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A study of the obstetric performance of the adolescent Jamaican primigravida
A study of the obstetric performance of the adolescent Jamaican primigravida DAVID
M.
HAY,
M.B.,
F.R.C.S.(C), JOHN
M.R.C.O.G.,
F.A.C.O.G. J.
BOYD,
F.R.C.S. Kingston,
CH.B.,
M.B.,
CH.B.,
M.R.C.O.G.,
(C) Jamaica,
West
Indies
The obstetric performance in the University Hospital, that of older primigravidas. hemorrhage, or anemia but low operative delivery rate and babies with good Apgar probably achieved by good
of 226 primigravidas, aged 16 years or less, delivered Kingston, Jamaica, was studied and compared with There was no increase of pre-eclampsia, antepartum postpartum hemorrhage was common in this group. The was associated with a low incidence of fetal distress scores. The over-all good obstetric performance wax antenatal care.
I N T I-I E Y E A R 1922 Harris’ suggested that 16 years of age or less was the optimum time for the occurrence of a first labor. Since then several studies have been made on the effect of pregnancy in young teenagers with different results. A higher incidence of preeclampsia has been reported in these girls but there has been no unanimity regarding prolonged labor, cesarean section, or prematurity. Israel and Woutersz’ pointed out that only three studies had dealt with more than 500 deliveries in this group of patients:‘-” and suggested that the different results recorded by different authors may have been due to variations in age, marital status, or socioeconomic factors: they proceeded with a cooperative study of 3,395 teenage pregnancies from a group of ten hospitals. These patients were all less than 20 years of age and accounted for 9.8 per cent of the total deliveries in the study. The teenage patients \rere comFrom Received 1972. Accepted Reprint Division University Alberta,
the
University for
Hospital,
publication
November requests: Dr. of Obstetrics of Calgary,
Kingston.
November 14,
pared with women of all ages and parities. This was the first attempt to study a population of teenage pregnancies and compare it with a control population. Roopnarinesingh,” in Jamaica, reported his study of 122 teenage pregnancies and compared these with a control group of 122 22-year-old primigravidas. The results of this study suggested that there was an increased incidence of hypertension, premature labor, operative delivery, postpartum hemorrhage, and prematurity in the juvenile primigravidas, but that frank cephalopelvic disproportion was uncommon. He claimed that earlier cesarean section might improve fetal results. This assumption was based on the incidence of low Apgar scores in the infants of teenage mothers. Previous authors had studied groups of teenage girls with a*ge groups of less than 20 years of age,? 14 years and under.’ 16 years and under,” and 15 years and under.” In all these studies control groups have varied from full hospital populations of pregnant mothers’ to highly selected controls, as in Roopnarinesingh’s study. We decided to compare the reproductive performance of teenagers of 16 years or less with older primigravidas in the same hospital population.
2,
1972.
David M. Hay, and Gynaecology, Calgary,
Canada. 34
Vcrlume Kumbw
116 1
Materials
Obstetric
and
performance
methods
Hospital records at the University Hospital of the West Indies, Kingston, Jamaica, were almost complete for the year 1966 and those of 1969 were completed carefully by the authors. In all, 0.7 per cent of case notes were unobtainable. A total of 1,982 primigravidas were studied in this series. The hospital incidence of primigravidas was 39.4 per cent. Heights were not recorded in 70 cases (3.5 per cent). The incidence of twin pregnancy was very low-l 1 cases in the primigravid group, giving an instance of 1: 180. Singleton pregnancies only are considered in the results shown later.
of adolescent
Table
I. Age and height
~;;~“~~!;~h
61 and under 61-64 64 and over Unknown Mean height
54 1% 38 8 61.45
Table
II. Antenatal
“3.9 5.58 16:8 3.5
258 966 470 62 62.87
I-NO.
