Reproductive female: teen pregnancy: ABP and AM PREP Board content

Case of Teen pregnancy: ectopic pregnancy

#3-A 15-year-old sexually active girl complains of worsening left lower quadrant pain and vaginal bleeding. Three or four days ago, she had an aching pain in her left lower quadrant. Starting at a level of 3 on a 0 to 10 scale, the pain has gradually worsened and is described as 7 and sharper. The pain does not seem to radiate, and nothing makes it better. She denies fever, vomiting, diarrhea, constipation, or urinary symptoms. She has never had this kind of pain before. Her menses have been a "little off lately," as she missed some pills last month. She thinks that her last normal period was about 6 weeks ago. The vaginal bleeding started very lightly yesterday and now seems to be heavier, but there are no clots. On examination, she is in some distress; her temperature is 37.2° C; respiratory rate, 19 breaths/min; heart rate, 99 beats/min; and blood pressure, 118/74 mm Hg. The abdomen is soft, with tenderness to mild palpation in the left lower quadrant, voluntary guarding, no rebound, and normoactive bowel sounds. The genitourinary examination reveals a small amount of bright red blood in the vaginal vault with no clots, and the os appears closed. No adnexal mass is palpable, and the uterus is not enlarged. There is no cervical motion tenderness. Except for blood, her urine is normal, and the urine pregnancy test is positive. The best next step in her management is: transvaginal ultrasonography (TVUS) and quantitative beta human chorionic gonadotropin (bHCG) test -If the patient is hemodynamically unstable with a positive pregnancy test, it is a surgical emergency. -- If she is hemodynamically stable, as the patient described is, an evaluation with an urgent TVUS plus a quantitative bHCG is required. ***A bHCG level of 1,500 mIU/mL is usually consistent with an intrauterine pregnancy,

when to consider ectopic pregnancy

--so if the TVUS is indeterminate and the bHCG is greater than 1,500 mIU/mL, then an ectopic pregnancy is likely and consultation is needed.

When to use Transvaginal us

-Although serial bHCG can be used to follow up a threatened abortion or intrauterine pregnancy, a TVUS is needed to determine the location of the pregnancy. --If the TVUS notes an ectopic pregnancy, then it is possible to consider the use of methotrexate or urgent referral to a surgeon.

Estimate gestational age by history and physical examination

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Identify the risk factors and protective factors for adolescent pregnancy

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Know how to counsel an adolescent regarding pregnancy options

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Know which interventions during an office visit contribute to preventing a first or subsequent pregnancy

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MOLAR pregnancy: Recognize the signs and symptoms of a molar pregnancy

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Recognize that pregnant adolescents are at high risk of having sexually transmitted infections

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Understand the attitudes and customs among various cultural groups about sexual activity and pregnancy in adolescence

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Understand the complications of abortion at different stages of gestation

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Understand the effects of maternal DRUG USE on pregnancy outcomes

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Understand the reasons why adolescents may have a late diagnosis of pregnancy and inadequate prenatal care

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Understand the role of ultrasonography in diagnosing pregnancy

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Understand the techniques for abortion at different stages of gestation

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Understanding the timing and management of a medical abortion

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nterpret the findings on abdominal and transvaginal ULTRASONAGRPHY for a normal and abnormal pregnancy

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Formulate a management plan for an adolescent requesting an abortion

...Complications: Spontaneous Abortion (Miscarriage) • Management: - Prophylaxis against chlamydial endometritis, - Determination of Rh antibody status (administration of Rhogam to those at risk of Rh sensitization), and - Suction curettage (D&C) if the abortion is incomplete - Missed abortion (no e/o fetal life, but has not yet started to abort spontaneously): treat medically (misoprostil) to induce miscarriage

Plan the management of a patient with missed or threatened abortion

...Complications: Spontaneous Abortion (Miscarriage) • Management: - Prophylaxis against chlamydial endometritis, - Determination of Rh antibody status (administration of Rhogam to those at risk of Rh sensitization), and - Suction curettage (D&C) if the abortion is incomplete - Missed abortion (no e/o fetal life, but has not yet started to abort spontaneously): treat medically (misoprostil) to induce miscarriage

ABORTION: Understand the symptoms and signs of missed or threatened abortion

...Complications: Spontaneous Abortion (Miscarriage) • Occurs in about 15% of clinically recognized pregnancies, most in first trimester • Sxs: crampy lower abdominal pain and vaginal bleeding • Causes: - 60% associated with abnormal chromosomal compliment - Uterine or cervical structural abnormalities (e.g. bicornuate uterus), endocrinologic causes (e.g. luteal phase deficiency), autoimmune disorders (e.g. SLE), infection (e.g. rubella), and teratogen exposure.

Recognize the clinical manifestations of adolescent pregnancy: signs and symptoms

...Signs/Symptoms of Pregnancy: Symptoms: • Missed menstrual period or lighter or shorter period than usual (spotting may occur around the time of the missed menses due to invasion of the trophoblast into the decidua- implantation bleed). • Breast tenderness • Fatigue • Dizziness or syncope • Nausea or morning sickness • Frequent urination Signs: • Softening of the cervix (Goodell's sign) • Softening of the uterus (Hegar's sign) • Bluish discoloration of the cervix due to hyperemia (Chadwick's sign) • Enlargement of the uterus (detectable by the experienced examiner on vaginal bimanual examination by 8 weeks gestation) • Abdominally palpable uterus at the symphysis pubis by 12-13 weeks gestation and at the umbilicus by 20 weeks Signs: • Fetal heart can be heard as early as 10 weeks gestation by Doppler fetoscopy and by stethoscope at about 20 weeks gestation (120-200 beats/minute) • Uterine souffle may be heard by stethoscope earlier than 20 weeks (rate same as maternal heart rate 80 - 90 beats/minute) • From 20 - 36 weeks gestation fundal height in centimeters corresponds to gestational age in weeks • Fetal movement (quickening) is usually noticed by the pregnant woman at about 20 weeks gestation • Vaginal ultrasound can detect fetal cardiac activity at approximately 7 weeks from the last menstrual period.

