pediatrics
May 1998, VOLUME101 /ISSUE 5

Counseling the Adolescent About Pregnancy Options

  1. Committee on Adolescence

Abstract

When consulted by a pregnant adolescent, pediatricians should be able to make a timely diagnosis and to help the adolescent understand her options and act on her decision to continue or terminate her pregnancy. Pediatricians may not impose their values on the decision-making process and should be prepared to support the adolescent in her decision or refer her to a physician who can.

Pediatricians are likely to encounter adolescent patients who become pregnant and need counseling on the options available to them. The American Academy of Pediatrics continues to endorse the principles published in its statement on this topic in 1989,1 namely:

  1. The statement represents an objective guide for pediatricians assisting patients and their families in making decisions about adolescent pregnancy.

  2. None of the options offered is necessarily ideal or universally preferred by physicians or their patients.

  3. The pediatrician, the adolescent patient, and other concerned persons must be given complete information on all available options to help the adolescent make an informed decision.

More than 1 million individuals <20 years old become pregnant annually.2-4 Slightly >50% of adolescent pregnancies result in a birth.2,4 The basic approach to effective ethical counseling has not changed since the 1989 statement; however, medical, sociological, and technological advances warrant an update of earlier information.

Premarital sex, pregnancy, and abortion engender strong personal and individual feelings. Pediatricians and other health professionals should not allow their personal beliefs and values to interfere with optimal patient health care. The physician needs to respect the adolescent's personal decision and her legal right to continue or to terminate her pregnancy and not impose barriers to health services from another provider. Should a pediatrician choose not to counsel the adolescent patient about sexual matters such as pregnancy and abortion, the patient should be referred to other experienced professionals.

IDENTIFICATION

All pregnancy options benefit from an early diagnosis. Some adolescents will seek medical care with characteristic signs and symptoms of pregnancy or as the result of a positive home pregnancy test. However, pregnancy symptoms may also be vague and nonspecific, particularly in the younger adolescent. The pediatrician cannot always rely on the menstrual and sexual history of the patient to diagnose pregnancy. Psychological denial may exist to such an extent that the adolescent may not consider pregnancy to be the cause of her symptoms, even when it is evident to others.

Laboratory test results for pregnancy are likely to become positive before the appearance of clinical symptoms or signs on physical examination. A serum β-subunit human chorionic gonadotropin (β-hCG) assay may show positive results as early as 1 week after conception. Most pregnancies are diagnosed by monoclonal human chorionic gonadotropin (hCG) urine pregnancy tests, which are rapid, cost-effective, specific to hCG, and almost as sensitive as the serum hCG assays. These urine tests will also demonstrate positive results within 7 to 10 days after conception, before the first missed menstrual period. Office personnel can be educated to perform these tests. When there is clinical suspicion of pregnancy, a negative test result suggests the need to repeat the test in 1 to 2 weeks. The pediatrician should use the negative result of the pregnancy test as an opportunity for further counseling.

The physical diagnosis of a normal intrauterine pregnancy can usually be made by 6 weeks from the last menstrual period with the finding of an enlarged softened uterus during a pelvic examination. The fetal heart tones may be detected as early as 10 weeks' gestation by Doppler fetoscopy. The observation or notice of fetal movement occurs at about 20 weeks in women experiencing their first pregnancy. If questions remain about uterine size or the confirmation of pregnancy, obstetric consultation or ultrasonography should be arranged. Ultrasonography can confirm an intrauterine pregnancy, with cardiac activity demonstrable at approximately 6 weeks from the last menstrual period. Concurrent with pregnancy evaluation, appropriate testing for sexually transmitted diseases should be performed.4,5 Early first trimester complications include ectopic pregnancy and spontaneous abortion, and these problems should be considered if abdominal pain or vaginal bleeding develops. An ectopic pregnancy should also be considered in a patient with a positive pregnancy test in the absence of expected uterine enlargement.

COMMUNICATION

While waiting for the results of a urine pregnancy test, the pediatrician has the opportunity to discuss the adolescent's expectations and feelings about her possible pregnancy. The pediatrician should convey the results of the pregnancy test to the adolescent alone in a private setting.

Minors have legal rights protecting their privacy about the diagnosis and treatment of pregnancy. Pediatricians should be familiar with local confidentiality laws being aware that they vary from state to state. In considering confidentiality, the pediatrician should assess the adolescent's ability to understand the diagnosis of pregnancy and appreciate the implications of that diagnosis. The diagnosis should not be conveyed to others, including parents, until the patient's consent is obtained, except when there are concerns about suicide, homicide, or abuse. The pediatrician should be sensitive to the possibility of sexual abuse or incest in the young or developmentally delayed pregnant adolescent. In those cases, the pediatrician should inform child protective services as required by the law in most jurisdictions.

