Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s13

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

SYNOPSIS OF DISSERTATION

"MATERNAL AND PERINATAL OUTCOME IN TEENAGE PRIMIGRAVIDAE AS COMPARED TO PRIMIGRAVIDAE AGED 20-29YRS"

Submitted by Dr. INDRANIL DUTTA M.B.B.S. POST GRADUATE STUDENT IN OBSTETRICS AND GYNAECOLOGY (M.S)

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES, B.G.NAGARA-571448 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE Dr. INDRANIL DUTTA AND ADDRESS P.G IN OBSTETRICS AND GYNAECOLOGY, (in block letters) ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES.B.G NAGARA, MANDYA DISTRICT -571448 ADICHUNCHANAGIRI INSTITUTE OF 2. NAME OF THE INSTITUTION MEDICAL SCIENCES, B.G.NAGARA.

3. COURSE OF STUDY AND SUBJECT M.S. IN OBSTETRICS & GYNAECOLOGY

4. DATE OF ADMISSION TO COURSE 31st MAY 2010

"MATERNAL AND PERINATAL 5. TITLE OF THE TOPIC OUTCOME IN TEENAGE PRIMIGRAVIDAE AS COMPARED TO PRIMIGRAVIDAE AGED 20-29YRS" 6. BRIEF RESUME OF INTENDED WORK APPENDIX-I 6.1 NEED FOR THE STUDY APPENDIX-IA 6.2 REVIEW OF LITERATURE APPENDIX-IB 6.3 OBJECTIVES OF THE STUDY APPENDIX-IC 7 MATERIALS AND METHODS APPENDIX-II

7.1 SOURCE OF DATA APPENDIX-IIA

7.2 METHOD OF COLLECTION OF DATA : (INCLUDING SAMPLING APPENDIX-IIB PROCEDURE IF ANY)

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS YES TO BE CONDUCTED ON PATIENTS OR APPENDIX-IIC OTHER ANIMALS, IF SO PLEASE DESCRIBE BRIEFLY.

7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION YES IN CASE OF 7.3 APPENDIX-IID

8. LIST OF REFERENCES APPENDIX - III

2 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE IT IS A WELL DESIGNED PROTOCOL TO STUDY THE OUTCOME OF TEENAGE PREGNANCY IN RURAL INDIA

NAME AND DESIGNATION 11 (in Block Letters)

11.1 GUIDE Dr. PRASHANT JOSHI M.D. D.N.B. Associate Professor, Department of Obstetrics and Gynecology, AIMS, B.G. Nagara-571448

11.2 SIGNATURE OF THE GUIDE

11.3 CO-GUIDE (IF ANY) -

11.4 SIGNATURE -

11.5 HEAD OF DEPARTMENT Dr. S. VIJAYALAKSHMI, M.D , D.G.O Professor and Head Department of Obstetrics and Gynecology AIMS, B.G. Nagara-571448

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE

APPENDIX-I

3 6.BRIEF RESUME OF THE INTENDED WORK:

APPENDIX –I A

6.1 NEED FOR THE STUDY:

Teenage pregnancy is common in rural India and therefore there is a need to study the effect of maternal age in determination of obstetric outcome of pregnancy and to reduce maternal morbidity and mortality.

APPENDIX –I B

6.2 REVIEW OF LITERATURE

The youngest mother whose history is authenticated in the world is Lima Madina, who was delivered by Ceasarean Section in Lema, Peru, May 1939. Her age at the time of delivery was 5 years and 8 months.

WORLD WIDE INCIDENCE OF TEENAGE PREGNANCIES

After the second world war, Teenage Pregnancy in England and Wales have Increased.

For example, in 1956, among girls aged 15 years, the chances of pregnancy was 0.8 per 1000 girls; but in 1973,the rate increased to 4 per 1000.The incidence in England and Wales is between 2-44 per 1000.

The teenage pregnancy rate varies in USA from 25-75 per 1000 for 15-17 years and 92 to 165 per 1000 for 18-19yrs. United States has highest teenage pregnancy rate of all developed countries. Nearly 13 percent of all USA births in 1997 were teens, aged 15-19 yrs.