Antepartum hemorrhage : ‘Abruptio placentae Placenta previa Cause unknown Total Premature spontaneous rupture of membranes Anemia: Iron deficiency Sickle-cell disease Total
14.7 55.0 26.8 3.5
complications 16 and under
Pre-eclampsia Eclampsia
35
primigravida
of primigravidas
?&&”
Results
Stature. Table I shows the stature of the two groups studied. The higher incidence of small patients in the juvenile group might be expected to result in an increased number of operative deliveries, all other things being equal. This will be discussed later. Pre-eclampsia. The criteria for diagnosing pre-eclampsia were an increase in diastolic blood pressure by more than 15 mm. Hg on more than one occasion, a diastolic blood pressure of 90 mm. Hg on more than one occasion, in association with edema other than dependent edema, or proteinuria other than that due to urinary tract infections. By these strict criteria, 8.4 per cent of the juvenile group suffered from this syndrome compared with 9.8 per cent of patients in the older group. Eclampsia occurred in 11 patients, all of whom were older than 16 years of age. Antepartum hemorrhage. This was divided (as shown in Table II) into abruptio placentae, placenta previa, and “cause unknown.” Most cases of antepartum hemorrhage were labeled “cause unknown,” as would be expected. The incidence of 0.9 per cent in the teenage group was considerably less than the 3 per cent of the older age groups. Spontaneous premature rupture of the membranes. This again was less frequent in the teenage patient-l.8 per cent compared with 2.4 per cent in the older age group.
Jamaican
19 0
Over
I 76
I No.
a.4
172 11
1 0 .__ 1 ‘>
__ 0.9
4 35 ‘1 37
~
6 9 38
16
%
1
9.8
~
53
3.0
1.8
43
2.4
15.5
272
15.5
0.9
“1
1.7
16.4
293
16.7
Anemia. This was defined as a hemoglobin of less than 11 gm. at any time during the antenatal period. A total of 330 patients were anemic: 23 of those had one form or another of sickle-cell disease: 272 of the older patients (15.5 per cent) had iron deficiency anemia whereas 35 of the teenage patients (15.5 per cent) had this type of anemia. Postpartum hemorrhage. The incidence of this complication (Table III) was higher in the teenage patient-12.8 per cent compared with 9.3 per cent in the older age wv. Fetal distress. meconium staining stage of labor, or the normal range minute with or larity. Meconium
This was defined as either of the liquor amnii at any fetal heart variations from of 110 to 160 beats per without associated irregustaining of the liquor was
36
Hay
and
Table III. deliverv
Boyd
Complications
of labor
16 and No.
under j
and
Ouer
16 1
%
Table V. Incidence of premature infants i under 2,500 grams) according to stature of the mother Height
qo
No.
12.8
163
9.3
119
6.8
61 and 61-64 64 and Total
(in.)
Postpartum hemorrhage Fetal distress: Meconium Heart rate changes Labor over L’4 hours Hypertension
29
‘I ‘, -.-
i 14
6.2
146
a.:i
1 .5 39
6.6 17.3
209 269
11.3 14.6
Table Table
IV. Incidence
TYPO
of
deher) Vacuum extraction Forceps Cesarean section Total
of operative
16 and
under
16 and No,
under ovc*r
under % 9.3 15.1 7.9
I No. :40 113 18
11.6 11.7 :i.8
117
11.9
161
9.2
I
‘/:a
VI. Fetal outcome o:*er i%l
16 /
16
5 t9 3
delivery Over
Ooer
No.
%
No.
