CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Diagnosis of Pregnancy and ProvidingLaurie L. Hornberger, MD, MPH, FAAP,Options COMMITTEE ON ADOLESCENCE Counseling for the Adolescent Patient The American Academy of Pediatrics policy statement “Options Counseling abstract for the Pregnant Adolescent Patient” recommends the basic content of the pediatrician’s counseling for an adolescent facing a new diagnosis of pregnancy. However, options counseling is just one aspect of what may be one of the more challenging scenarios in the pediatric office. Pediatricians Division of Adolescent Medicine, Children’s Mercy Hospital and Clinics, must remain alert to the possibility of pregnancy among their adolescent Kansas City, Missouri female patients. When discovering symptoms suggestive of pregnancy, Dr Hornberger was responsible for all aspects of writing and editing pediatricians must obtain a relevant history, perform diagnostic testing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors; and all authors and properly interpret the results, and understand the significance of approve the final manuscript as submitted. the results from the patient perspective and reveal them to the patient in This document is copyrighted and is property of the American a sensitive manner. If the patient is indeed pregnant, the pediatrician, in Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy addition to providing comprehensive options counseling, may need to help of Pediatrics. Any conflicts have been resolved through a process recruit adult support for the patient and should offer continued assistance approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial to the adolescent and her family after the office visit. All pediatricians involvement in the development of the content of this publication.
should be aware of the legal aspects of adolescent reproductive care Clinical reports from the American Academy of Pediatrics benefit from and the resources for pregnant adolescents in their communities. This expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of clinical report presents a more comprehensive view of the evaluation and Pediatrics may not reflect the views of the liaisons or the organizations management of pregnancy in the adolescent patient and a context for or government agencies that they represent. options counseling. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
“ DOI: https://doi.org/10.1542/peds.2017-2273 ” Address correspondence to Laurie L. Hornberger, MD, MPH, FAAP. The American Academy of Pediatrics policy– statement Counseling the E-mail: [email protected] Adolescent About Pregnancy Options was1 3 first published in 1989 and PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). has since been reaffirmed continuously. The purpose of this clinical Copyright 2017 by the American Academy of Pediatrics report is to guide the pediatrician through the diagnosis of pregnancy © in the adolescent patient and suggest a format for counseling regarding pregnancy options. In 2011, the US teen pregnancy rate fell to its– lowest To cite: Hornberger LL and AAP COMMITTEE ON ADOLESCENCE. Diagnosis of Pregnancy and Providing Options Counseling for point in 30 years, attributed largely to more effective use of contraception4 6 by adolescents, including long-acting reversible contraceptives. Despite the Adolescent Patient. Pediatrics. 2017;140(3):e20172273
these achievements, the United States continues to have one of7 the highest teen pregnancy rates among industrialized countries. In 2011, Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 140, number 3, September 2017:e20172273 From the American Academy of Pediatrics
Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics •• about 5% of all female adolescents 15 Would a pregnancy change immunoassays, which are rapid,
through 19 years of age in the United her plans for education or cost-effective, and easily performed •• States (more4 than 550000) became employment? by office personnel. Typically, pregnant. Most pediatricians, urine immunoassays can detect the Has she already considered how therefore, are likely to face this issue presence of hCG by the first day of she might choose to manage a during their careers. the missed period, and depending on •• pregnancy? Taking the History the test used, usually at a quantitative Are there social or cultural hCG value of 25 IU/L. issues that could influence her ’ •• management? Urine pregnancy testing usually is Some adolescents initiate a visit to highly accurate and straightforward, the pediatrician s office specifically What adult in her life would be her but misleading results can occur. for the diagnosis of pregnancy after •• greatest support at this time? The most common cause of a false- experiencing characteristic signs and If she is not pregnant, would she positive or false-negative result is symptoms or obtaining a positive human error in performing the test. result on a home pregnancy test. like to begin a more effective •• This is especially problematic in However, many adolescents present contraceptive method? the use and interpretation9,10 of home with a vague, nonspecific history Has the adolescent ever been pregnancy tests. It is essential ’ without an expressed