CAUSES OF TEENAGE PREGNANCIES IN INDIA

4 In rural India due to socioeconomic and religious problems most of the teenage girls are forced to marry early and subsequently they become pregnant due lack of knowledge of reproductive biology along with non compliance of contraception.

Family influence- often mother or a sibling became a parent as a teenager, lack of an extended family decreases family support. In single parent families or in families where both parents work, teenagers are not supervised much of the time. 20% of teenage pregnancies are forced by families, because of poverty, low education status and socioeconomic status.

Teenage pregnancy, a social problem distributed worldwide, has serious implications on maternal and child health, especially in the context of developing countries. In India, teenage pregnancy is an important public-health problem, although the national policy of the

Government of India advocates the minimum legal age of marriage for girls to be 18 years.

Data of the National Family Health Survey (NFHS)-3 revealed that 16% of women, aged 15-19 years, have already started childbearing. This proportion is the highest in the state of Jharkhand

(28%), followed by West Bengal (25%) and Bihar (25%), all located in Eastern India.

A substantial proportion of young married girls is already malnourished. Nearly 47% of adolescent women have body mass index of less than 18.5, 11.4% are stunted, and half of them have anemia1 While there is a growing realization of the need to promote adolescent reproductive health, work done in this field is often Inadequate. Teenage pregnancy occurs when women aged less than 20 years become pregnant. This is of serious concern because maternal age plays a Significant role in adverse outcome and complications of pregnancy.

Teenage pregnancies represent a high-risk group in reproductive terms because of the double burden of reproduction and growth. Complications of pregnancy and childbirth are the leading cause of mortality among girls aged 15-19 years in developing countries2. The combination of poor nutrition and early child bearing expose young women to serious health risks during pregnancy and childbirth, including damage to the reproductive tract, pregnancy related

5 complications, such as Anemia, Pregnancy Induced Hypertension, Preterm labour,

Cephalopelvic disproportion, maternal mortality, perinatal and neonatal mortality, and low birthweight 3,4.

Industrialized and developing countries have distinctly different incidences of teenage pregnancy. In developed regions, teenage mothers tend to be unmarried, and adolescent pregnancy is seen as a social issue whereas, in developing countries, such pregnancies mostly occur in married teenagers, and their pregnancy is most often welcomed by family and society.

However, in these societies, early pregnancy may combine with malnutrition and poor healthcare to cause medical problems. Studies on complications in teenage pregnancy have yielded conflicting results, and opinions of different authors vary in this regard. Some have opined that age by itself is not a risk factor, and poor outcomes are associated more with socioeconomic factors rather than with biological factors5.

Other researchers have failed to find any evidence for major impairments of pregnancy outcome among teenage mothers with provision of high-quality maternal care with complete coverage 6. With greater understanding of the antecedents of teenage pregnancy, especially in the context of developing countries like India, it may be possible to develop more effective interventions to tackle this widespread problem.

Most studies in India have used record-based data. There is a lack of recent data on the perinatal outcomes of teenage pregnancy in eastern India under the changing scenario of socioeconomic development and availability of better healthcare facilities.

Although the legal age at marriage is 18 years for females and 21 years for males in

India, early marriage is common. By the age of 15 years, 26% of females are married, and by the age of 18 years, this figure rises to 54%. Most reproduction in India occurs within marriage; so, the low age at marriage automatically links to early onset of sexual activity and thereby fertility8. Pregnancies occurring outside wedlock have the risk of terminating in unsafe

6 abortions by quacks and often do not reach the tertiary hospital. Early registration of pregnancy and consumption of the recommended number of prophylactic iron folic acid tablets is significantly lower among the teenage mothers. The teenage mothers are less careful about their pregnancy probably because of the lack of awareness and maturity. Many authors have reported early registration of pregnancy ranging from 40% to 90% in teenagers; however, the frequency of antenatal check-ups by them was consistently lower7,9,10-13.