%
6 15
2.7 6.6
48 113
2.7 6.4
8
3.5
I’,0
6.8
29
12.8
281
15.9
rare in the young age group-2.2 per cent compared with 6.8 per cent in the older age group. Fetal heart rate changes were similarly less common in the younger patient-6.2 per cent compared with 8.3 per cent in the older age group. Prolonged labor. This was defined as labor lasting longer than 24 hours. It occurred in 6.6 per cent of the teenage group of patients compared with 11.3 per cent in the older age group of patients despite earlier resort to cesarean section in the older primigravid patient. Hypertension. This was defined as a blood pressure of 140/90 mm. Hg recorded at any time during labor, delivery, or the puerperium. Of the 308 primigravid patients who suffered hypertension, 39 ( 17.3 per cent) were in the teenage group and 269 (14.6 per cent) in the older age group of patients. Operative delivery. Details are shown in Table IV. Vacuum extraction was used both at the end of the first and in the second stage of labor. There was no difference in the incidence of vacuum extraction in the two groups of patients. Forceps delivery was also
4pgar score at 1 minute: Over 5 5 and less Stillbirth rate (per 1,000) First-week death rate (per 1,000) Perinatal death rate (per 1,000)
93.7 4.7
91.9 6.6
15.7
I <.l
7.9
I :i.b:
13.6
“6.7 __--.-
16
similar in both groups of patients but cesarean section was much less frequent in the group--3.5 per cent comyoung teenage pared with 6.8 per cent in the older age There were 12.8 per cent of the group, young teenagers delivered by operative means compared with 15.9 per cent in the older age group. Prematurity. The incidence of babies weighing less than 2.5 kilograms is shown in Table V. Prematurity was a common complication in the younger teenager-l 1.9 per cent compared with 9.2 per cent in the older age group. Fetal outcome. This is shown in detail in Table VI. In both age groups over 90 per cent of babies born had an Apgar score of 6 or more at one minute. In the young primigravidas 4.7 per cent of babies had an Apgar score of 5 or less at one minute compared with an incidence of 6.6 per cent in the older group. The stillbirth rate in young primigravidas was slightly higher than the rate of the older age group but the rLltc of first-week deaths was almost half in thr young patirnts cornpared with that irl thr
Volume Kumber
116 1
Obstetric
performance
older age group. The over-all perinatal death rate in both groups. was similar, with the youngest group being slightly better. When stillbirths and first-week deaths are analyzed by cause (Table VII), it is seen that antepartum hemorrhage, pre-eclampsia, prematurity, and “cause unknown” are the greatest causes of both stillbirth and first-week deaths in both groups of patients. The perinatal mortality rate in primigravidas was similar to that of the hospital’s total population (24.8 per cent). Comment
Israel and Woutersz” noted that there was no unanimity of opinion regarding the reproduction performance in teenage pregnancy other than that pre-eclampsia was frequent in these girls. Their cooperative study was a significant contribution to our knowledge of teenage pregnancies and involved 3,995 women who were less than 20 years of age (9.8 per cent of deliveries), 100 of whom were less than 15 years of age. They compared the outcome of these pregnancies with thr remaining hospital deliveries. This is illustrated by comparing the results of the present study with that of Roopnarinesingh.” Until now the majority of investigations have reported an increased incidence of preeclampsia in the juvenile primigravida.“, L 7* ‘J. I” Only Briggs and associates,” Hulka and Schaaf’? and Donnelly and associates” reported no such increase. Using a strict definition of pre-eclampsia we found no increase in the juvenile patient. In Jamaica “physiological immaturity,” as was suggested by Montagu,‘” might be responsible. As little or no stigma is attached to teenage pregnancy, most girls attend regularly for antenatal care and this may account for the satisfactory results in this series. The “nutritional factors” suggested by Semmens and McGlamory’ may account for the relatively high hospital incidence of pre-eclampsia (10.5 per cent). Despite this relative freedom from pre-eclampsia a large number of young primigravidas developed hypertension for the first time in labor or the puerperiurn. Antepartum hemorrhage was rare in the young patient but was associated with still-
of adolescent
Jamaican
primigravida
37
Table VII. Causes of fetal deaths 16 and
under
Ouer
16
Stillbirths:
PET APH PU Tr MU Total First
week
6 6 9 t 1 5
0 0 2 0 0 0 -0 2
6 3 9 1 3 1 1 “4
deaths:
PET APH PU Tr MU Abn MD Total
Table VIII. length
1 2 1 0 0 T
Mean of labor
birth
weights
and
16 and Birth weight (grams) Length of labor (hours)
16
Over
under
2,944.3
i!,923.8
lR.‘?l
12.24
Table IX. Mean birth weights and lengths of labor in the under 17 age group according to height Ifeight CJnder 61
Birth weight (grams ) Length of labor (hours)
“,797.89 13.71
(in.)