concern for pregnant previously? If so, what to carefully follow the test kit pregnancy. Adolescents may be was the outcome? manufacturer s instructions, reading reluctant to voice their pregnancy Having this background knowledge the result at exactly the prescribed concerns, uneducated about the signs before sharing the diagnosis can time. A false-negative result and symptoms of pregnancy, or be make pregnancy counseling more also may be seen when very low in denial that pregnancy is possible. efficient and effective. concentrations of hCG are present Menstrual and sexual histories during the early days of pregnancy, Making the Diagnosis “ ” may be unreliable for making the if the urine sample is dilute, or in diagnosis. Therefore, the pediatrician association with11 the hook effect should be alert for the possibility of phenomenon. The hook effect can Laboratory test results for pregnancy pregnancy and not hesitate to pursue occur when hCG concentrations are are likely to be positive before testing. extremely high and overwhelm the clinical symptoms are reported Once pregnancy is suspected, it assay, preventing it from performing and before the physical signs of is important to further explore 8 properly and producing a false- ’ pregnancy are observed. Testing the patient history as well as the negative result. If a pregnancy is is based on the presence of human adolescent s feelings about a possible suspected and the urine test result is chorionic gonadotropin (hCG) in pregnancy and any actions she may negative, one should confirm that the the urine and serum. Although •have• already taken. test was performed properly. If so, a low concentrations of hCG can be repeat urine test may be indicated in Has the adolescent been produced by various tissues and several days, or a serum pregnancy involved in a consensual sexual some malignancies, hCG is produced test may be performed. relationship? Who is/are her primarily by the trophoblastic cells •• partner(s)? of the placenta. Concentrations Qualitative and quantitative Is there a history of sexual coercion of hCG increase quickly after the serum hCG immunoassays are •• or assault? implantation of an embryo, doubling often not immediately available every 2 to 2.5 days and peaking in the clinic setting and are more Does the adolescent desire a around the ninth week of gestation. expensive than urine-based tests α β •• pregnancy? The circulating hCG molecule, but can more accurately diagnose Does she think a pregnancy will consisting of and subunits, an early pregnancy. However, false- have a positive or negative effect is modified into many different positive qualitative serum test •• on her life? forms. These hCG heterodimers and results are possible and must be modified individual subunits are considered if, conversely, the urine Whom has she already told the targets of hCG immunoassays. test result is negative. Heterophile about this possible pregnancy? Approximately 20% of serum hCG is antibodies, rheumatoid factors, Her parents or guardians? Other excreted through the urine, although and some medications (eg, certain •• adults? Her partner? urine concentrations may be variable, anticonvulsants, hypnotics, or Will a pregnancy affect her living especially early in pregnancy. Most tranquilizers) may interfere with situation? pregnancies are diagnosed by urine serum immunoassays, giving a Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics ’ 12 false-positive result. As with urine- diagnostic visit in the pediatrician s previous 5 days)17 and pregnancy is based tests, false-negative qualitative office may not be considered a not desired. For adolescents with “ ” serum test results can occur because prenatal visit, testing for sexually a negative pregnancy test result, of low hCG concentrations in very transmitted infections needs to be a teachable moment exists to
early pregnancy or because of the considered if the history and/or discuss family 18planning and effective hook effect, as described earlier. physical examination are suggestive contraception. If the patient of an infection or if there may be a is disappointed in the negative If the pregnancy test confirms delay in obstetric care. pregnancy test result, further a pregnancy, the next step is to discussion about her desire and estimate the gestational age, First trimester complications include expectations for motherhood can be because this can influence options ectopic pregnancy and spontaneous helpful. counseling. With greater gestational abortion, which may present to age, adolescents may need to the pediatrician as abdominal pain Explaining to pregnant adolescents make their management decisions and/or vaginal bleeding in the the importance of involving their more quickly or may already be patient with a positive pregnancy parents (or legal guardians) may limited in their options. Counting test result. Ectopic pregnancy also persuade them to share their the number of weeks since the may present as a positive pregnancy positive test results with and involve first day of the last menstrual test result but with the absence their parents in the discussion of period (LMP) is the primary means of expected uterine enlargement. pregnancy options. It is suggested of estimating gestational age. Abdominal pain, vaginal bleeding, that the pediatrician explain how Uncertainty with dates, irregular and suspicion of ectopic pregnancy parental involvement usually menstrual cycles, recent use of are all indications for immediate16 is necessary, both emotionally hormonal contraceptives, and obstetric consultation. and financially, and reassure the recent pregnancy or breastfeeding Sharing the Test Result adolescent that parents are generally
