Pregnancy in adolescents

INTRODUCTION — 

Adolescent pregnancy is addressed by health care providers during pediatric visits for health maintenance and contraception; acute care visits; and diagnostic evaluations for menstrual irregularities, fatigue, gastrointestinal complaints, or pelvic pain. The topic may also be initiated by the adolescent during a visit with their health care provider.

Laws regarding confidential counseling when a minor has a positive pregnancy test vary from state to state. The United States Supreme Court Dobbs v Jackson ruling in June 2022, overturning the constitutional right to abortion, has limited the options available to patients with a positive pregnancy test in many states. Providers must be aware of the options in their state and be prepared to counsel adolescents who have a positive pregnancy test. (See "Confidentiality in adolescent health care" and "Consent in adolescent health care", section on 'Consent for specific services'.)

The diagnosis and early clinical management of adolescent pregnancy relevant to the pediatric health care provider will be discussed here. The prevention of pregnancy, contraceptive issues, and an overview of the diagnosis and clinical manifestations of early pregnancy are discussed separately. Prenatal and postpartum care, pregnancy complications, and labor and delivery issues also are reviewed separately. (See "Contraception: Overview of issues specific to adolescents" and "Clinical manifestations and diagnosis of early pregnancy".)

EPIDEMIOLOGY — 

The teenage birth rate in the United States (across racial and ethnic groups) declined 78 percent between 1991 and 2022 [1]. Although it increased transiently between 2005 and 2007, it decreased to historic lows between 2007 and 2022 [1-3], largely related to increased contraceptive use and increased use of highly effective methods of contraception [4]. (See "Contraception: Overview of issues specific to adolescents", section on 'Factors to consider'.)

The majority of teen pregnancies occur in 18- and 19-year-olds as this age group has the highest number of sexually active teenagers. The birth rate among adolescents aged 15 to 19 years was 13.9 per 1000 in 2021 and 13.6 per 1000 in 2022, declining from 15 per 1000 in 2020 and 16.7 per 1000 in 2019 [3,5]. The decreases occurred primarily among 18- to 19-year-olds. However, racial/ethnic disparities related to social determinants of health (eg, health care access) continue. The birth rate in Hispanic teens and non-Hispanic Black teens was approximately twice that of non-Hispanic White teens; the birth rate in American Indian/Alaska Native teens was approximately 2.5 times that of non-Hispanic White teens [2]. Adolescents with mental health symptoms or major mental illness (eg, major depression, bipolar disorder, psychotic disorders) appear to be at increased risk of pregnancy [6,7].

●Unintended pregnancies – The majority of pregnancies among teenagers are unintended (ie, mistimed or unwanted) [8-10]. In the United States between 2012 and 2017, unintended pregnancies in people age 15 to 44 declined in the majority of states; the declines varied by state, ranging from -1 to -31 per 1000 pregnancies [11].

In one meta-analysis, unintended pregnancies, including those in adolescents, were associated with adverse maternal and infant health outcomes (eg, higher odds of depression during or after pregnancy, interpersonal violence, preterm birth, infant low birth weight) [12].

Among 15- to 19-year-old people with unintended pregnancies resulting in live births between 2004 and 2008, 50 percent were not using any method of contraception before the pregnancy (24 percent because their partner did not want to use contraception), 31 percent believed they could not get pregnant at the time, 13 percent had trouble getting contraception, and 22 percent did not mind if they got pregnant [13].

●Repeat pregnancies – Surveillance data indicate that in 2017, approximately 16 percent of births to teenagers 15 to 19 years of age in the United States were repeat births [1,14]. Risk factors for repeat teenage pregnancy include depression, history of abortion, living with a partner or increased partner support, lower socioeconomic conditions (eg, poverty, unemployment), and fewer publicly funded family clinics [15,16]. Protective factors include higher levels of education and use of contraception, particularly long-acting reversible contraceptives [17].

●Characteristics of fathers – Approximately one in five infants born to adolescents is fathered by males five or more years older than the birthing parent. In a large observational study, 36 percent of adolescents with first pregnancy before age 15 years and 17 percent of adolescents with first pregnancy between 15 and 19 years reported that their sexual partner was ≥6 years older than they were at the time of their first sexual encounter [9].