FACTORS CONTRIBUTING TO TEENAGE CONCEPTION

In recent years the rate of teenage conception has fallen steadily in the USA and

Europe. In 2004 the conception rate in England was 41.5 per 1000 girls aged 15–17 years, representing an overall decline of 11.1% since 1998. However, the UK still has the highest rate of teenage pregnancy in Western Europe, while the USA possesses the highest rate in the world at 43.0 per 1000. It is important to recognise that teenage pregnancy can be a positive life choice for some young women, particularly those from certain ethnic or social groups. In some

South Asian ethnic groups in the UK, rates of teenage pregnancy within marriage are high.

Ethnicity and culture play a role and are an important consideration for healthcare professionals and for statistical purposes.

RISK FACTORS FOR TEENAGE PREGNANCY

The higher rates of teenage pregnancy tend to be concentrated in inner cities and are linked to poverty. Multiple socioeconomic risk factors have been identified and are shown :-

Risk factors for teenage pregnancy

 Social deprivation

 Lower socioeconomic group

 Low educational achievement

 Having had teenage parents

 Being in the care of social services

7  Poor transition from school to work at 16 years of age

 Sexual abuse

 Mental health problems

 Crime

SOCIAL DEPRIVATION

Teenagers from unskilled manual backgrounds (social class V) are 10 times more likely to become teenage mothers than those from professional backgrounds (social class I).Teenagers from socially deprived areas are up to six times more likely to become pregnant than teenagers from other areas and are much less likely to opt for a termination.

LOW EDUCATIONAL ACHIEVEMENT

Young people scoring below average on measures of educational achievement at ages 7 and 16 years have been found to be at significantly increased risk of becoming teenage parents, especially those whose performance declines between these ages. Wellings et al.14 surveyed over 11 000 males and females aged 16–44 years across the UK. They found that 29% of sexually active young women who left school at 16 years of age without any qualifications had a child before the age of 18 years, compared with 14% of those who left at 16 with qualifications and 1% of those who left at age 17 years or over.

TEENAGE PARENTS

There is evidence that women who were themselves children of teenage mothers are more likely to have a teenage pregnancy compared with those born to older mothers and their offspring are at risk for becoming teenaged mothers or fathers themselves15.

SOCIOECONOMIC DEPRIVATION

8 The strong association between teenage pregnancy and socioeconomic deprivation was highlighted in the report of the 1997–1999 Confidential Enquiry into Maternal and Child

Health16. There were 14 deaths of mothers aged 18 years, 5 of whom were 16 years old.

Thirteen out of 14 were socially excluded, 50% had disclosed domestic violence (compared with 12% of the entire cohort of mothers who died) and 50% were poor attenders at antenatal clinic (compared with 20% of the total cohort who were poor attenders or booked late).

In addition, four of the women were homeless at the time of death, despite three of them being under 16 years of age and under the care of social services at the time. The correlation between deprivation and maternal deaths was also seen in the subsequent report,

2000–200217

Teenage pregnancy has also been associated with an increased prevalence of domestic violence. However, a recent review of 15 studies has failed to clarify whether there is a causal link between maltreatment or violence and adolescent pregnancy or whether there is an increased risk of domestic violence to pregnant teenagers18

THE IMPACT OF TEENAGE PREGNANCY

Many adverse outcomes have been associated with teenage pregnancy including premature delivery, infants being small for gestational age, low birthweight and increased neonatal mortality, anemia and pregnancy-induced hypertension.

In the long term the offspring of adolescents have poorer cognitive development, lower educational attainment, more frequent criminal activity and a higher risk of abuse, neglect and behavioural problems during childhood. Despite the magnitude of the problem, it is unknown whether the poor outcomes of teenage pregnancy are partly attributable to the biological challenges presented by young maternal age or whether they are solely the consequence of sociodemographic factors. The biological risks may have been exaggerated in previous studies as a result of inadequate controls for sociodemographic risk factors. Sociodemographic

9 variables associated with teenage pregnancy undoubtedly increase the risk of adverse outcomes. However, recent studies have demonstrated that the relative risk remains significantly elevated for both younger and older teenage mothers after adjustment for marital status, level of education and adequacy of prenatal care19. The high risk of adverse pregnancy outcome in the adolescent has been attributed to gynaecological immaturity and the growth and nutritional status of the mother. Many adolescent girls retain the potential to grow while pregnant. Data from a study Camden, New Jersey20.

