 69 for maternal death, 4.7 for fetal death, 43 for uterine rupture, and 9.2 for placental abruption.38 Women who sustained trauma prior to their delivery hospitalization fared somewhat better, but also had significantly elevated risks of maternal death (OR 4.4), placental abruption (OR 1.6), and preterm labor (OR 2.7). Maternal death was most commonly related to internal injury.
Domestic or intimate partner violence can produce significant traumatic injuries in pregnancy. Although MVCs are the leading cause of injury in pregnancy, pregnant patients were more likely than nonpregnant women of childbearing age to have sustained their injuries from assault.40
While women report maintaining or increasing their pre-pregnancy rates of seatbelt use, a recent survey of women attending prenatal care clinics found that only 73% demonstrated correct seatbelt placement; attitudes varied — 60% reported that restraints would protect their baby in a collision, 12% thought the restraint could cause fetal injury, and 37% were unsure.41 Fewer than 40% of women surveyed reported receiving information regarding proper restraint use during the current pregnancy.
With the increasing involvement of young women in competitive sports, it can be expected that there will be an increase in the number of pregnant teenagers who sustain sports-related injuries. Few data are currently available on which to base recommendations for sports participation or evaluation of injured pregnant adolescent athletes.42
Invasive Infection and Sepsis. Despite subtle immune system defects that occur during pregnancy, sepsis is not more common in pregnant teenagers than in the general population.43 The pregnant patient in whom sepsis is a consideration, however, must be approached with caution because rapid deterioration may be imminent.
Sepsis resulting from abortions performed by nonmedical individuals continues to be a major source of maternal morbidity and mortality in the developing world. The possibility should not be overlooked in caring for a pregnant teenager with sepsis in the United States as well. Complications of septic abortion include the need for surgical interventions such as evacuation of infected intrauterine tissue and, rarely, laparotomy to repair visceral injuries. The surgical complication rate is high, and in one recent study, the mortality rate was 7.5% for patients who presented in septic shock post-abortion.44 Causes of death from septic abortion include disseminated intravascular coagulopathy (DIC), acute renal failure, and adult respiratory distress syndrome (ARDS). Severe anemia, as well as necrotizing fasciitis, has been reported secondary to septic abortion.
Respiratory Disease. Increased blood volume and physiologic stresses on the pulmonary and cardiovascular system can produce respiratory compromise during pregnancy. It is important to consider unique disease states (e.g., amniotic fluid emboli) when confronted with respiratory failure in the pregnant teenager.45
Acute bronchitis is common during pregnancy and is generally a mild, self-limited condition for which antibiotic treatment is rarely necessary. Influenza is often more serious during pregnancy, with subsequently higher mortality rates.46 Reduced T-helper cell activity in pregnancy may be one causal factor for this observation.43 The current generation of neuraminidase inhibitors has not been sufficiently evaluated for safety during pregnancy.43
Despite significant changes in the cardiopulmonary physiology during pregnancy, (Table 2) pneumonia does not occur more frequently during pregnancy than at other times. The complications of pneumonia, however, do occur at higher rates during pregnancy. The bacteriology of pneumonia in pregnancy is the same as for nonpregnant patients; Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae remain the most common etiologic agents.47 Pregnant teenagers with sickle cell disease are at particularly high risk for pulmonary complications.48
Sexually Transmitted Infections. Sexually transmitted infections (STIs) have the same behavioral etiologies as pregnancy itself, and therefore are common among pregnant adolescents. Virtually all STIs can occur asymptomatically, and screening studies should be considered in any pregnant teenager. Because teenagers disproportionately use EDs when seeking care for STIs, strong consideration to the possibility of pregnancy and its antecedent or co-morbid factors is imperative.49
Adolescents often fail to have their partners treated and develop recurrent infections. In 2000, 48% of new cases of STIs occurred in adolescents and young adults ages 15-24 years.50
A number of STIs, including HIV, pose a threat to the pregnancy and specifically to the fetus or neonate. Genital herpes simplex viral (HSV) infection is highly prevalent: 25% to 30% of reproductive age women have antibodies against HSV-2, despite a much smaller number of women with a known history of genital herpes. Therefore, the risk of transmission of HSV to the fetus or neonate is high and can have catastrophic consequences, including death.51
The primary site of infection with Neisseria gonorrhea is the endocervical canal, but the organism can ascend and cause uterine and tubal infection.52 Gonorrhea cervicitis may be associated with a yellow-green purulent cervical discharge and may cause pain, discomfort, urethritis, or dysuria. Ascending gonorrheal infection is rare in early pregnancy, but can occur in the first trimester and should be considered in the pregnant adolescent with abdominal or pelvic pain and STI risk factors.53 Prematurity and chorioamnionitis can result from gonorrheal infection in pregnancy, as can ophthalmia neonatorum.