Understand the symptoms and signs of ectopic pregnancy

...Understand the symptoms and signs of ectopic pregnancy Because a ruptured ectopic pregnancy is a leading cause of morbidity and mortality in the first trimester, it always should be considered in an adolescent who presents with pelvic pain or abnormal bleeding.

Estimate gestational age by history and physical examination

..Testing: Gestational Age • Most accurate by exam & U/S 1st trimester • Calculate gestational age from first day of LMP. Use gestational age wheel to determine expected date of confinement/delivery (EDC) or calculate due date using Nagele's Rule (LMP+7days, -3mos , +1yr = EDC). • Ultrasound dating when performed in the first trimester is accurate within 3-5 days; the margin of error increases in the second and third trimesters..

Know the epidemiology of adolescent pregnancy

.Teen pregnancy: • Highest teen pregnancy rate than any other industrialized nation, despite similar patterns of sexual activity among adolescents. • U.S. adolescents less effective contraceptive users, but getting better... ..Pregnancy • In adolescents - s/s may be vague - Teen girl may not openly share sexual history or bring up as hints ("Oh, by the way...") - Menstrual history may be unreliable - Goals: • Confirm diagnosis • Determine gestational age • Identify potential medical complications (incl. ectopic) • Perform options counseling • Refer for prenatal care or abortion or adoption services

Understand the indications for, interpretation of, and limitations of urine pregnancy tests

.Testing: • All blood , urine tests: beta-subunit of human chorionic gonadotrophin (hCG) using specific monoclonal antibodies and ELISA (mIU/ml) • hCG levels rise rapidly after implantation: 100 mIU/ml in maternal serum by expected date of the missed menses • ELISA - type urine pregnancy tests available for home and office testing sensitivities: 5-25 mIU/ml of hCG • Urine pregnancy testing positive - as early as 3-4 days after implantation (7-10 days after conception, before the first missed period) - almost certainly be positive by the expected date of the missed menstrual period. - first morning urine highest concentration of hCG and its metabolites, with levels approximating serum hCG levels. Testing: • Quantitative hCG levels important in diagnosis of ectopic pregnancy and other complications - Blood measurements preferred, should be conducted sequentially in same laboratory • hCG levels double every 1.7 to 2 days during the first 8-9 weeks of gestation • Gestational sac clearly identifiable on vaginal U/S at hCG levels by 2,000 mIU/ml (about 5 weeks after LMP) • After pregnancy termination by delivery or abortion, hCG levels decrease gradually. - After first trimester abortion, pregnancy test generally becomes negative by 40 days post procedure (but hCG fall not reliable)

1. Psychosocial issues

1. Psychosocial issues Know the epidemiology of adolescent pregnancy Identify the risk factors and protective factors for adolescent pregnancy Know which interventions during an office visit contribute to preventing a first or subsequent pregnancy Understand the attitudes and customs among various cultural groups about sexual activity and pregnancy in adolescence

2. Diagnosis oF PREGNANCY

2. Diagnosis of pregnancy Recognize the clinical manifestations of adolescent pregnancy Understand the indications for, interpretation of, and limitations of urine pregnancy tests Understand the indications for, interpretation of, and limitations of serum pregnancy tests Understand the role of ultrasonography in diagnosing pregnancy Estimate gestational age by history and physical examination Estimate gestational age by history and physical examination Know how to counsel an adolescent regarding pregnancy options Formulate a management plan for an adolescent requesting an abortion Understand the techniques for abortion at different stages of gestation Understand the complications of abortion at different stages of gestation Recognize that pregnant adolescents are at high risk of having sexually transmitted infections Recognize what factors contribute to poor outcomes of pregnancy for very young adolescents: socioeconomic status, substance abuse, nutrition, and 55 sexually transmitted infections Understand the reasons why adolescents may have a late diagnosis of pregnancy and inadequate prenatal care Understanding the timing and management of a medical abortion

2. Diagnosis of pregnancy

2. Diagnosis of pregnancy Recognize the clinical manifestations of adolescent pregnancy Understand the indications for, interpretation of, and limitations of urine pregnancy tests Understand the indications for, interpretation of, and limitations of serum pregnancy tests Understand the role of ultrasonography in diagnosing pregnancy Estimate gestational age by history and physical examination Understand the use and significance of changing serum human chorionic gonadotropin (hCG) concentrations during pregnancy Know how to counsel an adolescent regarding pregnancy options Formulate a management plan for an adolescent requesting an abortion Understand the techniques for abortion at different stages of gestation Understand the complications of abortion at different stages of gestation Recognize that pregnant adolescents are at high risk of having sexually transmitted infections Recognize what factors contribute to poor outcomes of pregnancy for very young adolescents: socioeconomic status, substance abuse, nutrition, and 55 sexually transmitted infections Understand the reasons why adolescents may have a late diagnosis of pregnancy and inadequate prenatal care Understanding the timing and management of a medical abortion

3. Disorders of pregnancy

3. Disorders of pregnancy Understand the symptoms and signs of ectopic pregnancy Plan the evaluation and management of an adolescent with suspected or confirmed ectopic pregnancy **Recognize the risk factors for ectopic pregnancy Understand the symptoms and signs of missed or threatened abortion Plan the management of a patient with missed or threatened abortion Recognize the signs and symptoms of a molar pregnancy Interpret the findings on abdominal and transvaginal ultrasonography for a normal and abnormal pregnancy Understand the effects of maternal drug use on pregnancy outcomes

3. Disorders of pregnancy:ectopic, moalr, abortion

3. Disorders of pregnancy Understand the symptoms and signs of ectopic pregnancy Plan the evaluation and management of an adolescent with suspected or confirmed ectopic pregnancy Plan the evaluation and management of an adolescent with suspected or confirmed ectopic pregnancy Understand the symptoms and signs of missed or threatened abortion Plan the management of a patient with missed or threatened abortion Recognize the signs and symptoms of a molar pregnancy Interpret the findings on abdominal and transvaginal ultrasonography for a normal and abnormal pregnancy Understand the effects of maternal drug use on pregnancy outcomes

repeat pregnancies

Although most births to adolescents are first births, repeat pregnancies --account for approximately 20% of teenage pregnancies.