Risks of teenage pregnancy

 Premature delivery

 Small-for-gestational-age infants

 Low birthweight

 Increased neonatal mortality

 Anemia

 Pregnancy-induced hypertension

 Postnatal depression

 Sexually transmitted infections

 High incidence of operative deliveries

Offspring of adolescents have:

1. Poorer cognitive development

2. Lower educational attainment

3. More frequent criminal activity

4. Higher risks of abuse, neglect and behavioural problems during childhood

10 RISKS ASSOCIATED WITH TEENAGE PREGNANCY

Sexually transmitted infections

The prevalence of sexually transmitted infections (STIs) is increasing and presents a particular problem in teenagers. The incidence of gonorrhoea increased by 35% between 1997 and 1999 in the UK and those most at risk in the female population were aged 16–19 years. A recent study in the USA revealed that 1 in 5 teenagers have an undiagnosed STI21. In addition,

1 in 8 teenagers attending a family planning clinic in Nottingham, in the UK, had an STI

Alcohol and substance misuse and smoking

These are common in adolescents. A UK survey of alcohol, tobacco and illicit drug use in teenagers aged 15 and 16 years reported that 36% smoked cigarettes and that levels of smoking were higher in girls than boys22.

Furthermore, girls who have had a teenage pregnancy are more likely to have smoked than those who have not conceived as teenagers. Interestingly, while the incidence of teenage pregnancy is declining in the UK, the proportion of teenage girls smoking has remained unchanged and in some areas is increasing. This is an important clinical problem as smoking compounds the potential for adverse outcomes of adolescent pregnancy, particularly intrauterine growth restriction. The birthweight-for- gestational-age curves of smoking adolescents show a marked fall off in weight from 36 weeks of gestation. Furthermore, at least

10% of adolescent smokers have pregnancies affected by severe early onset (before 32 weeks of gestation) fetal growth restriction.

Smoking during pregnancy is also known to be associated with an increased risk of placental abruption, preterm premature rupture of membranes, preterm birth, stillbirth and sudden infant death syndrome. Research has shown that prenatal exposure to tobacco smoke is a risk factor for respiratory infections, asthma, allergy, childhood cancer and adverse neuro behavioural development. The Centers for Disease Control and Prevention (CDCs) in the USA

11 analysed state specific trends in maternal smoking during 1990–2002. This report indicated that participating areas observed a significant decline in maternal smoking during the surveillance period while 10 states reported recent increases in smoking by pregnant teens. The widespread public health message to abstain during pregnancy has helped decrease maternal smoking. To reduce prevalence further, implementation of additional interventions is required.

Poor diet

Teenagers may have poor eating habits and neglect to take their vitamin supplements.

They are less likely than older women to be of adequate pre-pregnancy weight or to gain an adequate amount of weight during pregnancy23. Low weight gain increases the risk of having a low birthweight baby. This is frequently compounded by adverse social circumstances.

Postnatal depression and difficulties with breastfeeding

There is some evidence that teenage mothers are more likely to suffer from postnatal depression than older mothers. In addition, one study reported a 37–54% reduction in milk production6 months after childbirth in adolescents compared with older mothers24. There were some differences in breastfeeding behaviour between the two groups that may have contributed to the result but it appears that teenagers need extra support with breastfeeding.

T.T Lao et al studied “Relationship between preterm delivery and maternal height in teenage pregnancies” - A retrospective study was performed in singleton pregnancies born to mothers aged <=19 over 4year period to determine the relationship between maternal height and preterm deliveries(<37weeks).taken from human reproduction vol 15 no2 pp-463-468,2000

G.L Goldberg et al studied “ Obstetric complications in adolescent pregnancies” in which obstetric outcome was analysed and compared with previous studies. Pregnancy induced hypertension , premature labour , and anemia were significant complications in this group.

Taken from SA Medical journal volume 64, 19 November 1983.