I 61-64
1’,987.69 11.06
I
64 and ouer
2.9.30.73 1227
birth in both cases. Abruptio placentae and placenta previa were rare before the age of 25 years. Spontaneous premature rupture of the membranes, defined as rupture before 37 completed weeks and before the onset of labor, occurred less frequently in the teenagers than in the other primigravidas. Anemia was not common in the teenage group, agreeing with the reports of Coates? and Roopnarinesingh,” whereas Israel and Woutersz? and Salzmann and associates4 reported an increased incidence.
38
Hay
and
Boyd
Postpartum hemorrhage, defined as 500 1111. or greater, \vas very common in the young ,group, despite the higher incidence of elective cesarcan sections in these patients. This confirms Koopnarinesingh’s’ findings but is contrary to other reports.“. 7. ‘b “3 In The incidence of both mcconiunl staining of the amniotic fluid and fetal heart vrariations and irregularities was low in the young paticnts~ which vvas contrary to the findings of Battaglia” but Ivas reflected in the good Apgar scores of the majority of babies after the first minute of life. Prolonged labor of more than 24 hours \vas only half as common in the young teenagers as in the other group. Other authors:, 11. 12 have reported no increase in incidence of prolonged labor in young tecn1”, 1a all reported an inagers whereas others’, creased incidence of this problem. The low operative delivery rate, and in particular the low cesarean section rate, conflict with other reports.“. ‘1 i The latter’s population was identical to that of this study and is a reminder of the inadequacy of the statistical survey as opposed to a population study. Our results support those of Briggs and Israel and Woutersz” and colleagues’ but our cesarean section rate is even higher than that of Wong and Clark.‘” Prematurity influenced the perinatal mortality rate, the rate being four times higher
in babies weighing less than 2,500 grams, and vvas responsible for many of the perinatal deaths. Prematurity and pre-eclampsia were associated with 34 (64.1 per cent) of the 53 deaths. The incidence of prenlaturt infants \vas higher in the teenage ,qroup in this series, as in others.“, ‘3 I’. I:’ but was contrary to the reports of Coates’ and Israel and Woutersz.” The perinatal mortality rate in the teenage patients \\as slightly higher than in the older group brrt we could find no justification for Koopnarinesingh’s” suggestions that earlier cesarean section would improve fetal sur\:iv.al or quality in young teenagers more than in the older age group. Our results show, a remarkable constancy of birth weight and length of labor (Table VIII) in both groups. The young teenager was one inch shorter on average than her older sister but this had little effect on her obstetric performance. There ivas no evidence that she compensated for lack of inches by producing significantly lighter babies but in the under 17 age group (Table IX1 it is apparent that the girl under 61 inches tall requires a longer labor to effect delivery. Attention to good antenatal care. the proper management of labor. and research into the problems of pre-eclampsia and prematurity are problems of all ages and parities.
REFERENCES
1. 2.
Harris, J. W.: 12, 1922. Israel, S. L.,
4. 5. 6. 7. 8.
Johns
Hopkins
Hosp.
33:
Woutersz, T. B.: AM. J. 85: 659, 1963. Marchetti, A., and Manakerj J. S.: AM. J. OBSTET. GYNECOL. 59: 1013. 1950. Salzmann, B., Keating, W. ‘J., and Head, T.: Curr. Med. Dig. 24: 108, 1957. Semmens, J. B., and McGlamory, J. C.: Obstet. Gvnecol. 16: 31. 1960. Roopnarinesingh, S.’ S.: J, Obstet. Gynecol. Br. Commonw. 77: 424, 1970. Coates, J. B.: AM. J. OBSTET. GYNECOL. 108: 68, 1970. Briggs, R. M., Herren, R. R., and Thompson, W. B.: AM. J. OBSTET. GYNECOL. 84: 436, 1962. OBSTET.
3.
Bull.
9. 10.
and
GYNECOL.
11.
12. 13.
