Pregnancy in adolescents has a major impact all over the world due to its maternal, fetal and social complications. Establishing a good way to prevent adolescent pregnancy could decrease its incidence. In Romania, the incidence is one of the highest in Europe. Although the adolescents represent a special social category because of their immature physical and mental status, we should treat them in the most serious medical way. Also, fetal and maternal morbidity and mortality are high in this category of patients. This is why an appropriate management during pregnancy and peripartum plays an essential role in decreasing these complications. We present the experience of the Department of Obstetrics and Gynecology of the Bucharest University Emergency Hospital in the management of pregnancy in adolescents.
pregnancy, adolescents, management
Sarcina la adolescente are un impact negativ major în întreaga lume, din cauza complicaţiilor sale materne, fetale şi sociale. Stabilirea unei modalităţi eficiente de a preveni sarcina la adolescente ar putea să scadă incidenţa acesteia. În România, incidenţa este una dintre cele mai ridicate din Europa. Deşi adolescenţii reprezintă o categorie socială specială din cauza imaturităţii fizice şi mentale, ar trebui să-i tratăm în cel mai serios mod din punct de vedere medical. De asemenea, morbiditatea şi mortalitatea fetală şi maternă sunt ridicate la această categorie de pacienţi. Acesta este motivul pentru care un management adecvat în timpul sarcinii şi peripartum joacă un rol esenţial în scăderea acestor complicaţii. Vă prezentăm experienţa Departamentului de obstetrică şi ginecologie al Spitalului Universitar de Urgenţă Bucureşti în managementul sarcinii la adolescente.
Pregnancy in adolescents represents a concerning global issue due to an increasing number of cases. World Health Organization (WHO) defines adolescent pregnancy as pregnancy in women aged 10-19 years old, while pregnant women between 10 and 14 years old are termed as younger adolescents(1,2). It is well known that Romania has one of the highest numbers of births in adolescents. In 2015, Romania occupied the second place in pregnant adolescents aged 18 or less, with 29.2 per 1000 women, while in Nordic countries the percentage was less than 2 per 1000 women(3). In 2017, in Canada, 7858 live births were reported in women under 19 years old, accounting for 2.1% of all the births in the country(4,5). More than 70% of the pregnant women aged 15 to 19 years old in Canada reported the pregnancy was unintended, and this is why 51% of them opted for abortion(4,6,7). Worldwide, 60% of all adolescent pregnancies culminate in birth, representing about 11% of all births(2,8).
The main concern is the physical and mental health of these teenagers and their newborns(2,9). The complications that occur in pregnant adolescents and their newborns are greater than in the rest of the population(2,9). The most important complications that may occur include: preeclampsia, preterm delivery, low birth weight, and the need of newborn for treatment in NICU (Neonatal Intensive Care Unit)(2,9). Also, it must be mentioned that the complications during pregnancy and childbirth are the main cause of death for girls between 15 and 19 years old globally(10). In a study developed in an urban tertiary high-volume center in Turkey, over a period of 4 years, the maternal and neonatal outcomes were analyzed in adolescent pregnancies and compared with pregnant women aged between 25 and 30 years old(2). There were over 42,000 delivers, with 101 pregnant girls under the age of 15 years old and 3611 aged 15-19 years old(2). The specialists concluded that preeclampsia rates were higher in adolescents (p=0.004) and that the risk for preterm delivery was higher in girls under 15 years old, with a percentage of 32.7% (p<0.001)(2). Regarding neonatal complications, birth weight was lower in adolescents (p<0.001), with 31.3% cases under the 10th percentile for adolescent newborns in comparatison with 11% for the group control(2). The management in NICU was needed in most of the neonates of mothers aged under 15 years old, with a rate of 16.8% (p=0.014)(2).
In this paper, we present the rates of births in adolescents and their comorbidities, in the Department of Obstetrics and Gynecology of the Bucharest University Emergency Hospital.
Materials and method
We performed an observational, retrospective study of 598 deliveries of women aged 12 to 21 years old, who were admitted in the Department of Obstetrics and Gynecology of the Bucharest University Emergency Hospital, a tertiary center in Romania, between the 1st of January 2015 and 31st of December 2018. We divided pregnant women into two groups. In the first group, we enrolled pregnant patients aged less than 15 years old, while in the second group we enrolled pregnant adolescents between 15 and 21 years old. The information regarding pregnancy, delivery outcomes and neonatal data were retrieved from the hospitalization sheets and the Base Data System of the Bucharest University Emergency Hospital. The informed consent for participating in this study was obtained from the legal guardian of patients aged less than 18 years old or from the patient for the adolescents aged ≥18 years old. The study was approved by the Ethics Committee of the Bucharest University Emergency Hospital.
Maternal age was defined as that recorded at the time of delivery or presentation in the hospital. Gestational age was calculated based on the time of the last menstrual period. Pregnant adolescents who did not undergo prenatal visits were also included. Expulsions of the gestational product after completed 24 weeks were defined as deliveries, while before 24 weeks were considered abortions. Deliveries before 37 weeks of gestation were considered as preterm births.
We evaluated and compared the age of the patients, the rate of caesarean extraction and vaginal birth, the obstetrical complications and the management of patients enrolled in the two groups. The status of the newborns was assessed based on Apgar score at 1 minute and birth weight. The statistical analysis was performed using Microsoft Excel and SPSS 9.5.