Ashok kumar et al studied “outcome of teenage pregnancy” in which it was concluded that teenage pregnancy was associated with a significantly higher risk of PIH, PET, eclampsia,

12 premature onset of labor, fetal deaths and premature delivery. Increased neonatal morbidity and mortality was also seen in babies delivered to teenage mothers. Taken from Indian journal of paediatrics, volume 74- October ,2007

The objective of the present study is to compare the sociodemographic characteristics and perinatal outcomes of teenage mothers with those of adult primigravida mothers aged 20-

29 years attending a tertiary-care hospital for their deliveries.

APPENDIX –IC

6.3 AIMS AND OBJECTIVES OF STUDY

To evaluate the maternal and fetal outcome in teenage primigravida and primigravidae of age 20-29 yrs and to compare the outcome and complications of both groups.

13 APPENDIX-II

7.0 MATERIALS AND METHODS

APPENDIX-II A

7.1 SOURCE OF DATA

 During this period booked and unbooked cases attending Shri Adichunchanagiri

Hospital and Research Centre, B.G. Nagara. will be included in the study, for every

teenage primigravidae two subsequent adult primigravidae will be studied.

 The socioeconomic status, education, religion, onset of menarche, marital status,

number of antenatal visits will be recorded. A thourough general and obstetrics

examination will be done. Investigation such as Haemoglobin estimation, urine

analysis, VDRL test, HIV, HBsAg, Blood grouping and Rh typing will be done.

 Any medical or obstetrics problems in antenatal, intranatal, postnatal period will be

noted. Labour and its progress will be closely monitored. Mode of delivery and

perinatal outcome will be noted on both groups.

 Chi- square test will be used to compare the two groups. The statistical significance will

be considered at P value <.05.

Study Design : A prospective case control study

Study Period : 24 Months (November 2010 to November 2012)

APPENDIX-II B

7.2 METHOD OF COLLECTION OF DATA

SAMPLE SIZE

1. Teenage pregnancy (15-19 years) - 30

2. Pregnancy (20-29 Years) - 60

INCLUSION CRITERIA

 All booked and unbooked primigravida cases attending Shri Adichunchanagiri

Hospital and Research Centre, B.G. Nagara.

14  For every teenage primigravida pregnancy two subsequent adult primigravida will

be studied.

EXCLUSION CRITERIA: Mothers having:-

 Major skeletal deformity such as kyphoscoliosis, polio

 Pelvic fracture

 Diabetes mellitus

 Hypertension

 Renal disorders

 Height less than 145cm

 Morbid obesity

 All cases of molar pregnancy and,

 Primigravidas admitted for abortion

APPENDIX-II C

7.3 Does the study require any investigation or intervention to be conducted on the patients or animals , if so please describe briefly

YES Investigation :

 Haemoglobin estimation

 Random blood sugar

 Urine analysis

 VDRL test

 HIV, HBsAg

 Blood grouping and Rh typing

 USG

15 APPENDIX-II D

PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL

SECTION A “MATERNAL AND PERINATAL OUTCOME IN TEENAGE PRIMIGRAVIDAE AS a Title of the study COMPARED TO PRIMIGRAVIDAE AGED 20-29YRS” Dr. INDRANIL DUTTA P.G IN OBSTETRICS AND GYNAECOLOGY, Principle investigator b (Name and Designation) ADICHUNCHUNAGIRI INSTITUTE OF MEDICAL SCIENCES.B.G NAGARA, MANDYA DISTRICT -571448

Dr. PRASHANT JOSHI Co-investigator M.D.,D.N.B. c Associate Professor, (Name and Designation) Department of Obstetrics and Gynecology AIMS, B.G. Nagara-571448 Name of the Collaborating d NO Department/Institutions

Whether permission has been obtained from e the heads of the collaborating departments & NA Institution Section – B APPENDIX - I Summary of the Project Section – C APPENDIX - I Objectives of the study Section – D APPENDIX - II Methodology DEPARTMENT OF O.B.G., A Where the proposed study will be undertaken S.A.H. & R.C., B.G.NAGARA B Duration of the Project 24 MONTHS C Nature of the subjects: Does the study involve adult patients? YES Does the study involve Children? NO Does the study involve normal volunteers? NO Does the study involve Psychiatric patients? NO Does the study involve pregnant women? YES

16 D If the study involves health volunteers I. Will they be institute students? NO II. Will they be institute employees? NO III. Will they be Paid? NO IV. If they are to be paid, how much per NO session?