DIAGNOSIS OF PREGNANCY — 

The diagnosis and clinical manifestations of early pregnancy are discussed in detail separately. Aspects of the history that pertain specifically to adolescents are discussed below. (See "Clinical manifestations and diagnosis of early pregnancy".)

History — Pediatric health care providers should have a low threshold for suspecting pregnancy in adolescents. A pregnant adolescent may complain of missing or irregular periods. Some adolescents mistake implantation bleeding in early pregnancy for normal menstrual bleeding and, thus, do not seek pregnancy testing, whereas others may report early first-trimester vaginal bleeding [18]. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Presentation'.)

Pediatric health care providers need to be aware that an adolescent may or may not have considered the possibility of pregnancy or may present with vague complaints with suspected pregnancy as a "hidden agenda." One study compared the presenting complaints and historical information of pregnant adolescents (≤16 years) whose diagnosis of pregnancy was made or not made in the emergency department of a tertiary-care hospital [19]. The following findings were noted:

●Adolescents whose pregnancy was diagnosed more frequently had complaints related to the abdomen or genitourinary system than those whose pregnancy was not diagnosed (91 versus 22 percent).

●Less than 10 percent of the patients who had pregnancy diagnosed mentioned the possibility of pregnancy at initial triage, and 10.5 percent denied having had sexual activity.

●68 percent of patients whose pregnancies were not diagnosed (ie, who were pregnant at the time of the visit, but in whom the diagnosis was missed) had no documentation of their menstrual or sexual history.

Thus, pediatric health care providers should elicit a menstrual and sexual history routinely from their female adolescent patients, regardless of the nature of their complaints. Historical features, such as amenorrhea, morning sickness, urinary frequency, increased appetite, weight gain or bloating, and tender or tingling breasts, are suggestive of pregnancy but are not reliable indicators for excluding pregnancy when absent. In a clinical review, the sensitivity of amenorrhea was 63 percent and the specificity was 60 percent; the sensitivity of morning sickness was 39 percent and the specificity was 86 percent [20]. A patient's thinking that they could be pregnant and an abnormal last menstrual period were strongly correlated with a positive pregnancy test.

Specific screening questions that may be helpful include [20]:

●"When was your last menstrual period? Was it similar to your usual menstrual periods?"

●"How do you keep track of your periods? Do you use a 'period app' or your calendar?" If yes to either, "Can we take a look at your periods in recent months?"

●"Do you engage in sexual activity with partners assigned male at birth? If so, when was the last time?"

●"Do you use any birth control method, including condoms?"

●"Do you have any nausea, urinary frequency, increased appetite, or weight gain?"

●"Is there any chance you may be pregnant?"

Signs and symptoms of pregnancy are discussed in greater detail separately. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Clinical manifestations of early pregnancy'.)

Physical examination — Pertinent physical examination findings of the adolescent in whom pregnancy is suspected are discussed separately. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Findings on physical examination'.)

Laboratory evaluation — The laboratory evaluation of the adolescent in whom pregnancy is suspected is discussed separately. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Detection of human chorionic gonadotropin'.)

Pretest counseling — It is important to ask what the adolescent would do if the pregnancy test were positive before the test is performed so that appropriate support can be in place when the results are provided. It is also important to ask who they could tell about the pregnancy. Teenagers may have a variety of emotional responses to a newly diagnosed pregnancy, the most extreme of which may be suicidality, particularly if there is a history of previous suicide attempts. (See 'Posttest counseling' below.)

The conversation about how the teen would respond to the reality of pregnancy or parenthood before the test is performed may elicit further discussion about initiating a contraceptive method if the test is negative.

Posttest counseling — Clinicians providing posttest counseling must bear in mind the laws regarding the adolescent's right to confidentiality in their state. In some states, the provider "shall not" disclose the information to a parent or guardian; in others, they "may" do so. (See "Confidentiality in adolescent health care", section on 'Parental/caregiver notification'.)

●Positive pregnancy test

•Provide the results and factual information – The first step after confirming a pregnancy with a pregnancy test is informing the adolescent of the test result and providing factual information regarding the duration of pregnancy and estimated due date. This information should be provided using clear language (eg, "The pregnancy test shows that you are pregnant") and without emotional bias.

•Elicit the adolescent's thoughts and feelings about the result – Elicit the adolescent's thoughts and feelings about the test result. The provider might ask, "How are you feeling about this information?" Adolescents may have a variety of responses to pregnancy confirmation (eg, ambivalence, denial, fear, shock). Providing emotional support to the adolescent is important at this time, and these feelings should be acknowledged as normal.