Sexuality : B Pregnancy

B. Pregnancy 1. Psychosocial issues Know the epidemiology of adolescent pregnancy Identify the risk factors and protective factors for adolescent pregnancy Know which interventions during an office visit contribute to preventing a first or subsequent pregnancy Understand the attitudes and customs among various cultural groups about sexual activity and pregnancy in adolescence

Board content: teen pregnancy

B. Pregnancy 1. Psychosocial issues Know the epidemiology of adolescent pregnancy Identify the risk factors and protective factors for adolescent pregnancy Know which interventions during an office visit contribute to preventing a first or subsequent pregnancy Understand the attitudes and customs among various cultural groups about sexual activity and pregnancy in adolescence 2. Diagnosis of pregnancy Recognize the clinical manifestations of adolescent pregnancy Understand the indications for, interpretation of, and limitations of urine pregnancy tests Understand the indications for, interpretation of, and limitations of serum pregnancy tests Understand the role of ultrasonography in diagnosing pregnancy Estimate gestational age by history and physical examination Understand the use and significance of changing serum human chorionic gonadotropin (hCG) concentrations during pregnancy Know how to counsel an adolescent regarding pregnancy options Formulate a management plan for an adolescent requesting an abortion Understand the techniques for abortion at different stages of gestation Understand the complications of abortion at different stages of gestation Recognize that pregnant adolescents are at high risk of having sexually transmitted infections Recognize what factors contribute to poor outcomes of pregnancy for very young adolescents: socioeconomic status, substance abuse, nutrition, and 55 sexually transmitted infections Understand the reasons why adolescents may have a late diagnosis of pregnancy and inadequate prenatal care Understanding the timing and management of a medical abortion 3. Disorders of pregnancy Understand the symptoms and signs of ectopic pregnancy Plan the evaluation and management of an adolescent with suspected or confirmed ectopic pregnancy Recognize the risk factors for ectopic pregnancy Understand the symptoms and signs of missed or threatened abortion Plan the management of a patient with missed or threatened abortion Recognize the signs and symptoms of a molar pregnancy Interpret the findings on abdominal and transvaginal ultrasonography for a normal and abnormal pregnancy Understand the effects of maternal drug use on pregnancy outcomes

Complications: ECTOPOC Pregnancy

Complications: Ectopic Pregnancy • = pregnancy that develops at any site other than the endometrium • Epidemiology: - Increase in incidence d/t combo of increasing salpingitis and better antibiotics, which allow tubal patency, w/ resultant luminal damage. - Maternal mortality fallen due to improved diagnostic methods resulting in early detection before tubal rupture, but still most common cause in first trimester • Diagnosis: - Combination of U/S (lack of intrauterine gestation by vaginal U/S at 1,000-2,000 mIU/ml or 5wks s/p LMP) and subnormal rise in serum hCG - Early diagnosis helps prevent maternal mortality/tubal rupture and increases chance of medical treatment (methotrexate) vs. surgery

Consequences of teen childbearing

Consequences of teen childbearing are well documented and include -- lower educational attainment for the young mother; -- reliance on public assistance; -- subsequent teen child bearing; and -- increased developmental and medical challenges for the infant. &***Children of teen mothers are -- noted to have more behavior problems, --including mental health issues --; developmental delay; --an increased risk for school failure; and their own subsequent high-risk behaviors during adolescence. To compound the problem, adolescent fathers --- have an increased risk of incarceration, -- school delinquency, and == limited financial resources and income potential.

Know the epidemiology of adolescent pregnancy

Despite recent declines in the past 10 years, approximately 800,000 adolescent girls aged 15 to 19 years become pregnant in the United States each year. A majority of these pregnancies are -- unintentional and -- occur in 18- to 19-year-olds; however, younger teens and minorities continue to be well represented. The decline in teen pregnancy rates in the United States is attributed to --- increasingly consistent contraceptive use among adolescents as well as-- -- a decrease in sexual activity in this age group, with an emphasis on safe sex and abstinence (ie, delaying sexual intercourse). **However, despite these public health accomplishments, the United States ---continues to have one of the highest teen pregnancy rates among developed countries --, with 50% to 60% of teen pregnancies ending in live births --, 30% to 35% in abortion, and -- approximately 15% in miscarriages/still births.

Ectopic Pregnancy • Most common signs:

Ectopic Pregnancy • Most common signs: - Abdominal tenderness present over 90% of the time. - Palpable pelvic mass not helpful because only 50% of patients have one, and 20% of these patients have ectopic on contralateral side to mass. - Uterine size is normal 70% of the time. - Patients usually afebrile. - Orthostasis not commonly seen unless massive hemoperitoneum present. - Shoulder pain (caused by diaphragmatic irritation due to hemoperitoneum) occurs in up to 25% of patients.

Ectopic Pregnancy • Most common symptoms (not sensitive or specific):

Ectopic Pregnancy • Most common symptoms (not sensitive or specific): - Over 90% have abdominal pain. - Only 35% report totally missing a period (although careful history often reveals some abnormality with preceding cycle). - Abnormal bleeding at presentation is not uncommon. - Of note, most women with above symptoms have normal intrauterine pregnancies, so diagnosis must be accurate and timely and must use methods that do not interrupt viable intrauterine pregnancies.

ectopic pregnancy

Ectopic Pregnancy Two percent of pregnancies in the United States are ectopic, implanted outside the uterus. -- --Although most ectopic pregnancies are located in the fallopian tube, they also can be located on the ovary, the cervix, and the uterine cornua. -- --Because a ruptured ectopic pregnancy is a leading cause of morbidity and mortality in the first trimester, it always should be considered in an adolescent who presents with pelvic pain or abnormal bleeding. ---The death rate for this condition is highest among teens, so it is necessary to establish a diagnosis early

Disorders of pregnancy

Identify the risk factors and protective factors for adolescent pregnancy

Plan the evaluation and management of an adolescent with suspected or confirmed ectopic pregnancy

If the patient is hemodynamically unstable with a positive pregnancy test, it is a surgical emergency. -- If she is hemodynamically stable, as the patient described is, an evaluation with an urgent TVUS plus a quantitative bHCG is required. ***A bHCG level of 1,500 mIU/mL is usually consistent with an intrauterine pregnancy, --so if the TVUS is indeterminate and the bHCG is greater than 1,500 mIU/mL, then an ectopic pregnancy is likely and consultation is needed. _- --Although serial bHCG can be used to follow up a threatened abortion or intrauterine pregnancy, a TVUS is needed to determine the location of the pregnancy. --If the TVUS notes an ectopic pregnancy, then it is possible to consider the use of methotrexate or urgent referral to a surgeon.