are factors13 that can complicate supportive. If parental support is the task. A brief examination not possible or likely, the adolescent by the pediatrician may confirm It is best to convey the result of a should be encouraged to seek physical findings consistent with the pregnancy test to the adolescent the involvement of other trusted estimated gestational age by LMP. alone in a private setting. Although adults. Together, the adolescent and The presence of a softened uterus adolescents may be accompanied by pediatrician can decide who will be about the size of an orange may a family member, friend, or partner, notified and how they will be brought be appreciated by an experienced into the discussion. ’ adolescents often prefer to receive examiner on pelvic examination the result privately and may need the ’ Minors have legal rights protecting at 8 to 12 weeks gestation. By help of the pediatrician to remove their privacy concerning the approximately 12 weeks gestation, others from the room. Just like adult diagnosis and treatment of the uterus is about the size of a women, adolescents will have a wide pregnancy, and most professional grapefruit on pelvic examination, variety of reactions, ranging from joy medical associations have endorsed– and on abdominal examination, it to disappointment or excitement to the right of adolescents to receive is beginning to rise above the pubic anger or fear. It can be challenging 19 27 confidential health services. symphysis. The uterine fundus is for a pediatrician to offer empathy When considering confidentiality, the usually palpable midway between the and support when his or her own ’ ’ pediatrician may want to assess the pubic symphysis and the umbilicus at feelings about the result are at odds ’ adolescent s capacity to understand 16 weeks gestation and at the level with those of the patient. Providing the diagnosis of pregnancy and of the umbilicus by about 20 weeks compassionate, nurturing, and 14 ’ appreciate the implications of gestation. If questions remain patient-centered care is extremely that diagnosis. The American regarding accurate dating by LMP important, despite the pediatrician s “ Psychological Association has stated and uterine size, an ultrasonography personal feelings about adolescent that by middle adolescence (age can be arranged promptly along with sexuality and/or pregnancy. A 13 14-15) young people develop abilities obstetric consultation. pregnancy diagnosis should lead to a 3 similar to adults in reasoning about discussion of pregnancy options. Centers for Disease Control moral dilemmas, understanding guidelines (2015) recommend that In the case of a negative pregnancy social rules and laws, [and] reasoning ” all Chlamydiapregnant women <25 years of age test result, however, emergency about interpersonal relationships be tested for HIV, syphilis, hepatitis contraception should be offered and interpersonal problems ; this
B, , and gonorrhea15 at their if the adolescent has recently had has been affirmed in research in first prenatal visit. Although the unprotected intercourse (ie, in the other health areas, such as chronic Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 140, number 3, September 2017 3
Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics ’ 28 ’ and genetic disease management. partner s parents. However, it is or physical or developmental However, it is important for important that the patient s voice disability) that could influence the ’ pediatricians to be familiar with local remains heard and that she is not decision to continue or terminate ’ confidentiality laws and to be aware23,29, 30 coerced or dominated by others. If the pregnancy. The adolescent s that they vary from state to state. there is a question about the patient s list of medications (and drugs used In accordance with their state competence to make an informed illicitly) should be reviewed to ’ – statutes, pediatricians may have decision about the pregnancy, ensure that none are35 37contraindicated the option of sharing the pregnancy the pediatrician s knowledge and during pregnancy. The use diagnosis with parents at their understanding of state law and of teratogenic medications or the discretion or the responsibility to procedures necessary to make this presence of heritable conditions ’ disclose the diagnosis based on the determination is important. may warrant the involvement of a patient s age. Depending on the gestational age of genetic counselor. For the adolescent with complicated medical issues, Other limits to adolescent the pregnancy, the adolescent has 3 consultation with her subspecialty confidentiality exist. Pediatricians management options available: Continuingcare providers the isP regnancyimportant and. should be aware of their state laws 