Battaglia, M.: Pediatrics 32: 902, 1963. Bochner, K.: AM. J. OBSTET. GYNECOL. 53: 260, 1962. Donnelly, J. F., Abernathy, J. R., Creadick, R. N., Flowers, C. E., Greenberg, B. C., and Wells, H. B.: AM. J. OBSTET. GYNECOL. 80: 663, 1960. Hulka, Z., and Schaaf, F.: Obstet. Gynecol. 23: 678, 1964. Montagu, M. F. A.: The Reproductive DeveloDment of the Female. New York. 1957. Julian Press Inc. Mu&o, T. j.: AM. J. OBSTET. Gun-ECOI.. 84: 442, 1962. Wong, J. A., and Clark, J. F. J.: J. Natl. Med. Assoc. 63: 125, 1971. I
14. 15.
M.
HAY,
M.B.,
F.R.C.S.(C), JOHN
M.R.C.O.G.,
F.A.C.O.G. J.
BOYD,
F.R.C.S. Kingston,
CH.B.,
M.B.,
CH.B.,
M.R.C.O.G.,
(C) Jamaica,
West
Indies
The obstetric performance in the University Hospital, that of older primigravidas. hemorrhage, or anemia but low operative delivery rate and babies with good Apgar probably achieved by good
of 226 primigravidas, aged 16 years or less, delivered Kingston, Jamaica, was studied and compared with There was no increase of pre-eclampsia, antepartum postpartum hemorrhage was common in this group. The was associated with a low incidence of fetal distress scores. The over-all good obstetric performance wax antenatal care.
I N T I-I E Y E A R 1922 Harris’ suggested that 16 years of age or less was the optimum time for the occurrence of a first labor. Since then several studies have been made on the effect of pregnancy in young teenagers with different results. A higher incidence of preeclampsia has been reported in these girls but there has been no unanimity regarding prolonged labor, cesarean section, or prematurity. Israel and Woutersz’ pointed out that only three studies had dealt with more than 500 deliveries in this group of patients:‘-” and suggested that the different results recorded by different authors may have been due to variations in age, marital status, or socioeconomic factors: they proceeded with a cooperative study of 3,395 teenage pregnancies from a group of ten hospitals. These patients were all less than 20 years of age and accounted for 9.8 per cent of the total deliveries in the study. The teenage patients \rere comFrom Received 1972. Accepted Reprint Division University Alberta,
the
University for
Hospital,
publication
November requests: Dr. of Obstetrics of Calgary,
Kingston.
November 14,
pared with women of all ages and parities. This was the first attempt to study a population of teenage pregnancies and compare it with a control population. Roopnarinesingh,” in Jamaica, reported his study of 122 teenage pregnancies and compared these with a control group of 122 22-year-old primigravidas. The results of this study suggested that there was an increased incidence of hypertension, premature labor, operative delivery, postpartum hemorrhage, and prematurity in the juvenile primigravidas, but that frank cephalopelvic disproportion was uncommon. He claimed that earlier cesarean section might improve fetal results. This assumption was based on the incidence of low Apgar scores in the infants of teenage mothers. Previous authors had studied groups of teenage girls with a*ge groups of less than 20 years of age,? 14 years and under.’ 16 years and under,” and 15 years and under.” In all these studies control groups have varied from full hospital populations of pregnant mothers’ to highly selected controls, as in Roopnarinesingh’s study. We decided to compare the reproductive performance of teenagers of 16 years or less with older primigravidas in the same hospital population.
2,
1972.
David M. Hay, and Gynaecology, Calgary,
Canada. 34
Vcrlume Kumbw
116 1
Materials
Obstetric
and
performance
methods
Hospital records at the University Hospital of the West Indies, Kingston, Jamaica, were almost complete for the year 1966 and those of 1969 were completed carefully by the authors. In all, 0.7 per cent of case notes were unobtainable. A total of 1,982 primigravidas were studied in this series. The hospital incidence of primigravidas was 39.4 per cent. Heights were not recorded in 70 cases (3.5 per cent). The incidence of twin pregnancy was very low-l 1 cases in the primigravid group, giving an instance of 1: 180. Singleton pregnancies only are considered in the results shown later.
of adolescent
Table
I. Age and height
~;;~“~~!;~h
61 and under 61-64 64 and over Unknown Mean height
54 1% 38 8 61.45
Table
II. Antenatal
“3.9 5.58 16:8 3.5
258 966 470 62 62.87
I-NO.