B. Pregnancy 1. Psychosocial issues

Know the epidemiology of adolescent pregnancy

caseQuestion: 8 AM PRep 2012 You are seeing a 16-year-old girl for her annual preparticipation sports physical. During the confidential interview she discloses that she has been sexually active for the last nine months. She reports two lifetime partners and does not use contraception consistently. She does not wish to become pregnant.

Of the following choices, an additional historical factor that would contribute MOST to her risk for pregnancy is: A. family history of teen pregnancy B. history of depression C. late pubertal development D. poor school attendance E. tobacco use answer: A

Question: 7 A 16-year-old girl comes to your office with her mother and requests a referral to an obstetrician/gynecologist for pregnancy. Since menarche at age 12 years, she has had regular menses, has been sexually active with one partner for six months, and has used condoms intermittently. After missing her menses for the past two months, she took a home pregnancy test and it was positive. She wants to do everything she can to have a healthy baby. She is in good health and denies use of tobacco, alcohol, or drugs. She wants to know what she is supposed to be eating to have a healthy pregnancy but not gain too much weight. On examination, she is 5 feet 4 inches tall and weighs 54.4 kg (120 lb). Her Body Mass Index is 20.6, her blood pressure is 100/72 mm Hg, and her Sexual Maturity Rating is 5. The remainder of her examination is otherwise within normal limits. Her urine pregnancy test in the office is positive, and by the dates she provides you calculate she is nearing the end of her first trimester.

Of the following choices, your plan includes a prenatal vitamin, referral to an obstetrician, and: A. a recall of her food intake for the past 24 hours (24-hour diet recall) Not Correct B. nutritional liquid supplement daily C. obtain iron/total iron-binding capacity D. recommend an increase in fruits and vegetables daily E. referral to a registered dietician correcte A

Understand the dietary needs of pregnant adolescents

Proper nutrition during adolescence is important, and a 24-hour diet recall is helpful in determining the typical intake for an adolescent patient. When asked, "How is your diet?" the answer "Good" is insufficient. Asking for the details of what the patient had to eat or drink in the prior 24 hours helps the clinician determine possible harmful practices and potential for deficiencies. The diet recall can be augmented with specific questions regarding daily take of dairy and soda or other sweetened beverages and weekly consumption of fast-food servings. The clinician can make specific suggestions and recommendations and highlight current areas of deficiencies. The typical teen diet is markedly deficient in calcium intake and is notable for a high consumption of sweetened beverages. The pregnant teen is in a unique situation. As teens may still be growing, a pregnancy sets up a competition between the mother and baby that increases the risk for poor outcomes such as low birth weight, small for gestational age, and preterm delivery. Mature women accumulate fat in the first two trimesters and mobilize it in the third trimester for fetal growth. Pregnant teens, if they are still growing, will accumulate fat throughout pregnancy, and it may be deposited disproportionately on the trunk (consistent with late adolescent growth). This increases the long-term risk for diabetes, hypertension, and cardiovascular disease. Even with appropriate weight gain, teens may find their own growth compromised when delivering full-size babies. Recommending a liquid supplement can be helpful in patients who are unable to eat food, have an underlying medical condition causing malabsorption or cachexia, or who require additional caloric intake due to age, infirmity, or disease. Supplements are not recommended in otherwise healthy individuals as they do not provide any advantage over normal, healthy eating practices. After a 24-hour diet recall, referral to a dietician may be helpful. The patient can also be directed to a variety of well-established websites for healthy eating during pregnancy such as the following: http://www.webmd.com/baby/guide/eating-right-when-pregnant and http://www.marchofdimes.com/pregnancy/nutrition.html. Iron deficiency anemia during pregnancy can increase risk for small or early (preterm) babies, and the recommended daily intake for iron doubles during pregnancy. Because menstruating girls and women are at increased risk of iron deficiency with or without anemia due to a negative iron balance, a history of craving ice may be one sign of iron deficiency; others may have a craving for dirt, clay, and other nonfood items or may complain of fatigue, restless leg syndrome, shortness of breath, headaches, dizziness or lightheadedness, cold hands and feet, and irritability. On examination they may be pale, tachycardic, have brittle nails, a heart murmur, or a dry red tongue. Knowing that there is already an increased risk of iron deficiency in this age group, all patients are encouraged to eat foods rich in iron such as liver; lean red meats, including beef, pork, and lamb; seafood*(see below), such as oysters, clams, tuna, salmon, and shrimp; lentils and beans, including kidney, lima, navy, black, pinto, and soy beans; iron-fortified whole grains, including cereals, breads, rice, and pasta; greens, including collard greens, kale, mustard greens, spinach, and turnip greens; tofu; vegetables, including broccoli, swiss chard, asparagus, parsley, watercress, and brussel sprouts; chicken and turkey; blackstrap molasses; nuts; egg yolk; and dried fruits, such as raisins, prunes, dates, and apricots. Measuring the iron/total iron-binding capacity would be helpful if the teen were symptomatic, but it is not indicated in an asymptomatic individual, as the recommendation for increased iron-rich foods plus a prenatal vitamin will already have been made. There is no magic formula for nutrition in pregnancy, but a 24-hour diet recall will help the provider understand what the patient is doing currently and encourage suggestions on healthy eating patterns. Discussion of the current guidelines of the US Department of Agriculture (USDA) on healthy eating is a good start (http://www.choosemyplate.gov/foodgroups/index.html). Providers also can start by recommending two servings of fruits and vegetables, one serving of protein, one serving of a complex carbohydrate, a bread or starch, and a dairy product with every meal. Then they can explain the increased needs in pregnancy for calcium, folate, iron, and proteins. Thus, providers can reinforce healthy habits and suggest alternative choices when indicated. Simply saying that the teen should increase certain foods without giving specific suggestions may cause confusion and would bypass an important teaching opportunity. *Seafood, such as large predatory fish, shark, swordfish, mackerel, and tilefish may contain high levels of mercury. Although not generally toxic to adults, too much mercury can potentially damage the developing baby's brain and nervous system. Because of this, the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) recommend consuming no more than 12 oz (340 g) of seafood a week. That equals about two average meals of seafood per week. Suggested Readings Cox JT, Phelan ST. Nutrition during pregnancy. Obstet Gynecol Clin North Am. 2008;35(3):369-83. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18760225