1. carrying her pregnancy to delivery Raising the Child regarding the age of legal consent and raising the infant; for sexual activity. If the pregnant 2. carrying her pregnancy to delivery adolescent is less than the age and making an adoption or of consent, the pediatrician may The majority of adolescents will kinship care plan; or be required to notify authorities. choose to continue their pregnancies, 3. terminating her pregnancy. Similarly, if the pregnant adolescent although this varies considerably4,38 by is developmentally delayed and The pediatrician is encouraged state, race, and ethnicity. Pregnant the pediatrician is concerned about to discuss all 3 options with the adolescents are less likely than older sexual coercion, he or she should adolescent in a factual, respectful, women to receive39 early and adequate consider reporting the situation and nonjudgmental manner. If, on the prenatal care, so every effort should to authorities. Pediatricians are basis of conscience, the pediatrician be made to facilitate a timely referral mandated reporters when there recognizes his or her own limitations to an appropriate obstetric care is a reasonable31 suspicion of sexual to hold this conversation, prompt provider. Some obstetric providers abuse. Rarely, if an adolescent is may offer adolescent-focused referral to a willing colleague32 or so distraught with the results of consultant is recommended. When prenatal care. Such care may improve her pregnancy test result that she referring their patients elsewhere for infant health outcomes, decrease the becomes a threat to herself or others, options counseling, pediatricians are likelihood of suboptimal prenatal immediate evaluation by a mental encouraged to carefully investigate care, improve prenatal knowledge, – “ ” health professional or transfer to the providers they recommend. increase satisfaction with care, and40 42 “ ” an emergency department may be Crisis pregnancy centers or increase breastfeeding initiation. necessary. pregnancy resource centers in the Family and social support systems Options Counseling community may offer free services to are essential for favorable outcomes women with unplanned pregnancies for young adolescent43 parents and but typically do not offer a balanced their infants. Pediatricians should facilitate connections between their Once a positive pregnancy test result discussion of pregnancy options. Staff parenting patients and community has been shared with the adolescent at these types of facilities frequently programs for adolescent parents. and at least one trusted adult has have no medical training and Programs may vary in their goals (eg, been identified as a support, the may present medically inaccurate teaching parenting skills, promoting pediatrician should proceed with information about pregnancy,33, 34 high school completion, developing pregnancy options counseling. abortion, and contraception. It independent living skills, providing Options counseling may occur at is important that those providing mental health support, delaying the diagnostic visit or continue options counseling be medically subsequent pregnancies), structure over several office visits, although and legally knowledgeable and (eg, group classes, individual the adolescent must understand experienced in working with mentoring), and settings (eg, the importance of making a timely adolescents. ’ community centers, schools, clinics, decision. Included in the discussion It is also important for the 44,45 in-home visits). could be the adolescent s parents, pediatrician to identify any coexisting other identified supportive adults, medical conditions (chronic A more in-depth discussion of her male partner, and possibly her medical illness, psychiatric illness, the challenges unique to teen Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics parents and their children, along adoption, and cite positive51 peer to complete, requires more active with suggestions for support by approval for adoption. Although participation in the process by the ’ pediatricians, are outlined in the limited research exists, one study has patient, and is accompanied by more “ 53 American Academy of Pediatrics shown that adolescents who chose cramping and bleeding. Medical ” clinical report, Care of Adolescent43 adoption over parenting had slightly abortions can be performed further KParentsinship Careand Their Children. less satisfaction with their decision along in pregnancy, even into the but were more likely to complete second trimester, but are associated their education and/or training, with higher rates of incompletion