Twelve patients were enrolled in Group I and 586 in Group II. The mean age of patients included in the study was 16.9 years old. The mean age of patients included in Group I was 13.1 years old, while the mean age in Group II was 17.8 years old.
Most of the patients enrolled in the study did not undergo regulated pregnancy visits (n=421). None of the patients from Group I attended any medical visits during pregnancy.
We observed that most of the patients (n=353) delivered by caesarean section (Figure 1).
Nine patients from Group I (six of 14 years old and three of 13 years old) delivered vaginally; the caesarean extraction was performed in three cases from Group I (one of 12 years old, and two of 13 years old).
We also analyzed the indications for caesarean extraction (Figure 2).
The most frequent indication for caesarean extraction was cephalopelvic disproportion, representing 30.88% (n=109) of all indications. Another important indication for caesarean extraction was fetal distress (n=82). Dystocic presentations, such as breech presentation, sinciput or face presentations, were noticed in 10.76% of the cases.
Uterine scar after caesarean section was indicated in 49 cases, which represented 13.88% of cases. In the other category of indications there have been included patients with various preexistent pathologies (ex.: Hodgkin lymphoma, congenital malformations of the female genital tract, epilepsy, myasthenia gravis).
The neonatal status was evaluated using the Apgar score at 1 minute and the weight at birth (Figure 3).
The most frequent Apgar score was 9 and it was found in 58.79% (n=351) of deliveries. We found no newborns scored with Apgar 3 or 4, and we had only five cases of Apgar 1 and one case of Apgar 2. One hundred and four newborns had an Apgar score of 10.
The weight of newborns was evaluated by enrolling them into eight categories (Figure 4).
34.95 % of the newborns had a weight between 2500 and 2999 grams. 33.95% had a weight that varied between 3000 grams and 3499 grams. 1.84% of the newborns had a weight over 4000 grams. Only 10 newborns weighed under 1500 grams.
The incidence of pregnancy in adolescents is increasing continuously worldwide, being a global issue. In Romania, the problem is more dramatic due to the lack of education regarding contraceptive methods. In our hospital, we observed a high rate of pregnant adolescents which reflected the national problem.
Although in other studies caesarean section was less common in adolescents, in our study we noticed a high rate of emergency caesarean section. This is probably related to the multidisciplinary profile of the Bucharest University Emergency Hospital, where patients with associated conditions are referred. In a study conducted in Macedonia, over a period of three years, including 115 women under 19 years old and 817 women between 20 and 24 years old, it was noticed that spontaneous labour was more common in adolescents, with a percentage of 73% compared to 63.5% for the control group(11). In our study, we observed that caesarean extraction was needed in 54.48 % of the cases.
A percentage of 25.21% of the patients in Group II were diagnosed with severe preeclampsia, and emergency caesarean section was performed (Figure 2 and Figure 5).
However, there are contradictory results whether preeclampsia is increased or decreased in adolescents(2,12-14).
Preterm delivery has a high incidence in adolescents. This problem was investigated by multiple specialist in many centers and some studies determined that the risk of preterm delivery was higher in adolescents under the age of 15 years old(2,10,15-17). However, in the study we performed at the Bucharest University Emergency Hospital, we observed a lower rate of preterm births in adolescents.
Some studies observed that fetal distress was relatively rare in adolescent pregnancy compared to adult women(18). In a medical birth register study from Sweden in the period 1992-2010, newborns from adolescents were less likely to show fetal distress, with a rate of 0.4% for women aged 17-19 versus 0.5% for women aged 25-29(18). In our study we observed that, although a high number of patients were diagnosed with fetal distress, the Apgar score was satisfactory in most of the cases. This is related probably to a prompt diagnosis and correct management of the pregnant adolescents. Also, in the Department of Obstetrics and Gynecology of the Bucharest University Emergency Hospital, there are treated numerous patients with preexistent pathologies that usually determine chronic fetal distress (ex.: a 15-year-old pregnant adolescent with Hodgkin lymphoma nodular sclerosis stage II, a 19-year-old pregnant adolescent with permanent cardiac pacing and class III NYHA chronic heart failure).
Regarding the weight of the neonate from pregnant adolescents, some specialists determined that is significantly lower in adolescents(2). The rates of birth weight under the 3rd percentile by gestational age were 6.9% for women under 15 years old and 5.1% for women aged 15-19 years old versus 4.2% for women aged 25-30 years(2). In our study, only 83 neonates had a weight at birth lower than 2500 grams. Fifty-one of them were diagnosed antepartum with intrauterine growth restriction (Figure 6).
Another important aspect in our study is that most of the patients enrolled did not undergo regulated pregnancy visits (n=421). None of the patients from Group I has attended any medical visits during pregnancy. This is related to the poor level of sanitary education of the families of the adolescents’ mothers. The society and mainly their families should support them to correctly monitor the development of the fetus, in order to decrease both maternal and fetal morbidities.
Adolescent pregnancy is an important global issue. Pregnancy in adolescents involves multiple problems, such as obstetrical complications, newborns complications, mental disorders and social difficulties. Fetal and maternal morbidity and mortality are high in this category of patients. This is why an appropriate management during pregnancy and peripartum plays an essential role in decreasing these complications. We need to improve the educational system and to create a clinical guide for the management of pregnant adolescents, because they represent a different category with specific features.
Conflict of interests: The authors declare no conflict of interests.
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