Recognize the indications for pertussis vaccine in adolescents sept 2014

Question: 5 A 17-year-old female has come to your office for a routine physical examination. After reviewing her vaccination record, you discover that she received the tetanus-diphtheria-acellular pertussis (Tdap) vaccine and meningococcal conjugate vaccine (MCV4) at 11 years of age, she received her second MCV4 at 16 years of age, and she completed the HPV vaccination series by 14 years of age. The patient is concerned by reports that pertussis outbreaks have been occurring throughout the country, and she would like to confirm she is fully protected. Of the following, the MOST appropriate response to this patient is that an additional Tdap vaccine is recommended if A. she injured herself and a tetanus-containing vaccine were indicated B. she lives in a community in which there is a current pertussis outbreak C. she missed one of the DTaP vaccines in the primary series Correct D. she were in the third trimester of pregnancy E. there are no circumstances under which an additional Tdap vaccine is administered Correct View Peer Results Average Percent Correct: 40.16% Patient CarePracice-Based Learning and Improvement ABP Content Specifications In 2005, the Advisory Committee on Immunization Practices (ACIP) recommended the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine for all persons 11 to 12 years of age and all those through 64 years of age who had not previously received a dose. Since 2005, the recommendations for receipt of the Tdap vaccine have expanded. It is important to note that not all of the recommendations are in complete compliance with US Food and Drug Administration licensure guidelines; for example, the two available Tdap vaccines on the market in the United States are licensed for one-time use only. All ACIP recommendations, however, are covered by the National Vaccine Injury Compensation Program. The current recommendations for the Tdap vaccine are listed below. The date of the updated recommendation is in parentheses. The recommendations are: Single dose of vaccine for all 11- to 12-year-olds (recommended age for vaccination), all adolescents through 18 years of age, and adults 19 to 64 years of age who have not previously received the vaccine (2005) Single dose of vaccine for adults 65 years of age and older who have not previously received the vaccine (2012) With a special emphasis for those who have or anticipate close contact with an infant younger than 12 months of age (2010) Single dose for those 7 to 10 years of age who have not been fully vaccinated against pertussis (5 doses of Diptheria-Tetanus-Pertussis [DTaP] or 4 doses of DTaP if the 4th dose was administered on or after the 4th birthday) (2006) For 7- to 10-year-old children requiring the 3-dose catch-up series for DTaP, the first dose of the series should be Tdap A dose of Tdap during each pregnancy regardless of the patient's past history of receiving Tdap; optimal timing for administration is between the 27th and 36th week of gestation to maximize maternal antibody response and passive transfer of antibody to the infant (2012) The ACIP continues to review data to determine the need for routine booster doses of Tdap. For this vignette, the patient is a healthy young woman whose vaccines are up to date. She does not need further pertussis immunizations. Only a single dose of Tdap is recommended under all circumstances, with the exception of pregnancy, therefore response choices A and B are not correct. Response choice C is incorrect because this patient has already received a Tdap vaccine, so if she had missed a dose in the primary series, she has been updated with a Tdap dose at 11 years of age. Response choice E is not correct; repeated doses of Tdap are recommended with each pregnancy for the benefit of protecting the infant. PREP Pearls: The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is routinely recommended for all 11- to 12-year-olds. All persons 13 years of age and older who have not previously received the Tdap vaccine should be vaccinated. An additional Tdap vaccine is recommended during each pregnancy, ideally during the 27th through 36th week of gestation. Take Survey tooltip Suggested Readings Centers for Disease Control and Prevention. Guidelines for vaccinating pregnant women. US Centers for Disease Control and Prevention website. 2014. Accessed 5/8/2014 at: http://www.cdc.gov/vaccines/pubs/preg-guide.htm Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP) 2012. MMWR Morb Mortal Wkly Rep. 2012;61(25):468-470. Accessed 5/8/2014 at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm American Board of Pediatrics Content Specification(s) Recognize the indications for pertussis vaccine in adolescents