E Is the study a part of multi central trial? NO

F If yes, who is the coordinator? (Name and Designation) NA

Has the trail been approved by the ethics NA Committee of the other centers?

If the study involves the use of drugs please - indicate whether.

I. The drug is marketed in India for the NA indication in which it will be used in the study.

II. The drug is marketed in India but not for the indication in which it will be used in the NA study

III. The drug is only used for experimental use in humans. NA

IV. Clearance of the drugs controller of India NA has been obtained for:

 Use of the drug in healthy volunteers  Use of the drug in-patients for a new indication. NA  Phase one and two clinical trials  Experimental use in-patients and healthy volunteers.

17 G How do you propose to obtain the drug to be used in the study? - Gift from a drug company NA - Hospital supplies - Patients will be asked to purchase - Other sources (Explain) H Funding (If any) for the project please state - None - Amount NO - Source - To whom payable

Does any agency have a vested interest in the I NO out come of the Project?

Will data relating to subjects /controls be stored J NO in a computer? Will the data analysis be done by K - The researcher? YES - The funding agent NO L Will technical / nursing help be required form NO the staff of hospital.

If yes, will it interfere with their duties? NO

Will you recruit other staff for the duration of NO the study?

If Yes give details of I. Designation NA II. Qualification III. Number IV. Duration of Employment

18 M Will informed consent be taken? If yes Will it be written informed consent: Will it be oral consent? YES, CONSENT WILL BE TAKEN FROM Will it be taken from the subject themselves? THE PATIENT Will it be from the legal guardian? If no, give reason:

N Describe design, Methodology and techniques APPENDIX II

Ethical clearance has been accorded.

Chairman, P.G Training Cum-Research Institute, A.I.M.S., B.G.Nagara. Date :

PS : NA – Not Applicable

19 APPENDIX-III

8. LIST OF REFERENCES

1. International Institute for Population Sciences. National family health surveys, India.

Key findings from NFHS-3. Mumbai: International Institute for Population Sciences,

2007. (http://www.nfhsindia. org/factsheet.html, accessed on 26 November 2009).

2. Mayor S. Pregnancy and childbirth are leading causes of death in teenage girls in

developing countries. BMJ 2004;328:1152.

3. Agarwal N, Reddaiah VP. Factors affecting birthweight in a suburban community.

Health Popul Perspect Issue 2005;28:189-96.

4. World Health Organization. Towards adulthood: exploring the sexual and reproductive

health of adolescents in South Asia. Geneva: World Health Organization, 2003. 244 p.

5. Makinson C. The health consequences of teenage fertility. Fam Plann Perspect

1985;17:132-9.

6. Raatikainen K, Heiskanen N, Verkasalo PK, Heinonen S. Good outcome of teenage

pregnancies in high-quality maternity care. Eur J Public Health 2006; 16:157-61.

7. Chahande MS, Jadho AR, Wadhva SK, Udhade S. Study of some epidemiological

factors in teenage pregnancy hospital based case comparison study. Indian J

Community Med 2002;27:106-9.

8. World Health Organization. Adolescent pregnancy: issues in adolescent health and

development. Geneva: World Health Organization, 2004. 86 p. (WHO discussion

papers on adolescence).

9. Verma V, Das KB. Teenage primigravida: a comparative study. Indian J Public Health

1997;41:52-5.

10. Cahaba S. Perinatal outcome in teenage mothers. J Obstet Gynaecol India 1991;41:30-

11. Pal A, Gupta KB, Randhawa I. Adolescent pregnancy: a high risk group. J Indian Med

Assoc 1997;95:127-8. 20 12. Sharma AK, Verma K, Khatri S, Kannan AT. Pregnancy in adolescents: study of risks

and outcome in eastern Nepal. Indian Pediatr 2001;38:1405-9.

13. Nayak AH, Purnik KG, Dalal AR. Obstetric outcome in teenage pregnancy. J Obstet

Gynecol India 1992; 42:442-6.