There may be circumstances in delay marriage, be employed, and52 and need for surgical intervention. which the adolescent may wish to delay a subsequent pregnancy. Surgical abortion is a low-risk “ ” ’ continue a pregnancy but is unable To make appropriate referrals, the procedure57 shown to be safer than to parent her child. Kinship care pediatrician s familiarity with local childbirth and, depending on state is an arrangement whereby a family medical, legal, counseling, and social regulations and available providers, member who is willing to take on this service resources that facilitate may be performed58 at various responsibility may parent the child. adoption is helpful. Throughout the gestational ages. Surgical abortions This may be arranged informally pregnancy, opportunities for the in the first trimester are typically or by a legal process through the adolescent to discuss the possibility performed by vacuum aspiration state child welfare system. It is of adoption with her health care under local anesthesia and in the important for families to be aware of providersAbortion should be available. second trimester are performed59,60 by dilation and curettage. If the the legal and financial ramifications46 of these different arrangements. adolescent is considering terminating her pregnancy, she should be Consultation with legal services is It is important for pediatricians to be referred promptly to an adolescent- Aencourageddoption . aware of abortion services available friendly abortion provider for more in their communities and offer information and counseling. information about these resources Adoption may be an appealing to pregnant adolescents. Both Pediatricians should be familiar option for some adolescents but medical and surgical methods may be with state laws regarding parental appears to be chosen less often than available to the adolescent, although notification and consent for abortion in the past. The number of never- the gestational age of pregnancy and services, the process of judicial married women younger than 45 coexisting medical conditions53 will bypass, and the financial29, costs61 of years who made adoption plans for need to be considered. The point termination procedures. The their newborn infants declined from at which pregnancy termination is average cost of a first trimester nearly 9% before 1973 to less than 47,48 no longer an option (except in the abortion is $500 nationally for62 both 1% in the mid-1990s. case of life or health endangerment) ’ medical and surgical methods. Many teenagers have little knowledge varies by state but is often54 set at 20 Charges increase with increasing about adoption, so it is advisable or 24 weeks gestation. gestational age and complexity of the procedure (up to $5000 or more that the pediatrician be prepared to Medical abortion using a combination 62,63 for a second trimester abortion). describe the differences between the of the oral medications mifepristone — Travel expenses associated with the closed and open adoption processes. and misoprostol may be an option 62,64 ’ procedure also can be substantial. Open adoptions currently are much very early in the pregnancy The total costs often are a significant more common than in the past and typically less than 9 weeks gestation. burden to adolescents and their include planned communication This method has been shown to families, and pediatricians can be between the birth parent, adoptee, be both safe and effective on an a good resource for identifying and adoptive parents, with the outpatient basis when prescribed potential sources of funding within possibility of future contact between by experienced and licensed the birth parent(s) and the child over 55,56 their states to assist them with these 49,50 professionals and may appeal expenses. time. to some patients because it is less Additional Counseling and Follow-up “ ” Teenagers who choose adoption physically intrusive than surgical are more likely to be non-Hispanic abortion, appears more natural ’ white, come from an intact family, by simulating miscarriage, and is By the conclusion of options ’ have higher educational aspirations, completed outside the provider s counseling, the adolescent may or have a parent with more years of office in the patient s home. may not have made a firm decision. A education, have some personal However, compared to surgical list of community resources for each knowledge or experience with abortion, the procedure takes longer of the 3 pregnancy options is helpful Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 140, number 3, September 2017 5
Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics to the patient so she can further confidentiality by sharing with the adolescent patients. Office-based investigate them on her own or begin guarantor the diagnoses coded for urine pregnancy tests usually are to seek the services she desires. that visit and laboratory testing highly accurate in making the Girls who are pregnant should be performed. This lack of confidentiality diagnosis, but false-positive and encouraged to maintain a healthy can be problematic with reproductive false-negative results can occur, lifestyle, including an adequate well- care in general, not just with a and further evaluation may be balanced diet, daily exercise, and positive pregnancy test result. necessary. Once the diagnosis of abstinence from tobacco, alcohol, and Although standard practices for pregnancy is made, it is advisable other drugs. All adolescents who are protecting adolescent65,66 confidentiality that the pediatrician work with the pregnant and who intend to maintain are evolving, the pediatrician patient to identify supportive adults their pregnancies (and those who must be cognizant of the issues and, who can participate in a discussion are unsure) should be prescribed if necessary, willing to work with the ’ of pregnancy options. Pregnancy a daily prenatal vitamin. Whatever adolescent on an acceptable solution. options include continuation of an adolescent s initial leanings, it The Adolescent Father the pregnancy with the patient is advisable that the pediatrician parenting the infant, continuation of schedule a follow-up conversation the pregnancy with an adoption or with the patient and her supportive Little research exists on the level kinship care plan made for the infant, adult(s) to encourage that a timely of involvement that the male final decision be made. Once a or termination of the pregnancy. adolescent desires in the discussion decision is made, the pediatrician The pediatrician is encouraged to be of pregnancy options and subsequent ’ can follow up to be sure that the aware of local laws or regulations decision making when his female adolescent has made a successful that protect the adolescent s privacy partner has a positive pregnancy test connection with appropriate clinical 67 and affect her access to desired result. Even when an unplanned services and financial resources and services. Once the patient has chosen pregnancy is viewed as a negative that social support for her is in place. how to manage her pregnancy, the life event, male adolescents are often It is important for the pediatrician to pediatrician can assist the adolescent ’ able to construct a rational analysis emphasize his or her availability to in accessing appropriate care and can of its social costs and benefits, not provide for the adolescent s health be available to continue her care after only for themselves but also for care after her pregnancy, whatever 68 the pregnancy. their partner and an infant. In option she chooses. If she continues some cases, the pregnancy may her pregnancy and cares for the have been desired by the adolescent The diagnosis of pregnancy is a infant herself, the pediatrician is 69 male. Adolescent fathers may see sensitive and emotional time for the ideal care provider for both the parenthood as an opportunity to take the adolescent, her family, and her adolescent parent and the newborn 43 on an adult role and a reason to make sexual partner. Creating an accepting infant. environment in which the adolescent positive changes in their70, own71 health The time needed to advise the behaviors and lifestyle. Those feels secure to explore her own pregnant adolescent and provide who come from environments where feelings about the pregnancy and her options counseling can vary greatly teen pregnancy is prevalent may future is essential. No matter what
depending on circumstances. view an unplanned72 pregnancy with her decision (becoming a parent, Another appointment may be made more ambivalence. When the male making an adoption or kinship care so that discussions can include adolescent discovers that his partner ’ plan, or having an abortion) there her supportive adult(s) and allow is pregnant, the pediatrician may ’ will be personal consequences for adequate time in the pediatrician s facilitate an exploration of the young the adolescent. It is important for schedule. The utilization of billing man s feelings about the pregnancy the pediatrician to provide her with codes for counseling time will be and his interest in its outcome. accurate information and support, necessary. Involving his parents or trusted regardless of her management adults in the decision-making process When confidentiality is desired, decision. The pediatrician has may recruit support for both the male particularly by the adolescent who the counseling expertise, the ’ adolescent and his female partner. is older than 18 years but remains understanding of adolescent covered by her parent s insurance, it Conclusions developmental and medical is essential for the pediatrician to be issues, and often a long-standing mindful of the ways that insurance relationship with the patient and is, (most notably the explanation Pediatricians must be alert to the therefore, the best person to help her of benefits) may violate patient possibility of pregnancy in their through this life-changing event. Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics Lead Author William P. Adelman, MD, FAAP Lauren Zapata, MD – Centers for Disease Control Arik V. Marcell, MD, MPH, FAAP and Prevention Laurie L. Hornberger, MD, MPH, FAAP Staff Committee on Adolescence, 2016–2017 Karen Smith Cora C. Breuner, MD, MPH, FAAP, Chairperson Liaisons James Baumberger, MPP Elizabeth M. Alderman, MD, FSAHM, FAAP Laurie L. Hornberger, MD, MPH, FAAP – Section on Robert Garofalo, MD, FAAP Adolescent Health Laura K. Grubb, MD, FAAP Liwei L. Hua MD, PhD – American Academy of Makia E. Powers, MD, MPH, FAAP Child and Adolescent Psychiatry Krishna Kumari Upadhya, MD, FAAP Margo Lane, MD, FRCPC – Canadian Pediatric Abbreviations Stephenie B. Wallace, MD, FAAP Society Seema Menon, MD – North American Society Former Committee Members for Pediatric and Adolescent Gynecology Paula K. Braverman, MD, FAAP, Immediate Past Meredith Loveless, MD – American College of hCG: human chorionic Chairperson Obstetricians and Gynecologists gonadotropin LMP: last menstrual period FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics. or g/cgi/doi/10. 1542/peds.2017-2274.