Chlamydia trachomatis infection is the most common reportable STI, with a prevalence of 3 million cases in the United States annually.54 Pelvic inflammatory disease can occur in 20% to 40% of women not treated for the infection; this, in turn, can lead to ectopic pregnancy. Eighty-five to 90% of Chlamydia infections are asymptomatic, and can persist unknowingly for months.55 Chlamydia infection during pregnancy has been associated with preterm labor, low birth weight, premature rupture of membranes, neonatal death, and postpartum endometritis.56
HIV is the leading cause of maternal mortality in the world today, but it is far beyond the scope of this review to discuss. Patients at risk should be counseled to get HIV testing and prenatal care.
Urinary Tract Infection (UTI). Urinary symptoms are prevalent during pregnancy and may become more frequent as the pregnancy progresses. Increased screening for UTI is credited with maintaining relatively low rates of pyelonephritis in pregnancy, but when it does occur pyelonephritis is most common in young, nulliparous women during the second trimester. Pathogens do not differ significantly from those causing pyelo-nephritis in nonpregnant females.57
Social and Behavioral Issues. Pregnancy is both a risk for and a consequence of many inter-related social and behavioral morbidities including:
Domestic Violence. Pregnancy increases the likelihood that a woman will be the victim of domestic or intimate partner violence.58,59
Depression. Pregnancy does not increase the overall rate of depression among women, but women with a history of depressive illness may suffer an exacerbation during pregnancy.60
Suicide Attempts or Ideation. These are particularly prevalent; in one cohort of pregnant teenagers, 17% experienced suicidal ideation during pregnancy.61,62
Toxic Ingestion. This is a common form of suicide attempt among teenaged girls, including those who are or might be pregnant. Drug overdoses taken shortly before or during pregnancy have been shown to be associated with increased risk of miscarriage, but in surviving fetuses no increase in pathology was found.63
Post-traumatic stress disorder is extremely prevalent among victims of physical or sexual violence or abuse, and may be exacerbated or triggered by pregnancy.64
Female genital mutilation, also referred to as genital cutting, is seen with increasing frequency in EDs as immigrant and refugee populations in the United States and western Europe expand.65 This procedure can lead to a variety of early complications such as hemorrhage and infection as well as later obstetric, intrapartum and post-partum complications.65,66,67
Specific Conditions for Which Pregnancy is a Risk Factor
In addition to the conditions, which when exacerbated, complicate pregnancy, there are a small number of important conditions that are either exclusive to pregnancy or rarely occur outside of pregnancy in pediatric and adolescent medicine.
Threatened Abortion. Vaginal bleeding in any trimester may be a warning of a threatened or imminent miscarriage. Early first-trimester bleeding is often normal when it occurs in small quantities, but larger amounts or persistent bleeding may signal a threatened abortion.68 In one recent study using endovaginal ultrasonography, only 44% of first-trimester fetuses of mothers with vaginal bleeding were viable.69 The risk of fetal loss is substantially lower once true fetal heart activity has been detected; only 3.4% of fetuses with known fetal heart activity and threatened abortion were actually lost in one recent study.70
Gestational Diabetes. Gestational diabetes is a common complication of pregnancy at all ages.71 Women with relative insulin resistance prior to pregnancy are at increased risk; such resistance is associated with obesity.72 The most dramatic increase in insulin resistant diabetes in the United States in the past 20 years has been among adolescents in general. In one very large study, however, adolescents developed gestational diabetes less commonly than did older women.21 Gestational diabetes is independently associated with preeclampsia, another pregnancy-induced complication for which teenagers are at increased risk.73
Preeclampsia/ Eclampsia. Elevated blood pressure, proteinuria, pathologic edema, and neurologic irritability characterize preeclampsia, which can progress to eclampsia with the onset of convulsions.74 Preeclampsia can result in severe end-organ damage and other catastrophic consequences and may be the cause of as many as 50,000 maternal deaths annually. Preeclampsia/ eclampsia is the most common cause of admission to critical care units of pregnant women of any age.75 Pregnant women younger than 17 years have a higher incidence of preeclampsia than older women.67,76
HELLP Syndrome. The association of hemolysis, elevated liver enzymes, low platelets (HELLP syndrome) count, and pregnancy was identified in 1982. It occurs at a rate of approximately 2.3 per 1000 pregnancies, and is an important cause of maternal and fetal morbidity and mortality.77 The syndrome is typically a third-trimester event, and is overwhelmingly but not exclusively associated with preeclampsia/eclampsia.78 Because its main presenting symptom is often severe epigastric pain, delays in diagnosis may occur.79 HELLP is not independently associated with young maternal age beyond its association with preeclampsia.