-Some adolescents perceive positive consequences of pregnancy or childbearing and want to be pregnant [21-23]. In a 2014 nationally representative survey of 975 adolescent females, 15 percent reported a positive pregnancy attitude (response to the question: "If you got pregnant now, how would you feel? Would you be very upset, a little upset, a little pleased, or very pleased?") [23]. Another study in 1996 surveyed 200 pregnant 13- to 18-year-olds to see why they failed to use contraception before conception [24]. Nearly one-fifth responded that they wanted to get pregnant, and another one-fifth that they did not mind being pregnant. In a separate case-control study, adolescents who wanted a baby were more likely to be married and out of school before becoming pregnant than teens who reported their pregnancy "just happened" [25].

-Other adolescents may feel stigmatized by pregnancy. Cultural attitudes regarding adolescent pregnancies must be considered when assessing response to a positive test in an adolescent [26].

-Adolescents may be reticent to disclose physical or sexual abuse.

-Studies on suicidal ideation in pregnant adolescents are predominantly reported from low- and middle-income countries. Reports from the United States are limited. In a retrospective review of 18 pregnant adolescents admitted to an inpatient child and adolescent psychiatric unit with depressive mood and mood disorders over an eight-year period, the mean gestational age was 10.4 weeks; pregnancy contributed to suicidal ideation in 11 [27]. In a global review of the literature, suicidal ideation occurred in 5 to 14 percent of people during pregnancy and the postpartum period [28]. Adolescents appear to be at greater risk than adults to complete suicide [29]. A prior history of a suicidal attempt may place an adolescent diagnosed with a pregnancy at risk for a repeat suicidal attempt [30]. (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors".)

•Discuss whether and how to inform others – Discuss with the adolescent their thoughts on whether and how to inform their parent(s)/caregiver(s) and their partner, bearing in mind that delays in informing others may delay prenatal care. Although adolescents tend to delay informing parents/caregivers, their mothers usually have a strong influence on the adolescent's pregnancy decision. We usually encourage the pregnant adolescent to inform their parent(s)/caregiver(s) and their partner, but some adolescents have valid reasons not to tell them (eg, if doing so will threaten the adolescent's safety). In those cases, it is important to explore whether the adolescent can confide in another supportive adult.

Special attention should be given to teenagers belonging to cultures that stigmatize unmarried mothers (eg, immigrant families from the African continent, Middle East, and Asia), although stigma can occur in any community [26,31].

If caregivers are present at an office visit, the adolescent may not be comfortable informing their caregivers at the visit when pregnancy is confirmed, although the health care provider may feel caregiver involvement is the next best step to take. In this situation, scheduling another office visit or a phone call in 24 to 48 hours for a follow-up is advisable. During this period, older adolescents may seek support from extended family and friends. In the author's experience, most adolescents inform their caregivers within this time period and on their own terms.

The provider may also offer to help the adolescent disclose the information to their parents/guardians, either by simply being present for support or by helping the adolescent initiate the discussion. Additional information on providing confidential services to adolescents is described separately. (See "Confidentiality in adolescent health care".)

●Negative pregnancy test – A negative pregnancy test provides an opportunity to discuss effective contraception. However, adolescents (18 to 19 years old) who experience pregnancy scares often continue to use less effective or no methods of contraception, leading to unintended pregnancy [32,33]. (See "Contraception: Overview of issues specific to adolescents", section on 'Factors to consider' and "Emergency contraception", section on 'Candidates'.)

Emergency contraception may be warranted if the adolescent had unprotected sex in the past five days and does not desire pregnancy. (See "Emergency contraception", section on 'Candidates'.)

CLINICAL MANAGEMENT OF EARLY PREGNANCY

Pregnancy counseling — The adolescent may have considered their options already; the options should be discussed in a developmentally appropriate, factual, respectful, nonjudgmental, and open manner, using neutral language: "What thoughts do you have about what you might want to do?" [26]. The adolescent should be counseled on all options (ie, abortion, adoption or kinship care, parenthood), especially when they have ambivalent feelings. Estimating gestational age and expected date of delivery provides important information when making referral decisions in states with abortion bans; it is important to make a referral to a reliable clinical resource as soon as possible. Gestational age can be estimated by a pregnancy calculator. (See "Prenatal assessment of gestational age, date of delivery, and fetal weight", section on 'Best estimate of delivery date'.)