Antepartum hemorrhage : ‘Abruptio placentae Placenta previa Cause unknown Total Premature spontaneous rupture of membranes Anemia: Iron deficiency Sickle-cell disease Total
14.7 55.0 26.8 3.5
complications 16 and under
Pre-eclampsia Eclampsia
35
primigravida
of primigravidas
?&&”
Results
Stature. Table I shows the stature of the two groups studied. The higher incidence of small patients in the juvenile group might be expected to result in an increased number of operative deliveries, all other things being equal. This will be discussed later. Pre-eclampsia. The criteria for diagnosing pre-eclampsia were an increase in diastolic blood pressure by more than 15 mm. Hg on more than one occasion, a diastolic blood pressure of 90 mm. Hg on more than one occasion, in association with edema other than dependent edema, or proteinuria other than that due to urinary tract infections. By these strict criteria, 8.4 per cent of the juvenile group suffered from this syndrome compared with 9.8 per cent of patients in the older group. Eclampsia occurred in 11 patients, all of whom were older than 16 years of age. Antepartum hemorrhage. This was divided (as shown in Table II) into abruptio placentae, placenta previa, and “cause unknown.” Most cases of antepartum hemorrhage were labeled “cause unknown,” as would be expected. The incidence of 0.9 per cent in the teenage group was considerably less than the 3 per cent of the older age groups. Spontaneous premature rupture of the membranes. This again was less frequent in the teenage patient-l.8 per cent compared with 2.4 per cent in the older age group.
Jamaican
19 0
Over
I 76
I No.
a.4
172 11
1 0 .__ 1 ‘>
__ 0.9
4 35 ‘1 37
~
6 9 38
16
%
1
9.8
~
53
3.0
1.8
43
2.4
15.5
272
15.5
0.9
“1
1.7
16.4
293
16.7
Anemia. This was defined as a hemoglobin of less than 11 gm. at any time during the antenatal period. A total of 330 patients were anemic: 23 of those had one form or another of sickle-cell disease: 272 of the older patients (15.5 per cent) had iron deficiency anemia whereas 35 of the teenage patients (15.5 per cent) had this type of anemia. Postpartum hemorrhage. The incidence of this complication (Table III) was higher in the teenage patient-12.8 per cent compared with 9.3 per cent in the older age wv. Fetal distress. meconium staining stage of labor, or the normal range minute with or larity. Meconium
This was defined as either of the liquor amnii at any fetal heart variations from of 110 to 160 beats per without associated irregustaining of the liquor was
36
Hay
and
Table III. deliverv
Boyd
Complications
of labor
16 and No.
under j
and
Ouer
16 1
%
Table V. Incidence of premature infants i under 2,500 grams) according to stature of the mother Height
qo
No.
12.8
163
9.3
119
6.8
61 and 61-64 64 and Total
(in.)
Postpartum hemorrhage Fetal distress: Meconium Heart rate changes Labor over L’4 hours Hypertension
29
‘I ‘, -.-
i 14
6.2
146
a.:i
1 .5 39
6.6 17.3
209 269
11.3 14.6
Table Table
IV. Incidence
TYPO
of
deher) Vacuum extraction Forceps Cesarean section Total
of operative
16 and
under
16 and No,
under ovc*r
under % 9.3 15.1 7.9
I No. :40 113 18
11.6 11.7 :i.8
117
11.9
161
9.2
I
‘/:a
VI. Fetal outcome o:*er i%l
16 /
16
5 t9 3
delivery Over
Ooer
No.
%
No.