Abruptio Placentae. Pathological disruption of the placenta prior to delivery (abruptio placentae) is a common cause of fetal distress, fetal death, and other obstetric complications.80 This condition occurs more frequently with advancing maternal age,81 but it still must be considered in adolescents.80 In one recent large study, there was a 6.5% overall occurrence rate of abruptio placentae, with an increased risk associated with maternal diabetes, hypertension, pre-eclampsia, and polyhydramnios.80 Although this condition is uncommon in adolescents, it still should be considered in the adolescent with late term vaginal bleeding and abdominal pain and/or with evidence of fetal distress. Placental abruption is also a common complication of abdominal trauma in pregnant patients.38
DVT/PE. Deep venous thrombosis (DVT) occurs with increased frequency during pregnancy, as does the complication of thromboembolic events such as pulmonary embolism (PE).82 In one study, pregnancy doubled the rate of DVT in teenaged girls.83 Smoking and the use of oral contraceptives are independent risk factors for DVT and PE. Because of high rates of smoking among adolescents and known delays in diagnosis of pregnancy in adolescents, special attention must be given to the teenaged female who presents with chest pain, dyspnea, or extremity pain and swelling.
Peripartum and Postpartum Cardiomyopathy. Dilated cardiomyopathy occurs in a very small number of women in association with pregnancy; it has an uneven geographic distribution, suggesting a role for environmental factors.84, 85 The mortality rate can be as high as 14%, and causes and risk factors are unclear. A history of worsening dyspnea or dyspnea on exertion with an abnormal physical examination with abnormal cardiac sounds should prompt one to seek an initial electrocardiogram, which can be the harbinger of this diagnosis. Further diagnostic evaluations to confirm cardiomyopathy (e.g., an echocardiogram) have been shown to have both a diagnostic and a prognostic value.86
Management
The approach to the ED management of the pregnant adolescent will vary with the presenting complaint, the stage of pregnancy, the age of the adolescent, and other factors. Bear in mind the general rule: What is good for the mother is good for the fetus. Any initial care should be focused on supporting the pregnant teenager's vital functions with subsequent attention to evaluation of the fetus.
Most ED encounters with pregnant teenagers are not directly related to the pregnancy itself and can be managed with routine care for the presenting problem, provided one pays appropriate attention to the potential side effects of diagnostic and therapeutic measures. It is of note, however, that if a pregnant teenager of advanced gestational age presented to the ED for a common medical problem, fetal monitoring should take place with concomitant therapy. For example, if a patient of advanced gestational age presented to the ED with an asthma exacerbation, she may not need to go to labor and delivery, but she should get fetal monitoring while being treated in the ED.
Airway and Breathing. Pregnancy increases the risk of upper airway obstruction. Because of the risks of difficult intubation in pregnancy,87, 88 anticipate and avoid the need for emergency intubation when possible. This necessitates aggressive management of other conditions that threaten the airway, early elective intubation when there is any question of respiratory compromise, and consultation with anesthesiologists skilled in obstetric airway management when necessary. Maintaining the patient in an upright position markedly reduces the upper airway obstruction of pregnancy88 and serves to lower the diaphragm and reduce pressure of the gravid uterus on the chest contents. This maneuver may help to avoid the need for intubation in some patients.
Remain aware of various causes of respiratory distress in pregnancy including:
- Pulmonary: pneumonia and influenza (and other viral pneumonitides,89 which tend to be more severe in pregnancy), and pulmonary fibrosis90
- Extrapulmonary: congestive heart failure from causes such as fluid overload and cardiomyopathy, pulmonary thromboembolus, or amniotic fluid embolus.
Consider conditions that are unique to—or at least much more common in—pregnancy (e.g., acute or chronic inhalant abuse).91 Finally, remember that the normal fetus lives at oxygen saturation levels well below 50%.