Understanding the timing and management of a medical abortion

Question: 5 A 17-year-old female patient with no significant medical history is asking to be seen urgently for a "personal matter." A home pregnancy test this morning was positive. Her mother has accompanied her and knows that she may be pregnant. A rapid urine pregnancy test in your office is also positive. Her physical examination, including vital signs and pelvic examination, is unremarkable. The estimated gestational age of her uterus is 7 to 8 weeks, as per her last menstrual period. You discuss pregnancy options counseling with the patient and her mother, as per the patient's request, and they request detailed information about the procedure of a medical abortion. Of the following, the MOST accurate statement about the timing and management of a medical abortion is that Correct A. absolute contraindications of medical abortion include ectopic pregnancy B. cramping after medical abortion is insignificant C. follow-up after medical abortion is not as important as after surgical abortion D. medical abortion is most successful between 7 to 9 weeks from last menstrual period E. medical abortion is not an option for adolescents Correct View Peer Results Average Percent Correct: 53.10% Patient CarePracice-Based Learning and ImprovementInterpersonal and Communication Skills ABP Content Specifications Medical (or "medication") abortion is an effective method of early intrauterine pregnancy termination for healthy teenagers; in medical abortion, complete expulsion of products of conception occurs without the need for surgical intervention. Both adult and adolescent women are increasingly using this method of termination with similar success rates during the first 9 weeks of pregnancy. The highest success rates occur when medical abortion is administered at 7 weeks or less from the last menstrual period, with small decreases in efficacy during weeks 7 through 9 (Table 1). Current coagulation disorders, chronic adrenal failure, long term use of corticosteroids, suspected ectopic pregnancy, intrauterine device in place, inherited porphyrias, and an allergy to mifepristone or misoprostol are known contraindications to medical abortions. The US Food and Drug Administration approved the combination of mifepristone (a potent progesterone protagonist causing involution and detachment of the implanted trophoblast) followed by misoprostol (a synthetic prostaglandin E1 analog causing uterine contractions, softening of the cervix, and eventual expulsion of the products of conception) for medical abortion in 2001, and this is still the most commonly used regimen, although other similar protocols have been published and are in use (Table 2). It is important to note that the bleeding may persist even until the next menses. Most patients describe the passing of clots and therefore require privacy during this time, which may be difficult for adolescents requesting confidentiality. However, counseling about seeking and access to emergency care is important, should the bleeding become abnormally heavy. Pain from the contractions is generally alleviated by nonsteroidal anti-inflammatory drugs; some patients may require narcotics. Follow-up care to determine complete abortion, as described, is very important in medical abortions. Complications include uterine perforation, problems with anesthesia when used, and endometriosis. In cases of ongoing pregnancy and failed termination, teratogenic risk is greater than in surgical abortions. At follow-up, a small percentage of medical abortions may need surgical intervention in the case of incomplete evacuation of the products of conception. However, medical abortion is generally safe, has been more than 95% effective in complete termination, and has become highly acceptable to healthy adolescents. PREP Pearls: Medical abortion is a 2-step procedure and includes follow-up to guarantee complete termination. Medical abortion is an option for healthy adolescents; contraindications include bleeding disorders, ectopic pregnancy, and long term use of corticosteroids. Medical abortion is an option during the first trimester of pregnancy and is most effective before 7 weeks of pregnancy. Suggested Readings Davis A. Abortion in adolescents. In: Fisher MM, Alderman EM, Kreipe RE, Rosenfeld WD, ed. Textbook of Adolescent Healthcare. Elk Grove Village, IL: American Academy of Pediatrics; 2011:526-530. Harwood B. First trimester medication abortion (termination of pregnancy). UpToDate. 2014. Accessed 4/24/2014 at: http://www.uptodate.com/contents/first-trimester-medication-abortion-termination-of-pregnancy American Board of Pediatrics Content Specification(s) Understanding the timing and management of a medical abortion

AM prep Dec 2012 adol pregnancy case Understand the symptoms and signs of missed or threatened abortion Plan the management of a patient with missed or threatened abortion

Question: 8 A 15-year-old girl comes to your office with a history of vaginal bleeding for one week associated with mild abdominal cramping. Her last menstrual period was two months ago and only lasted two days, and a home pregnancy test was positive. She has no history of fever, dysuria, vaginal discharge, vomiting, or diarrhea. On further questioning, she reports minimal morning nausea for the last few days, that she attributes to the onset of her menses. She is sexually active with one male partner and last had unprotected sexual intercourse about six weeks ago. On physical examination, she is afebrile, with a heart rate of 90 beats per minute and a blood pressure of 110/75 mm Hg. Her respiratory rate is normal. Her abdomen is soft and nontender in all quadrants. There is no hepatosplenomegaly. She has no rashes, and her capillary refill is less than two seconds. A speculum examination reveals minimal blood in the vaginal vault, no lesions, and no cervical discharge. The bimanual examination reveals no cervical motion tenderness and a closed os. A urine pregnancy test is positive. A quantitative serum ß-human chorionic gonadotropin (ß-hCG) test, complete blood cell count (CBC), and blood type are pending. Of the following choices, the NEXT best step in the management of this adolescent is to: A. administer O negative packed red blood cells B. administer Rh immune globulin C. obtain a clean-catch urinalysis D. order transvaginal ultrasonography E. refer her to clinical social work for supportive services Correct Average Percent Correct: 90.80% The adolescent described in the vignette is presenting with signs and symptoms suggestive of a threatened abortion. She is sexually active, does not consistently use contraception, and has a positive pregnancy test. In addition, the patient is experiencing prolonged vaginal bleeding without abdominal pain early in pregnancy. Based on her last menstrual cycle, which was atypical and occurred approximately two months prior to this visit, the adolescent is probably in her first trimester. The speculum examination is consistent with a threatened abortion, although other common causes of vaginal bleeding early in pregnancy must be excluded, such as ectopic pregnancy and spontaneous miscarriage/abortion. These conditions are summarized in the (Table) and can be further differentiated by the transvaginal ultrasound. A complete pelvic examination is essential to differentiate between the various causes of vaginal bleeding in early pregnancy. Verifying that the blood is in fact originating from the cervix or vagina is important as is an evaluation of the status of the internal cervical os on bimanual examination. If the patient is experiencing a spontaneous abortion, the internal os must dilate in order for products of conception to pass. Transvaginal ultrasonography is crucial to confirm an intrauterine pregnancy in this adolescent with vaginal bleeding and a positive pregnancy test. More importantly, it is necessary to satisfactorily rule out an ectopic pregnancy, which could evolve into a surgical emergency if undiagnosed. A transfusion of packed red blood cells before the results of the CBC are known is not justified in this adolescent because she currently is hemodynamically stable. It is also prudent to wait for the results of her blood type before administering Rh immune globulin to reduce the risk of future hemolytic disease if the adolescent turns out to be Rh negative. Although a clean-catch urinalysis should be a part of the initial evaluation of this teen, it is not the most important part of the workup at this time. A referral to social services is also important but is not appropriate before the pelvic ultrasound is obtained. The clinical diagnosis of a threatened abortion is made when there is bloody discharge or vaginal bleeding during the first trimester of pregnancy. It is confirmed by transvaginal ultrasound as early as five weeks' gestation in a patient with a history of vaginal bleeding, fetal cardiac activity, and a closed cervical os on speculum examination. The management for a threatened abortion is rest, close observation as an outpatient until the bleeding has stopped, serial serum hCG levels, and a repeat ultrasound. Management also should include a discussion of the outcome of this unexpected pregnancy with the adolescent. There are three options for the management of a missed abortion: expectant therapy (allow the patient to continue bleeding and expel the products of conception spontaneously); medical therapy with misoprostol or mifepristone; or surgical therapy (dilatation and curettage or manual vacuum aspiration). Management depends on whether the adolescent has already completed a spontaneous abortion by the time she presents for an evaluation. If the ultrasound shows an empty uterus and evaluation of the expelled tissue confirms products of conception, no further action is needed and the patient can continue to be managed expectantly. Suggested Readings Dyne PM. Vaginal bleeding and other common complaints in early pregnancy. In: Perlman MD, Tintinalli JE, Dyne PL, ed. Obstetric & Gynecologic Emergencies: Diagnosis and Management. New York, NY: McGraw-Hill Co, Inc; 2004:39-45. Emans SJ, Smith VAM, Laufer MR. Teenage pregnancy. In: Emans SJ, Laufer MR, Goldstein DP, ed. Pediatric and Adolescent Gynecology, 5th ed. Philadelphia: Lippincott-Raven; 2005:chap 41. Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243-1250. Available at: http://www.aafp.org/afp/2005/1001/p1243.html American Board of Pediatrics Content Specification(s) Understand the symptoms and signs of missed or threatened abortion Plan the management of a patient with missed or threatened abortion