●Adolescents considering termination of the pregnancy – When an adolescent is interested in abortion, the counseling approach depends upon the availability of resources, including a support system, and the laws of the state, country, or institution. An American Academy of Pediatrics policy statement affirms the right of an adolescent to confidential care when considering abortion [34].

•Locations where abortion is permitted based on gestational age – In locations where an abortion is permitted based on gestational age, calculation of the gestational age is essential and the adolescent should be referred as soon as possible to a clinician or clinic where comprehensive pregnancy counseling involving shared or collaborative decision-making is provided, unless the health care provider has expertise in pregnancy counseling [26,35].

If a pregnancy is considered too advanced for a termination (based on state/country law), it is important that the provider convey this information. (See "Counseling in abortion care".)

•Locations where abortion is prohibited – In locations where abortion is totally banned, patients may have options including access to the procedure in other states or countries. Access to these services can be explored with the help of expert pregnancy counselors. However, in the United States, providers in states that have prohibited abortion may be cautious about offering details. They can provide information regarding resources for pregnancy counseling that can be obtained through referrals from colleagues, reproductive clinics, and the internet. The location and limits of abortion clinics in the United States can be accessed through the National Abortion Federation. (See "Counseling in abortion care".)

Providers in states with an abortion ban in effect should be mindful that primary care providers may not be permitted to provide any counseling or assistance with connecting patients and families to in-state or out-of-state counseling services. Doing so could result in a potential civil penalty (ie, "providing or aiding a person to obtain an abortion"). However, handing out a list of in-state and out-of-state counseling services may not be considered aiding in an abortion [36].

Fears about on-site whistleblowers submitting a report about a provider who connects a patient and family to abortion resources can be mitigated by consulting legal counsel and developing clear guidelines and protocols for counseling patients with unintended pregnancies.

In the United States, adolescents choosing abortion should also be aware that at least 35 states require parental involvement for a legal abortion. Most of these states require consent or notification from only one parent/guardian, with submission of consent typically 24 to 48 hours before the procedure. A few states require involvement of both parents/guardians. Some states require government identification, and, in some states, proof of parenthood is also required [37]. The gestational limit for an abortion also varies by state. State-specific information about parental notification/involvement and gestational limits is available through the Guttmacher Institute.

If an adolescent chooses abortion, parental notification of an abortion in a minor is required only of health care personnel directly involved with providing legal abortions. This statute should not be interpreted as parental notification by the health care provider. A judicial bypass system also exists whereby a minor may ask a judge to consent to the procedure in lieu of a parent/guardian [34,38]. The judge must consent if they have determined the adolescent to be a mature minor or if termination of pregnancy is in the minor's best interest. In the United States, there is no legal requirement to notify the patient's partner prior to an abortion.

It might be helpful to prepare the adolescent for the potential presence of protesters outside the clinic that performs abortions and to let them know that such clinics frequently provide a volunteer escort service during an active protest.

●Adolescents who are uncertain about continuing pregnancy or plan to continue pregnancy – Adolescents who decide to continue the pregnancy, or are uncertain whether they will continue the pregnancy, should initiate folic acid-containing prenatal vitamins and be counseled about the adverse effects of alcohol, drugs, and smoking on the developing fetus [39]. The health care provider should contact the adolescent approximately one week after the initial visit to follow up and ensure that appropriate care is in place.

Adolescents who decide to continue their pregnancies to term should be referred for specialized prenatal care as soon as possible [26,40]. Adolescents younger than 15 years of age are less likely to receive prenatal care, and late entry into prenatal care has been positively correlated with preterm or low-birth-weight delivery and complications from preeclampsia [41,42]. Early testing for sexually transmitted diseases, initiation of folic acid-containing prenatal vitamins and good nutrition, avoidance of alcohol and other substances, and assessment of underlying familial and medical conditions are important for a healthy pregnancy [39]. The health care provider also can assist with smoking or vaping cessation by educating an adolescent smoker or e-cigarette user on the negative effects of nicotine on the developing fetus and by encouraging them to stop smoking. (See "Prenatal care: Initial assessment" and "Cigarette and tobacco products in pregnancy: Screening and impact on pregnancy and the neonate" and "Alcohol intake and pregnancy", section on 'Perinatal outcomes'.)