Circulation and Fluid Management. Maternal circulating fluid volume is greatly expanded during pregnancy to maintain adequate uterine perfusion, and conversely the uterus may become under-perfused in conditions of maternal hypovolemia. Chronic low maternal circulating volume is associated with the development of oligohydramnios, while acute plasma volume expansion has been shown to increase amniotic fluid volume.92 In the absence of clear contraindications (e.g., pulmonary edema), support maternal circulating volume with substantial amounts of isotonic fluids when hypovolemia or evidence of hypoperfusion are present. Give early consideration to the transfusion of blood products to provide ample time for the most thorough cross-matching possible. Begin fetal heart monitoring in any pregnancy likely to be 22 weeks or more,39 and obtain prompt obstetrical consultation.
Distributive shock resulting from septic abortion is a risk unique to pregnancy. Septic abortion is defined as infection of the uterus and adnexa following any abortion, whether spontaneous, induced, or illegal.93 Consider septic abortion in a teenager with a recent history of complete or partial abortion, with a temperature greater than 38°C, purulent vaginal discharge, and lower abdominal pain or tenderness.
Fluids and Medications. In emergency circumstances, give priority to maternal health. Remember that expanded plasma volume may require increased doses of titratable drugs. Virtually all medications used in resuscitation and rapid sequence intubation are safe in pregnancy.94-96 As has recently been found with procedural sedation,97 a rigid 'NPO' policy for women in whom labor may be imminent is not necessary. A cautiously permissive approach in which clear liquids and isotonic drinks are allowed to patients with a normal sensorium seems to be indicated.98 Patients who have received sedating or anesthetic drugs should no longer be permitted oral intake.
For the treatment of pneumonia, choose a first or second-generation beta-lactam antibiotic or a macrolide, which are safe and effective during pregnancy; consult with an infectious disease specialist for alternatives in the truly allergic patient.47 Because trimethoprim selectively antagonizes the activity of folate (required for neural tube development), avoid trimethoprim-sulfamethoxazole (TMP/SMZ) during pregnancy. The single exception is in the treatment of Pneumocysitis carinii pneumonitis, for which TMP/SMZ remains the treatment of choice.47 Remember that a pregnant teenager with sickle cell disease may have respiratory compromise not only from pneumonia but from acute chest syndrome or high output congestive heart failure.
Chronic benzodiazepine treatment should be avoided in the first trimester of pregnancy, but short-acting benzodiazepines (e.g., lorazepam) are safe and effective for acute seizure management.99 Benzodiazepines given immediately pre-partum will be transmitted to the neonate, who may experience respiratory depression.
Management of Specific Conditions
Threatened Abortion. Vaginal bleeding before the sixth week of gestation is associated with the highest (29%) risk of fetal loss, and there is a 15% likelihood of spontaneous abortion with bleeding at any time in the first trimester.68 This risk drops to 6% in the second trimester.68 There are few medical interventions available to change the course of a threatened abortion in the first trimester. Advise the pregnant adolescent of the risks and offer as much support and counseling as possible. Obtain obstetric consultation for management of threatened second-trimester abortions or evidence of preterm labor in the third trimester. Obtain laboratory work to confirm Rh status and make sure that RhoGAM is given promptly if indicated. Management of a threatened abortion is often dependent on the amount of vaginal bleeding and viability of a pregnancy. If nonviability is established and confirmed through ultrasound and laboratory testing and the patient is hemodynamically stable, both medical and surgical interventions can be offered. Adolescents may be more ambivalent about their desires for the ultimate outcome of the pregnancy than older women,100,101 and therefore may require even more sensitivity and resources than do more mature women.