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Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics Obstetric, Gynecologic, and Neonatal care setting when sexual abuse is in a CenteringPregnancy program. Nurses; National Medical Association. suspected. Pediatrics. 2013;132(2). J Midwifery Womens Health. Confidentiality in adolescent health Available at: www.pediatrics.org/cgi/ 2004;49(5):412–420 care. AAP News. 1989;5(4):9 content/full/132/2/e558 43. Pinzon JL, Jones VF; Committee on 22. American Medical Association, National 32. Committee on Bioethics. Policy Adolescence; Committee on Early Coalition on Adolescent Health. statement–physician refusal to provide Childhood. Care of adolescent parents Policy Compendium on Confidential information or treatment on the basis and their children. Pediatrics. Health Services for Adolescents. 1st of claims of conscience. 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Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics than those who raise them? Fam Plann 59. Hamoda H, Templeton A. Medical and to confidential care for adolescents Perspect. 1988;20(1):25–32 surgical options for induced abortion and young adults in an explanation of 53. American College of Obstetricians in first trimester. Best Pract Res Clin benefits environment. J Adolesc Health. and Gynecologists. Practice bulletin Obstet Gynaecol. 2010;24(4):503–516 2015;56(1):7–9 no. 143: medical management of first- 60. ACOG practice bulletin no. 135: second- 67. Lohan M, Cruise S, O’Halloran P, trimester abortion. Obstet Gynecol. trimester abortion. Obstet Gynecol. Alderdice F, Hyde A. Adolescent men’s 2014;123(3):676–692 2013;121(6):1394–1406 attitudes in relation to pregnancy and 54. The Guttmacher Institute. An overview 61. Committee on Adolescence. The pregnancy outcomes: a systematic review of the literature from 1980-2009. of abortion laws. Available at: www. adolescent’s right to confidential care guttmacher.org/statecenter/spibs/ when considering abortion. Pediatrics. J Adolesc Health. 2010;47(4):327–345 spib_OAL.pdf. Accessed December 8, 1996;97(5):746–751 68. Corkindale CJ, Condon JT, Russell A, 2015 62. Rober ts SCM, Gould H, Kimport K, Weitz Quinlivan JA. Factors that adolescent 55. US Food and Drug Administration. TA, Foster DG. Out-of-pocket costs and males take into account in decisions Mifeprex (mifepristone) information. insurance coverage for abortion in the about an unplanned pregnancy. Available at: www.fda.gov/Drugs/ United States. Womens Health Issues. J Adolesc. 2009;32(4):995–1008 DrugSafety/PostmarketDrugSaf 2014;24(2):e211–e218 69. Deslauriers J. Becoming a young etyInformationforPatientsandProvid 63. Jerman J, Jones RK. Secondary father: a decision or an “accident?”. ers/ucm111323.htm. Accessed measures of access to abortion Int J Adolesc Youth. 2011;16(3):289–308 December 8, 2015 services in the United States, 2011 and 70. Wilkes L, Mannix J, Jackson D. ‘I am 56. Kulier R, Kapp N, Gülmezoglu AM, 2012: gestational age limits, cost, and going to be a dad’: experiences and Hofmeyr GJ, Cheng L, Campana A. harassment. Womens Health Issues. expectations of adolescent and young Medical methods for first trimester 2014;24(4):e419–e424 adult expectant fathers. J Clin Nurs. abortion. Cochrane Database Syst Rev. 64. Jones RK, Upadhyay UD, Weitz TA. At 2012;21(1–2):180–188 2011;(11):CD002855 what cost? Payment for abortion care 71. Dallas CM, Kavanaugh K. Making room 57. Raymond EG, Grimes DA. The by U.S. women. Womens Health Issues. for daddy: the unmarried adolescent comparative safety of legal induced 2013;23(3):e173–e178 father’s role in pregnancy. In: Johnson abortion and childbirth in the United 65. Society for Adolescent Health and WE Jr, ed. Social Work With African States. Obstet Gynecol. 2012;119(2, pt 1): Medicine; American Academy of American Males: Health, Mental Health, 215–219 Pediatrics. Confidentiality protections and Social Policy. New York, NY: Oxford 58. American College of Obstetricians for adolescents and young adults in University Press; 2010:27–41 and Gynecologists. Guidelines for the health care billing and insurance 72. Tanner AE, Jelenewicz SM, Ma A, Women’s Health care. 3rd ed. claims process. J Adolesc Health. Rodgers CR, Houston AM, Paluzzi P. 2016;58(3):374 377 Washington, DC: American College – Ambivalent messages: adolescents’ of Obstetricians and Gynecologists; 66. Sedlander E, Brindis CD, Bausch SH, perspectives on pregnancy and birth. 2007 Tebb KP. Options for assuring access J Adolesc Health. 2013;53(1):105–111
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Hornberger and COMMITTEE ON 2017 ROUGH GALLEY PROOF ADOLESCENCE https://doi.org/10.1542/peds.2017-2273 September 2017 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient 3 140 Pediatrics Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient Laurie L. Hornberger and COMMITTEE ON ADOLESCENCE Pediatrics 2017;140; DOI: 10.1542/peds.2017-2273 originally published online August 21, 2017;
Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/140/3/e20172273 References This article cites 53 articles, 12 of which you can access for free at: http://pediatrics.aappublications.org/content/140/3/e20172273#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Committee on Adolescence http://www.aappublications.org/cgi/collection/committee_on_adolesc ence Adolescent Health/Medicine http://www.aappublications.org/cgi/collection/adolescent_health:med icine_sub Teen Pregnancy http://www.aappublications.org/cgi/collection/teen_pregnancy_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml
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