Assistance from a social worker may be necessary to facilitate referral for comprehensive pregnancy counseling and enrollment into prenatal care and financial assistance programs because adolescents identify lack of finances, transportation, and waiting time for appointments as barriers to public prenatal care [42,43]. Social workers also can help to arrange tutoring or enrollment in special educational programs to allow the adolescent to remain in school or complete academic requirements for graduation at home.

Morning sickness — The evaluation and management of pregnancy-related nausea and vomiting are discussed separately. (See "Nausea and vomiting of pregnancy: Clinical findings and evaluation" and "Nausea and vomiting of pregnancy: Treatment and outcome".)

Nutrition — Pregnant adolescents should take one folic acid-containing prenatal vitamin every day [39]. Adequate nutrition during pregnancy is necessary to optimize maternal, fetal, and infant health. Pregnant adolescents are at particular risk for nutritional deficiencies [44]. Adolescents have increased nutritional needs related to normal pubertal changes (eg, increased height and changes in body composition). At baseline, they may have poor diet quality, with insufficient intake of micronutrients (eg, iron, folate, zinc, calcium) and excess intake of total fat, saturated fat, and sugar [45]. Pregnancy compounds these risks. (See "Normal puberty" and "Healthy eating for adolescents".)

A complete discussion of nutrition during adolescent pregnancy is beyond the scope of this review. Areas of particular importance include [44]:

●Adequate energy intake – Recommendations for weight gain during pregnancy are the same for adolescents and adults. (See "Gestational weight gain".)

●Iron – Iron is necessary for both fetal/placental development and to expand the maternal red cell mass. (See "Iron requirements and iron deficiency in adolescents" and "Nutrition in pregnancy: Dietary requirements and supplements", section on 'Iron'.)

●Folic acid intake – Folic acid (folate) requirements are increased during pregnancy. Adequate folate intake is important for making ribonucleic acid (RNA) and deoxyribonucleic acid (DNA; genetic material), preventing some congenital anomalies, and in producing red blood cells. The preconception period is the optimal time for ensuring adequate folic acid consumption. (See "Preconception and prenatal folic acid supplementation" and "Nutrition in pregnancy: Dietary requirements and supplements", section on 'Folate/folic acid'.)

●Calcium intake – Calcium intake during adolescence is an important determinant of bone mineralization and bone density. Adequate calcium intake in pregnant and nonpregnant adolescents (14 to 18 years) is 1300 mg per day. (See "Bone health and calcium requirements in adolescents", section on 'Calcium intake'.)

Referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may be helpful for pregnant teenagers who meet eligibility requirements.

OUTCOME

Pregnancy outcome

●Pregnancy termination – In the United States, before the Supreme Court Dobbs v Jackson ruling in June 2022, which overturned the constitutional right to abortion, approximately 25 percent of pregnancies in adolescents (<20 years old) were terminated and 61 percent resulted in a live birth [46]. Abortions were obtained at ≤9 weeks' gestation for approximately 60 percent of adolescents <15 years old and 74 percent of those ages 15 to 19 years [47].

Between 2011 and 2020, abortion rates decreased by 56 percent (from 0.9 to 0.4 per 1000) among adolescents <15 years and by 48 percent (from 10.5 to 5.5 per 1000) among adolescents ages 15 to 19 years.

Data from 2020 indicate that adolescents 18 to 19 years old accounted for 71 percent of abortions obtained by adolescents, and those <15 years old accounted for approximately 3 percent [47].

Adolescents depend on more support than adults when seeking abortion care. Data from the Guttmacher Institute's 2021-2022 Abortion Patient Survey indicate that adolescents are more likely than adults to seek second trimester abortion [48]. Compared with adults, delays in care were more likely to be due to not knowing they were pregnant or not knowing where to seek an abortion. More than one-half delayed due to expenses or sold something to help cover costs, and one-quarter didn't have health insurance. Two-thirds of adolescents reported that someone had driven them to the facility.

●Pregnancy continuation – Most adolescents (<20 years) in the United States carry their pregnancies to term [47].