Preeclampsia/Eclampsia and HELLP Syndrome. Suspicion of preeclampsia/eclampsia and the HELLP syndrome require prompt consultation with an obstetrician. Initial management includes hypertensive management, obtaining intravenous access, and careful monitoring of intravascular hydration,102 as well as obtaining laboratory studies to monitor worsening disease. Intravenous magnesium sulfate continues to be the mainstay of medical therapy for moderate or severe preeclampsia.103
Abdominal Pain. Management of abdominal pain in the pregnant adolescent can be challenging. The majority of cases have benign or self-limited etiologies, but a small proportion will have significant abdominal or pelvic pathology. One of the most common surgical complications of pregnancy is appendicitis with an incidence of 1 to 2 per 1000 gestations. Although the incidence of appendicitis in pregnancy is roughly that of the general population, it can be a diagnostic dilemma. The location of the appendix changes with advancing gestation. Although pain generally occurs in the right lower quadrant even with anatomical changes to the appendix in the pregnant patient, occasionally the onset of pain may be localized to an area superior. The elevated white blood cell count seen in appendicitis can be masked by the normal leukocytosis seen in pregnancy (14,000/mm3). The extent of appendicitis may be greater at the enlarged uterus and can often mask the usual peritoneal signs. Because of the risk of premature labor (8.2%) and fetal death (10%) in the setting of advanced peritonitis in appendicitis, it is of utmost urgency to make a timely diagnosis. Newer diagnostic modalities, such as ultrasound104 and computed tomography (CT) scanning, can aid in the diagnosis of appendicitis; when such advanced imaging is unavailable, early surgical intervention is recommended to avoid complications.105, 106
Imaging Studies of the Abdomen during Pregnancy. With multiple imaging studies available, the clinician must choose that which is most appropriate to the setting, giving consideration to risks to both fetus and mother. The main factor determining the degree of risk to the fetus in obtaining an imaging technique is the amount of exposure to ionizing radiation. Other risk factors to consider are the age of the fetus at exposure and proximity to the radiation source. The first week after conception is the time during which the risk of fetal mortality is highest. The risk of radiation-induced abnormalities is believed to be negligible at less than 5 rad (150 mGy) with the greatest risk of fetal abnormalities occurring between 2 and 15 weeks. (The most sensitive time frame for central nervous system teratogenesis is between 10 and 17 weeks of gestation.) The estimated dose of radiation delivered during an abdominal CT scan is 2.6 rad. Therefore, non-urgent radiologic testing should be avoided prior to the 18th gestational week, but both physician and patient should remember the relative safety of these procedures under urgent and emergent circumstances.107,108
Because it produces zero risk of ionizing radiation, however, abdominal ultrasound may provide a superior approach. Lim and colleagues performed an investigation of 45 pregnant women with a clinical suspicion of appendicitis and determined sonography to have a sensitivity of 100%, a specificity of 96%, and an accuracy of 98%.109 The authors concluded that ultrasound is a valuable procedure for detecting acute appendicitis in pregnant women.
Sexually Transmitted Infections. ED management of any pregnant teenager who has no recent history of participation in prenatal care includes obtaining screening cultures or other diagnostic studies for all STIs —including chlamydia, gonorrhea (GC), trichomonas, syphilis, candida, bacterial vaginosis, and HIV— as well as ensuring a means of delivering test results to the patient. If the pelvic examination reveals a purulent discharge or the wet prep analysis reveals numerous PMNs and trichomonas, presumptive treatment for GC and chlamydia is warranted. This is of particular importance for HIV, because early and aggressive administration of highly active antiretroviral therapy (HAART) is known to interrupt maternal-fetal transmission of the virus.110 Report all known or suspected cases of reportable STIs to local health authorities.
Metronidazole during Pregnancy. In the past, physicians have been hesitant to use oral metronidazole in the first trimester of pregnancy because of both mutagenic and teratogenic concerns (which have been based on animal studies). Meta-analyses by Caro-Paton and colleagues111 and Burtin and colleagues112 suggest that metronidazole does not appear to be related to an increased teratogenic risk during the first trimester in humans. The Centers for Disease Control and Prevention recommends treatment of symptomatic pregnant females with a single dose of metronidazole to ameliorate symptoms and not administering metronidazole in asymptomatic cases of trichomoniasis.113 By contrast, several recent critical reviews and meta-analyses have concluded that routine screening and treatment of all pregnant women with asymptomatic bacterial vaginosis is unwarranted.114,115 In women with a history of previous preterm delivery, there is some evidence that treatment of bacterial vaginosis may reduce the risk of preterm rupture of membranes and low birth weight.116
Urinary Tract Infection and Pyelonephritis. Acute flank pain in a pregnant teenager may indicate pyelonephritis with or without ureteropelvic junction obstruction. Ultrasonography is the diagnostic study of choice in evaluation for pyelonephritis.117 Because of the high frequency of voiding complaints, particularly late in pregnancy, use judgment in determining when to send a urine specimen for culture and when to initiate treatment in the absence of culture results. Many authors believe that specimens with no abnormalities on bedside urinalysis —including being negative for nitrite and white blood cells—do not require further testing. The presence of red or white blood cells on dipstick testing suggest a culture would be valuable, but there is no need for empiric treatment based on this test alone. However, a positive nitrite test result has a high positive predictive value, and may warrant not only further testing but empiric antibiotic therapy pending results.118 Obese women (BMI > 29) have higher rates of true UTIs in pregnancy, and more aggressive testing is indicated in such patients.119 Actual UTIs may be markers of sexual activity in adolescents,120 and the EM physician should consider a pregnancy test in the case of a known UTI in a teenaged female.
