O&G Clinical Case Discussion regarding Teen Pregnancy

1. Clinical Case Discussion
Afiqi

2. Ms SA, a 19 year old, single mother G2 P1, at 22 weeks 6 days
of gestation was referred from KK Klebang for low hemoglobin
level during antenatal check up.
Patient was apparently well when came for regular antenatal
check up. In the clinic, routine investigation was done and found
that her hemoglobin level was 6.8 g/dl.
She denies any dizziness, lethargy or palpitation. USG was done
and she was told that her baby is healthy. She was admitted for
further investigation.

3. She was encouraged to take iron rich diet and double haematinics.
She also claims that she is compliance to medication.
She had no significant medical and surgical history. Her antenatal
booking was at 3 weeks of gestation in KK Tenggera.
On further inquiry, both pregnancy are from premarital relationship.
She is non-smoker and her antenatal history until current
gestational age is unremarkable.

4. Ms SA, a 19 year old single mother, G2 P1, at 22 weeks 6 days of
gestation was referred from KK Klebang for low hemoglobin
level during antenatal check up.
Patient was apparently well when came for regular antenatal
check up. In the clinic, routine investigation was done and found
that her hemoglobin level was 6.8 g/dl.
She denies any dizziness, lethargy or palpitation. USG was done
and she was told that her baby is healthy. She was admitted for
further investigation.

5. She was encouraged to take iron rich diet and double
haematinics. She also claims that she is compliance to
medication.
She had no significant medical and surgical history. Her antenatal
booking was at 3 weeks of gestation in KK Tenggera.
On further inquiry, both pregnancy is from premarital
relationship. She is non-smoker and her antenatal history until
current gestational age is unremarkable.

6. • On general examination:
– Weight: 54 kg, height: 150 cm, pulse: 78 bpm, BP: 100/68 mmHg,
temperature: 37 ⁰C. She had mild pallor, no icterus.
• Obstetric examination showed her uterus is non-tender and
corresponds to gestational age. (SFH – 22 cm). There is single
fetus with cephalic presentation and fetal heart rate is 125/min.
• Latest scan (28/6/2016)
– Parameter: 19-20 weeks
– Placenta: posterior
– Liquor: adequate

7. Teenage Pregnancy

8. DIAGNOSIS?

9. TEENAGE PREGNANCY
•Defined as teenage girl, within the age of 13-19, becoming
pregnant
•It is associated with adverse outcomes especially perinatal
morbidity and mortality

10. RISK FACTORS
•Social deprivation
•Low socioeconomic status
•Low educational background
•Teenage parents
•Crime
•Sexual abuse
•Mental illness

11. INVESTIGATION DONE ON MS SA:
•Full blood count
•Hb: 7.3 g/dl
•HCT: 26.4 %
•MCV: 63 fL
•MCH: 18.3 pg
•MCHC: 29.3 g/dl
•WBC: 10.0 x 10^9/L

12. •Iron status- serum ferritin: 13.6 pmol/L
•Hb analysis: once the iron deficiency anemia corrected
•Peripheral blood film
•Hypochromic and microcytic
•Mild anisopoikilocytosis with pencil cells and target cells

13. Adolescent Birth Rates
62/1000 in SGH, Kuching
(2010-11)
20-25/1000 in UK
62/1000 in
SGH,
Kuching
(2010-11)
Teenage Pregnancy
43.8% unmarried
80% stopped schooling
33% SGA
16.7% preterm deliveries
9.6% nutritional anaemia
Muniswaran et.al. Adolescent pregnancies in Sarawak: the unspoken facts.
BJOG; 2012.

14. Impact to Pregnant Teen
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol

15. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Multifactorial involving adolescent
pubertal growth, pregnanccy
physiological changes & teenage
habits

16. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Pregnancy induced hypertension

17. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Sexually abused, neglected, ill-treated

18. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
They still retain the potential to grow while
pregnant. But, the growth is associated with
paradoxical outcome:
- Spontaneous miscarrige
- IUGR / SGA (competition for nutrients
between maternal body & gravid uterus)
- Very preterm birth (< 32 weeks)
Immature pelvis -> obstructed labour

19. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Due to complication of prematurity &
severe IUGR
Secondary outcome following maternal
disease complications e.g. placental
abruption, severe PIH, STIs

20. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Nutritional inadequacy & non-compliance to
oral iron supplement

21. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Offspring of adolescents tend to have:
− Poor cognitive development
− Lower education achievement
− More frequent criminal activity
− Higher risk of abuse, neglect, &
behavioural problems during childhood
− Teeenage pregnancy

22. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Post-natal depression

23. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
USA: 1:5 had STI
UK: 1:8 had STI
Gonorrhoea, Chlamydia, Syphilis, HIV,
Herpes simplex infection

24. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
Poor eating habits & neglect to
vitamin & iron supplements, thus at
risk of poor weight gain & LBW
baby

25. Issues with Teenage Pregnancy
• Preterm birth / SGA / LBW
• Raised BP
• Easily abused
• Gynaecological immaturity
• Neonatal mortality
• Anaemia
•Next generation impact
• Cry
• Infections
• Eat badly
• Smoking / substance abuse / alcohol
10% risk of severe IUGR (< 32 weeks)
among smokers
Maternal risk:
Placental abruptions, PPROM
Fetal risk:
Preterm birth, stillbirth, sudden infant
death syndrome, prenatal exposure to
tobacco smoking predisposes to
respiratory infection, asthma, allergy,
child hood cancer, & adverse
neurobehavioural development

26. Management

27. •Antenatal care
• Choice for termination of pregnancy.
Abortion is legal in Malaysia in the following situations
only:
When a woman's life is in danger
When a woman's physical health is in danger
When a woman's mental health is in danger
Furthermore, a woman must consent to an abortion,
and she must have a medical professional's
authorization. The legal period within which an
abortion can take place is 120 days.

28. •Continuation of pregnancy
•Encourage the pregnant mother to access antenatal care
•General measures
•Psychosocial support, dietary advice, contraception advice
and adequate post natal follow up
•Gestational age needs to be confirmed (late presenter for
antenatal care)
•Information regarding antenatal follow up and labor should be
provided

29. •Care during labor and delivery
•Same as for other laboring women
•In teen mothers, there is an increase risk of obstructed labor
(because of small and immature pelvis)
•Post natal care
•Counsel and educate mother regarding infant care
•Some areas that need special attention are discussed
pertaining to financial issues, returning to school and
contraceptive advice

30. •Management given to Ms SA:
•Tab. Ferrous fumarate 400 mg BD
•Tab. Vit C, B complex, folate ½ OD
•IV venofer (iron sucrose)
•Initially she refused for blood transfusion
but after counseling session, she agreed to
receive blood transfusion.
•During 1 pint of packed red cell transfusion,
she experience rashes. After further
investigation, she was suspected to have
Bombay blood type.

31. PREVENTION
•Sexual education
•Use and provision of contraception (already sexually active)
•‘Double Dutch’: combined use of condom plus
contraception (most effective option to protect against STI)
•Close links with association services: STI clinics, social
services, etc