•Type of delivery – The primary cesarean birth rate for teenagers was approximately 18 percent in 2019 [2]. Teenagers require instrumental deliveries (ie, forceps or vacuum extraction) approximately twice as often as those aged 20 to 24 years [49,50]. The reason for the higher rates of instrumental delivery is not clear. Proposed explanations include the physical immaturity of the teen and fright or lack of cooperation during the second stage of labor [50,51].

•Maternal morbidity and mortality – The risk of adverse maternal outcomes for adolescent pregnancies appears to be increasing. In a cross-sectional study of >6 million deliveries among patients age 11 to 19 years from 2000 to 2018, rates of hypertensive disorders of pregnancy (eg, gestational diabetes, preeclampsia), postpartum hemorrhage, and severe maternal morbidity (defined as an unexpected outcome associated with short- or long-term consequences for maternal health) increased over time [52]. The prevalence of comorbid conditions complicating pregnancy (eg, obesity, mental health conditions, substance use disorder, asthma, and pregestational and gestational diabetes) increased among patients age 11 to 19 years also increased overtime.

Maternal mortality rates are not available for the age group ≤19 years of age. In 2022, the maternal mortality rate for those ≤25 years of age was 14.4 per 100,000 live births, a decrease from 20.4 in 2021 [53]. Mortality rate per 100,000 live births varied by race/ethnicity (31.3 Black/non-Hispanic, 10.8 White/non-Hispanic, and 9.5 Hispanic).

•Delivery outcomes – Adolescent pregnancy appears to be associated with adverse delivery outcomes including preterm birth, fetal growth restriction, low birth weight, and infant deaths, particularly for younger adolescents [54-61]. This is especially true if adolescents do not receive adequate prenatal care [61]. Whether these outcomes are the result of biologic immaturity (ie, age at menarche) or sociodemographic factors related to adolescent pregnancy (eg, level of education, support of partner, financial stability) remains unclear.

However, in a multicountry study that included 124,446 mothers ≤24 years of age, the risk of adverse outcomes remained increased in adolescents (≤19 years) compared with young adults (ie, 20 to 24 years) after controlling for country, marital status, educational attainment, and parity [56]. Similar results were noted in an earlier study in a homogeneous population (134,088 White primiparous people ≤24 years of age from a single state in the United States) [61].

Mortality rates of infants born to adolescents appears to be declining in the United States. From 1996 to 2019, infant mortality rate in this group decreased from 10.3 to 8.6 per 1000 live births. This decrease occurred for infants born to Black, White, and Hispanic teenagers; however, infant mortality remained the highest among babies born to Black adolescents throughout this time period [62].

•Adoption – There are few data regarding the rate of adoptions from teen pregnancies. The rate of adoptions from pregnancies is not reported in the same manner as other reproductive health variables. The "adoption at the time of birth" rate has not been a standard pregnancy outcome measure in national/state surveys. Estimating adoption rates is also difficult because infants may be relinquished at different times (eg, at birth or after being assigned to foster care). Data from the National Survey of Family Growth, which asked respondents about the status of each child ever born, indicate that the rate of premarital births with a plan for adoption declined from 9 percent in the 1970s to 3 percent in the 1980s and approximately 1 percent in the early 1990s [63,64].

Subsequent pregnancies — Other reports have evaluated the outcomes of subsequent pregnancies after a first teenage pregnancy. In a population-based series limited to teenage pregnancies, adverse perinatal outcomes were more common among second, but not first, births to nonsmoking teenagers [65]. In another study, the increased rate of preterm birth diminished in subsequent pregnancies after the teenage period [66].

Postpartum depression — Adolescents are at risk for post-partum depression. In a systematic review, reported rates of postpartum depression in adolescents ranged from 7 to 37 percent, in part secondary to the methods of assessment (eg, structured interview versus self-report) [67]. The prevalence of depressive symptoms was increased during the first three months after delivery. Postpartum depression is discussed separately. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

Long-term effects — Data regarding long-term effects of adolescent pregnancy on physical development are too limited to draw any conclusions [68].

Social impact — Adolescent parenthood is challenging [26]. Family and social support is crucial to mitigating the adverse socioeconomic outcomes associated with adolescent parenthood [69]. For the adolescent parents, adverse socioeconomic outcomes include fewer years of education, increased risk of living in poverty, and increased risk of intimate partner violence [45,70-73]. For the infants, adverse outcomes during childhood and adolescence include increased risk of cognitive and learning problems, internalizing problems (eg, depression, anxiety, suicidal ideation), and externalizing problems (eg, conduct disorder, delinquency, behavioral problems), early sexual debut, and early parenthood [69,74].