Recognize the risk factors for ectopic pregnancy

Risk factors for ectopic pregnancy include use of an intrauterine device (IUD), recurrent chlamydial infections, pelvic inflammatory disease, tobacco abuse, exposure to diethylstilbestrol (DES), prior ectopic pregnancy, prior tubal surgery, or untreated sexually transmitted infection. --Although it is uncommon for teens to have had tubal surgery, IUDs are becoming more popular and their use may increase the risk of ectopic pregnancy. --Chlamydia-associated tubal inflammation can result in fibrosis, scarring, and loss of tubal function, which in turn can lead to long-term sequelae, such as tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. --The exact mechanism by which cigarette smoking causes an increase in ectopic pregnancy is unknown, but the increase is presumed to be due to damage to the fallopian tube and impaired tubal motility. The calculated risk is up to 3.5 times higher than the risk of a nonsmoker. Because approximately one quarter of all US high school students smoke, it is important to encourage smoking cessation as part of the reproductive health care examination.

teen pregnancy statistics in the United States: race and ethnic group

Specific races and ethnic groups are disproportionately represented in overall teen pregnancy statistics in the United States. I n 2009, black and Hispanic young women aged 15 to 19 years -----had the highest pregnancy rates compared to non-Hispanic whites (59.0 and 70.1 per 1,000 vs 25.6 per 1,000, respectively). In addition, geographical differences occur within the United States. ---Birth rates are lowest in the Northeast and upper Midwest and -- highest among southern states.

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Table. Vaginal Bleeding in Early Pregnancy* Clinical Findings Vaginal bleeding or abdominal/pelvic pain; cervical os closed; abnormal increase ß-hCG† Vaginal bleeding or abdominal/pelvic pain; blood or brownish discharge in vagina; cervical os closed Vaginal bleeding (worse than with threatened abortion); cramping; cervical os open History of vaginal bleeding and abdominal pain; normal abdominal exam; blood in vaginal vault; cervical os closed; falling ß-hCG History of heavy vaginal bleeding; abdominal cramping; normal or tender exam; os open or closed; slowly falling or plateau ß-hCG No symptoms except amenorrhea; os closed (no uterine activity to expel the products of conception) Ultrasound Findings Empty uterus or noncystic adnexal mass or heart beat in the adnexa Embryo with cardiac activity or empty gestational sac in uterus Gestational sac in process of expulsion (products of conception located in lower uterine segment or cervical canal) Empty uterus; some but not all of the products of conception have been passed Thickened, irregular endometrium (may note some products of conception present in uterus) Embryo lacking cardiac activity with crown- rump length >5 mm *With permission from Dyne PM. Vaginal bleeding and other common complaints in early pregnancy. In: Pearlman MD, Tintinalli JE, and Dyne PL, eds. Obstetric & Gynecologic Emergencies: Diagnosis and Mana

The role of the health care provider

The role of the health care provider is -- to encourage the postponement of early sexual activity --; encourage parents to educate their children about sexual development and -- responsible decision-making; -- identify the adolescent at risk for teen pregnancy; and -ensure that all adolescents have the knowledge of and access to contraceptive services.

dentify the risk factors and protective factors for adolescent pregnancy

They include -- early sexual experiences within a culture or family (ie, a pattern of teen pregnancy in the family) -- early pubertal development; -- a history of physical and sexual abuse; -- environmental factors such as poverty; history of substance abuse, including alcohol; poor academic performance; -- and school delinquency. Other risk factors include ---a lack of school or career goals and --the absence of an attentive or nurturing parent/guardian. Although psychological factors such - as depression may influence the decision to become sexually active, - their direct contribution to adolescent pregnancy remains unclear. *** Tobacco use is considered a gateway drug and -- --may lead to the use of other substances; ----however, it has not been cited in the literature as contributing to teenage pregnancy.