Psychosocial Care. Although time-consuming and often difficult, it is critical to offer the pregnant teenager in the ED a few minutes of undivided attention from health care providers. Misconceptions about pregnancy in adolescence abound, and are perpetuated by stereotyping and lack of knowledge of the individual's circumstances. Because pregnancy in adolescence is so highly associated with violence and sexual abuse, consider date rape and intimate partner violence in the baseline evaluation of any pregnant adolescent.16 Offer any pregnant teenager at any stage of pregnancy the opportunity to speak with support services including social workers, clergy, domestic violence services, rape crisis counselors, and others. Some hospitals now offer domestic violence coordinators who can help to link patients with appropriate services.121 Remember that adolescents as a group are keenly self-conscious and typically express higher levels of self-esteem than they truly feel; therefore, pregnant teenagers are likely to be highly vigilant and responsive to staff comments, remarks, and nonverbal cues regarding their status. Adherence to medical and psychosocial treatment regiments are impaired by a lack of trust in, or fear of, health care providers.122,123
Diagnostic Studies
Diagnostic testing in the pregnant adolescent should be guided, as in any other condition, by the differential diagnosis and based on history and physical examination findings. (See Table 3.) Avoid unnecessary laboratory or imaging studies or obtaining 'baseline' values without a clear indication; most laboratory values in otherwise healthy adolescents are unchanged in pregnancy. The presence of a pregnancy in a teenager should alert the clinician to broaden his or her differential diagnosis, but it should not trigger an automatic 'scattershot' approach to ordering laboratory or imaging tests.
Considerations for Discharge/Admission
The pregnant teenager represents the potential convergence of many of the so-called "new morbidities" unique to the modern world (e.g., STIs, substance abuse, and domestic violence).124
Make all decisions regarding discharge or admission in the context of the teenager's substantially higher risk and greater vulnerability to psychosocial factors.28 Do not discharge a pregnant teenager from the ED until there is assurance of a safe and supportive home environment. Do not assume that the adolescent who does not volunteer information about physical, sexual, or psychological abuse is not the victim of such abuse.61 Multiple pregnancies increase, rather than decrease, the risk for such abusive experiences among teenagers.
Make ample use of medical consults, social work, and other support services during the ED visit to ensure adequate follow-up medical care, nutrition, housing, substance abuse, domestic violence, and other appropriate services (e.g., educational services). Aggressively screen for depression and suicidality and make appropriate referrals when necessary. Primary health care providers, social workers, and the ED staff should work in partnership to ensure that appropriate services are made available.
Few areas of EM are more fraught with legal and ethical considerations than the management of the pregnant adolescent.125 A detailed treatment of this area is beyond the scope of this review. It is important for EM physicians to learn the applicable state-specific laws and hospital policies before an encounter with a pregnant teenager, and remain abreast of new developments. In particular, be keenly aware of the statutory definitions of terms such as emancipation, confidentiality, capacity, and obligation, and their relevance to the ED adolescent population.
Consultation
The ED physician may readily manage many basic medical problems in pregnant adolescents without the consultation of an obstetrician-gynecologist (OB-GYN). Nonetheless, complications arising from pregnancy can develop rapidly and may not be immediately apparent. Keep a low threshold for obtaining formal OB-GYN consultation in particular for pregnant teenagers. It is wise to learn the availability of OB-GYNs who specialize in the care of children and adolescents ahead of time, so that communication may be facilitated. When practicing in a community hospital setting, give early and serious consideration to transferring a pregnant teenager to a facility where a higher and more comprehensive level of care may be provided.
Summary
Pregnancy in adolescence is both a consequence of, and a risk factor for, many of the morbidities associated with adolescence itself. The ED is often the primary site of care for pregnant adolescents. The ED approach to the pregnant teenager is in many ways similar to the approach to the nonpregnant teenager, but pregnancy should be seen as a marker for major potential morbidities that should be aggressively sought and addressed. The ED physician must be well-versed in risk factors that lead to pregnancy as well as those that threaten the pregnant teenager, and the ED physician should have a set of resources available prior to actual encounters with pregnant adolescents to provide maximally effective, sensitive, and appropriate services.
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