PREVENTION — 

Systematic reviews of pregnancy prevention programs suggest that successful programs include a combination of interventions that provide community or school-based comprehensive sexuality education, focus on delay of sexual activity in young teens, and promote consistent and correct use of effective contraceptives, including the contraceptive implant and intrauterine device [75-78]. Individual counseling, provision of contraceptives or prescriptions for contraceptives, and free or low cost services also contribute to program effectiveness. A list of evidence-based teen pregnancy prevention programs in the United States is available through the Office of Adolescent Health Teen Pregnancy Prevention Program. (See "Sexual development and sexuality in children and adolescents" and "Contraception: Overview of issues specific to adolescents".)

Although they are popular, "infant simulator" programs, which combine educational sessions and "care" for a doll that is programmed to replicate infant behaviors, are not effective in reducing teen pregnancy. In a school-based cluster randomized trial, 13- to 15-year-olds received the infant simulator intervention (n = 1267) or standard health education curriculum [79]. By 20 years of age, adolescents in the intervention schools had higher rates of birth and abortion than those who received the standard curriculum (8 versus 4 percent for birth; 9 versus 6 percent for abortion; adjusted relative risk for either outcome 1.4, 95% CI 1.1-1.7). These findings support those from smaller observational studies and literature reviews [80].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Adolescent sexual health and pregnancy".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Teen sexuality (The Basics)")

●Beyond the Basics topic (see "Patient education: Adolescent sexuality (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology – The teenage birth rate in the United States has declined since 1991. The majority of adolescent pregnancies occur in 18- and 19-year-olds. (See 'Epidemiology' above.)

●Diagnosis of pregnancy

•Pediatric health care providers should have a low threshold for suspecting pregnancy in adolescents. A pregnant adolescent may complain of missing or irregular periods. Pediatric health care providers also must be aware that a pregnant adolescent may present with vague complaints and may or may not have considered the possibility of pregnancy. (See 'History' above.)

•The diagnosis and clinical manifestations of early pregnancy are discussed separately. (See "Clinical manifestations and diagnosis of early pregnancy".)

●Counseling adolescents

•Pretest counseling – It is important to ask what the teenager would do if the pregnancy test were positive before the test is performed, so that appropriate support can be in place when the results are provided, particularly if the adolescent responds that they would kill or otherwise endanger themself if they were pregnant. (See 'Pretest counseling' above.)

•Posttest counseling – When the results of a positive pregnancy test are disclosed to the adolescent, their thoughts and feelings about the test result should be elicited and emotional support provided. In addition, factual information regarding the duration of pregnancy and estimated due date should be provided. It is also important to determine how the adolescent wants to go about informing their parent(s) or caregiver(s) and their partner. (See 'Posttest counseling' above.)

•Pregnancy counseling – Options regarding the pregnancy should be discussed in a nonjudgmental manner. If the adolescent is seeking an abortion, they should be referred as soon as possible to a clinician or clinic where abortion services are provided. In states that ban abortions, time for travel to another state will impact the timeline.

Adolescents who decide to continue the pregnancy, or are uncertain whether they will continue the pregnancy, should initiate prenatal vitamins and be counseled about the adverse effects of substance use on the developing fetus. Adolescents who decide to continue their pregnancies should also be referred for specialized prenatal care as soon as possible.

The health care provider should contact the adolescent approximately one week after the initial visit to follow up and ensure that appropriate care is in place. (See 'Pregnancy counseling' above.)

●Outcome

•Adolescents appear to be at increased risk for adverse pregnancy outcomes, such as low-birth-weight babies and infant deaths. Whether these outcomes are the result of biologic immaturity or sociodemographic factors related to adolescent pregnancy remains unclear. (See 'Pregnancy outcome' above.)

•Adolescent pregnancy is associated with several adverse socioeconomic outcomes for the parents and child. (See 'Social impact' above.)

●Pregnancy prevention – Pregnancy prevention is multifaceted and should include comprehensive sexuality education, focus on delay of sexual activity in young teens, and promote consistent and correct use of effective contraceptives. (See 'Prevention' above and "Contraception: Overview of issues specific to adolescents".)