14. Wellings K, Nanchahal K, Macdowall W, McManus S, Erens B, Mercer CH, et al.

Sexual behaviour in Britain: early heterosexual experience. Lancet 2001;358:1843–50.

doi:10.1016/S0140-6736(01)06885-4.

15. Elfebein DS, Felice ME. Adolescent pregnancy. Pediatr Clin North Am 2003;50:781–

16. Lewis G, Drife J. Confidential Enquiry into Maternal and Child Health. Why Mothers

Die 1997–1999. The Fifth Report of the Confidential Enquiries into Maternal Deaths in

the United Kingdom. London: RCOG Press; 2001.

17. Confidential Enquiry into Maternal and Child Health, Why Mothers Die 2000–2002.

The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United

Kingdom 2004.

18. Blinn-Pike L, Berger T, Dixon D, Kuschel D, Kaplan M. Is there a causal link between

maltreatment and adolescent pregnancy? A literature Review. Perspect Sex Reprod

Health 2002;34:68–75. doi:10.2307/ 3030209.

19. Olausson PO, Cnattingius S, Haglund B. Does the increased risk of preterm delivery in

teenagers persist in pregnancies after the teenage period? BJOG 2001;108:721–5.

doi:10.1111/j.1471-0528.2001.00182.x

20. Scholl TO, Hediger ML, Ances IG. Maternal growth during pregnancy and decreased

infant birth weight. Am J Clin Nutr 1990;51:790–3

21. Wiesenfeld HC, Lowry DL, Heine RP, Krohn MA, Bittner H, Kellinger K, et al. Self-

collection of vaginal swabs for the detection of Chlamydia, gonorrhea, and

trichomoniasis: opportunity to encourage sexually transmitted disease testing among

adolescents. Sex Transm Dis 2001;28:321–5. doi:10.1097/00007435-200106000-00003

21 22. Miller PM, Plant M. Drinking, smoking, and illicit drug use among 15 and 16 year olds

in the United Kingdom. BMJ 1996;313:394–7

23. Kirchengast S, Hartmann B. Impact of maternal age and maternal somatic

characteristics on newborn size. Am J Hum Biol 2003;15:220–8

24. Motil KJ, Kertz B, Thotathuchery M. Lactational performance of adolescent mothers

shows preliminary differences from that of adult women. J Adolesc

Health 1997;20:442–9. doi:10.1016/S1054-139X(97)00036-0

22 PROFORMA

Name: Age: IP no:

Address: Income

Religion

Education

D.O.A: Date of Delivery:

Marital status : Married/ unmarried

H/O Consanguinity : Immunized/unimmunized

Booked/ Unbooked :

GRAVIDA PARA LMP MENSTRUAL HISTORY

Past history : Infection / bleeding disorders Seizures / bronchial asthma Surgery

Family history : H/O diabetes/ hypertension/ twins / malformed baby

Personal history : Diet-Veg / Nonveg Tobacco chewing-yes/no Alcohol intake Smoker/ non smoker

General examination:

Ht: Wt: Pulse: BP:

Anemia: YES/NO Breast : CVS:

Pedal oedema: YES/NO Thyroid: RS:

Spine: Obstetrics Examination:

Per abdomen: Per vaginal:

Fundal height :

Presentation :

Engagement :

23 Foetal heart rate:

Abdominal girth:

Investigations : Urine alb / sugar Hb%: VDRL: BLOOD GRP / Rh typing: HIV , HBS Ag: USG Antenatal complications and their Management:

Hyperemesis

Anemia

Hydramnios

Heart disease

Antepartum haemorrhage

Multiple pregnancy

Miscellaneous

LABOUR

Duration of labour:

Period of gestation at onset of labour:

Mode of Delivery

Labour Normal / Abnormal

Labour Operative – Vacuum (Indications) Assisted breech Forceps- outlet / Low Midcavity Caesarean Any third stage complications: Retained placenta / PPH

Baby: alive/ dead born , term/ preterm

Weight: sex: Apgar: 1min/5min

Congenital malformation

Contraception: Copper T insertion / barrier methods / oral contraceptive pills

Condition of mother and baby at discharge