Reactions to the diagnosis of pregnancy vary. Some adolescents may be pleased, while others may be upset or confused. Some may have already discussed potential options with their family or sexual partner. The pediatrician needs to be sensitive to family, social, and cultural issues that may influence the adolescent and her decisions about pregnancy.5,6 Adolescents should be encouraged to include their parents in a full discussion of their options. The pediatrician should explain how parental involvement can be helpful and that parents generally are supportive. If parental support is not possible, minors should be urged to seek the advice and counsel of adults in whom they have confidence, including other relatives, counselors, teachers, or clergy. This is especially true for younger adolescents, age 12 to 15 years.

MANAGEMENT

The duration of the pregnancy should be assessed and documented because options depend on this assessment. Usually, the adolescent has the following options available:

  1. Carrying her pregnancy to delivery and raising the baby.

  2. Carrying her pregnancy to delivery and placing the baby for adoption.

  3. Terminating her pregnancy.

The pediatrician should discuss with or counsel the adolescent about all three options or refer the adolescent to a health care professional who will discuss all three options.

Financial status should not deprive a person of her options for management of the pregnancy. The pediatrician should be knowledgeable about local funding resources for continuing or terminating her pregnancy. The patient should be counseled to consider all options, encouraged to return for as many visits as needed, and helped to understand the need to make a timely decision. She should be encouraged to include her parents and the father of the baby in these counseling sessions. If the adolescent is reluctant to reveal the identity of the father, the pediatrician should consider the possibility of sexual abuse, sexual assault, or incest. Pediatricians should be aware of state laws about reporting suspected abuse or statutory rape and take appropriate action.

The pediatrician should address any coexisting medical conditions—chronic medical illness, physical disability, or psychiatric illness—that could affect the decision to continue or terminate the pregnancy. If there is a question of the adolescent's mental competence to make an informed decision about the pregnancy, the pediatrician should be aware of state law and procedures necessary to make this determination.

If the adolescent decides to continue the pregnancy, the pediatrician should refer her for timely and appropriate prenatal care. Adolescents receiving prenatal care in comprehensive adolescent pregnancy programs generally have had better outcomes than adolescents not in such programs, and pediatricians may choose to refer preferentially to such programs, when available.7 Family and social support systems are essential for optimal outcomes for young adolescent parents and their infants.8

Adoption is an important option for the pediatrician to discuss with the adolescent. To make appropriate referrals, the pediatrician should be familiar with the available medical, legal, counseling, and social service resources that facilitate adoption. Throughout the pregnancy, the adolescent should have the opportunity to discuss the possibility of adoption with the pediatrician or other health care professionals.

If the adolescent decides to terminate her pregnancy, the pediatrician should be knowledgeable about community resources, considering the stage of pregnancy and any coexisting medical conditions. The pediatrician should also consider the adolescent's financial resources and should be aware of local or federal law affecting the availability of services, parental notification, or consent.9 With the anticipated US Food and Drug Administration approval of pharmacologic agents, such as mifepristone, and the availability of prostaglandin analogues and methotrexate to induce abortion nonsurgically, pediatricians need to become aware of the nature and availability of these methods and have a clear understanding of their role in the counseling, provision of care, or referral for these methods.

Whatever the adolescent's decision, the pediatrician should follow up with the patient to ensure that there has been a successful referral and that appropriate social support is in place and to discuss the prevention of future unintended pregnancies. If the adolescent chooses to continue her pregnancy, the pediatrician should remain available for further discussion during the pregnancy should later events require reconsideration of decisions made at the time of the initial confirmation of pregnancy. If the adolescent chooses to place the child for adoption or to terminate her pregnancy, the pediatrician should be available to provide for her subsequent health care and emotional support. In either case, the pediatrician should encourage the adolescent to continue her education and be available to help her identify appropriate community scholastic programs.

The diagnosis of pregnancy is a sensitive and emotional time for the adolescent, her family, and her sexual partner. A warm and accepting environment in which the adolescent feels sufficiently secure to explore her own feelings about pregnancy is essential. Becoming a parent, placing a child for adoption, or having an abortion may have significant personal and long-term consequences for adolescents. It is important to ensure continuing help and support, regardless of the adolescent's decisions about her pregnancy. Ideally, the pediatrician has the counseling expertise, an understanding of adolescent developmental and medical issues, and, often, a long-standing relationship with the patient, and, therefore, is the appropriate person to review these issues with her.

Committee on Adolescence, 1997 to 1998

Marianne E. Felice, MD, Chairperson

Ronald A. Feinstein, MD

Martin Fisher, MD

David W. Kaplan, MD, MPH

Luis F. Olmedo, MD

Ellen S. Rome, MD, MPH

Barbara C. Staggers, MD

Liaison Representatives

Paula Hillard, MD

American College of Obstetricians and Gynecologists

Diane Sacks, MD

Canadian Paediatric Society

Glen Pearson, MD

American Academy of Child/Adolescent Psychiatry

Section Liaison

Samuel Leavitt, MD

Section on School Health

Consultant

Edward M. Gotlieb, MD

Footnotes

  • This statement has been approved by the Council on Child and Adolescent Health.

  • The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

β-hCG =
β-subunit human chorionic gonadotropin
hCG =
human chorionic gonadotropin

REFERENCES