Know the relationship between gestational diabetes and the risk of other types of diabetes Question: 7 A 17-year-old female presents to your clinic for the first postpartum visit in the teen-tot clinic. In discussing her pregnancy course, she tells you that she was diagnosed with gestational diabetes by a screening oral glucose tolerance test, and was able to manage it by controlling her diet. She asks if having diabetes in pregnancy means that she and her baby are both going to develop diabetes. Both she and the newborn are well, and a finger stick test for serum glucose for the mother shows a level of 70 mg/dL (3.89 mmol/L). Of the following, the MOST accurate statement regarding this adolescent mother and her baby is that A. both she and her newborn are at higher risk for the future development of diabetes B. her newborn is at higher risk for the future development of diabetes, but she is not C. neither she nor her newborn is at higher risk for the future development of diabetes D. she can be considered to have already developed diabetes E. she is at high risk for the future development of diabetes, but her newborn is not Correct View Peer Results Average Percent Correct: 48.70%

correct A Patient Care ABP Content Specifications Gestational diabetes mellitus (GDM), defined as glucose intolerance first diagnosed during pregnancy, is the most common metabolic disorder related to pregnancy. Up to 14% of all pregnancies are complicated by GDM. The rates of GDM are increasing and mirror increases seen in the general population of obesity, type 2 diabetes, and metabolic syndrome. Normal physiological changes, which occur during pregnancy, include a decrease in insulin sensitivity in order to supply more glucose to the developing fetus and a corresponding increase in insulin secretion. When the insulin secretion cannot meet the increased demand caused by pregnancy, GDM develops. Risk factors for the development of GDM include a previous pregnancy complicated by GDM, obesity, polycystic ovarian syndrome, family history of type 2 diabetes, and an age older than 25 years. Presence of GDM does not necessarily mean that the woman has developed diabetes, and in fact, most women return to euglycemia after delivery. However, any woman diagnosed with GDM is at extremely high risk for developing type 2 diabetes mellitus (DM), with some studies showing up to 70% of women with GDM developing type 2 DM later in life. A study that followed women for 9 years after a GDM complicated pregnancy showed a 9-fold increased risk of diabetes compared to pregnancies not complicated by GDM. The risk is highest within the first 9 months postpartum, and then rises evenly and steadily throughout life. It is possible that some women had undiagnosed diabetes prior to the pregnancy, and the abnormal screening during pregnancy reflected a preexisting condition. Nonetheless, anyone with diabetes diagnosed during pregnancy should be considered to be at high risk for developing diabetes afterwards. Gestational diabetes mellitus is also associated with an up to 25% higher risk of developing later hypertension. Whether this relationship is causative or related to common risk factors for diabetes and hypertension is unknown. Presence of maternal GDM is also associated with higher incidence of prediabetes and diabetes in adolescent and adult offspring, with children born with macrosomia at an even higher risk. The data on whether obesity is more common in children of GDM pregnancies is mixed; a recent study showed no increased risk of childhood obesity in offspring of a GDM-complicated pregnancy, though other studies do show increased risk. However, most of these studies looked at obesity later in life. The uncertain association with obesity and the fact that poorly controlled GDM, as evidenced by macrosomia, increases the risk of DM in offspring implies that the hyperglycemic intrauterine environment affects glucose metabolism, though the exact mechanism is unknown. Therefore, this mother can be accurately told that both her and her newborn's risk for diabetes is increased and that she is more likely to develop GDM during subsequent pregnancies than if she did not have GDM. Breastfeeding has been demonstrated to promote weight loss and reduce diabetes risk in the mother, and reduce to obesity risk, along with many other health benefits, in the child and should be strongly encouraged and supported. Lifestyle changes, including weight reduction and moderate exercise, have been shown to prevent or delay development of type 2 diabetes and recurrence of GDM in those at risk. The mother in the vignette should also be counseled on healthy nutrition and lifestyle for her newborn. If everybody in the household follows the same diet plan, adherence may be improved. Metformin may also help delay the development of type 2 DM in those with prediabetes and may be offered to this mother. PREP Pearls: Presence of gestational diabetes confers significantly higher risk of developing type 2 diabetes and hypertension later in life. Offspring of mothers with gestational diabetes have a higher risk for the development of type 2 diabetes later in life, particularly those born with macrosomia. Lifestyle changes, which include weight reduction and moderate exercise, are imperative in those who have had gestational diabetes mellitus, to delay or prevent the development of diabetes. Suggested Readings Feig DS, Zinman B, Wang X, Hux JE. Risk of development of diabetes mellitus after diagnosis of gestational diabetes. CMAJ. 2008;179(3):229-234. DOI: 10.1503/cmaj.080012 Feig DS. Avoiding the slippery slope: preventing the development of diabetes in women with a history of gestational diabetes. Diabetes Metab Res Rev. 2012;28(4):317-320. DOI: 10.1002/dmrr.2276 Tobias DK, Hu FB, Forman JP, Chavarro J, Zhang C. Increased risk of hypertension after gestational diabetes mellitus: findings from a large prospective cohort study. Diabetes Care. 2011;34(7):1582-1584. DOI: 10.2337/dc11-0268 Whitaker RC, Pepe MS, Seidel KD, Wright JA, Knopp RH. Gestational diabetes and the risk of offspring obesity. Pediatrics. 1998;101(2):E9. DOI: 10.1542/peds.101.2.e9 American Board of Pediatrics Content Specification(s) Know the relationship between gestational diabetes and the risk of other types of diabetes

Recognize what factors contribute to poor outcomes of pregnancy for very young adolescents: socioeconomic status, substance abuse, nutrition, and sexually transmitted infections

factors contribute to poor outcomes of pregnancy for very young adolescents: socioeconomic status, substance abuse, nutrition, and sexually transmitted infections

Factors that are associated with a delay in the initiation of sexual activity and therefore are considered protective against adolescent pregnancy

factors that are associated with a delay in the initiation of sexual activity and therefore are considered protective against adolescent pregnancy are ---living in a stable and nurturing family environment; -- regular attendance at places of worship; -- and higher family income. -- Increased parental supervision and expectations and -- communication about sex between parent and child also have been recently recognized as protective factors. Primary and secondary programs to prevent teen pregnancy have been developed and report variable success --; however, promising results include ------- abstinence promotion, -sexual and contraceptive education, -academic completion strategies, job training, and -extracurricular involvement in arts or athletics. ** Secondary abstinence and the use of long-acting contraceptive methods such as medroxyprogesterone acetate and etonogestrel implant also ---are protective factors for adolescent pregnancy.