%
6 15
2.7 6.6
48 113
2.7 6.4
8
3.5
I’,0
6.8
29
12.8
281
15.9
rare in the young age group-2.2 per cent compared with 6.8 per cent in the older age group. Fetal heart rate changes were similarly less common in the younger patient-6.2 per cent compared with 8.3 per cent in the older age group. Prolonged labor. This was defined as labor lasting longer than 24 hours. It occurred in 6.6 per cent of the teenage group of patients compared with 11.3 per cent in the older age group of patients despite earlier resort to cesarean section in the older primigravid patient. Hypertension. This was defined as a blood pressure of 140/90 mm. Hg recorded at any time during labor, delivery, or the puerperium. Of the 308 primigravid patients who suffered hypertension, 39 ( 17.3 per cent) were in the teenage group and 269 (14.6 per cent) in the older age group of patients. Operative delivery. Details are shown in Table IV. Vacuum extraction was used both at the end of the first and in the second stage of labor. There was no difference in the incidence of vacuum extraction in the two groups of patients. Forceps delivery was also
4pgar score at 1 minute: Over 5 5 and less Stillbirth rate (per 1,000) First-week death rate (per 1,000) Perinatal death rate (per 1,000)
93.7 4.7
91.9 6.6
15.7
I <.l
7.9
I :i.b:
13.6
“6.7 __--.-
16
similar in both groups of patients but cesarean section was much less frequent in the group--3.5 per cent comyoung teenage pared with 6.8 per cent in the older age There were 12.8 per cent of the group, young teenagers delivered by operative means compared with 15.9 per cent in the older age group. Prematurity. The incidence of babies weighing less than 2.5 kilograms is shown in Table V. Prematurity was a common complication in the younger teenager-l 1.9 per cent compared with 9.2 per cent in the older age group. Fetal outcome. This is shown in detail in Table VI. In both age groups over 90 per cent of babies born had an Apgar score of 6 or more at one minute. In the young primigravidas 4.7 per cent of babies had an Apgar score of 5 or less at one minute compared with an incidence of 6.6 per cent in the older group. The stillbirth rate in young primigravidas was slightly higher than the rate of the older age group but the rLltc of first-week deaths was almost half in thr young patirnts cornpared with that irl thr
Volume Kumber
116 1
Obstetric
performance
older age group. The over-all perinatal death rate in both groups. was similar, with the youngest group being slightly better. When stillbirths and first-week deaths are analyzed by cause (Table VII), it is seen that antepartum hemorrhage, pre-eclampsia, prematurity, and “cause unknown” are the greatest causes of both stillbirth and first-week deaths in both groups of patients. The perinatal mortality rate in primigravidas was similar to that of the hospital’s total population (24.8 per cent). Comment
Israel and Woutersz” noted that there was no unanimity of opinion regarding the reproduction performance in teenage pregnancy other than that pre-eclampsia was frequent in these girls. Their cooperative study was a significant contribution to our knowledge of teenage pregnancies and involved 3,995 women who were less than 20 years of age (9.8 per cent of deliveries), 100 of whom were less than 15 years of age. They compared the outcome of these pregnancies with thr remaining hospital deliveries. This is illustrated by comparing the results of the present study with that of Roopnarinesingh.” Until now the majority of investigations have reported an increased incidence of preeclampsia in the juvenile primigravida.“, L 7* ‘J. I” Only Briggs and associates,” Hulka and Schaaf’? and Donnelly and associates” reported no such increase. Using a strict definition of pre-eclampsia we found no increase in the juvenile patient. In Jamaica “physiological immaturity,” as was suggested by Montagu,‘” might be responsible. As little or no stigma is attached to teenage pregnancy, most girls attend regularly for antenatal care and this may account for the satisfactory results in this series. The “nutritional factors” suggested by Semmens and McGlamory’ may account for the relatively high hospital incidence of pre-eclampsia (10.5 per cent). Despite this relative freedom from pre-eclampsia a large number of young primigravidas developed hypertension for the first time in labor or the puerperiurn. Antepartum hemorrhage was rare in the young patient but was associated with still-
of adolescent
Jamaican
primigravida
37
Table VII. Causes of fetal deaths 16 and
under
Ouer
16
Stillbirths:
PET APH PU Tr MU Total First
week
6 6 9 t 1 5
0 0 2 0 0 0 -0 2
6 3 9 1 3 1 1 “4
deaths:
PET APH PU Tr MU Abn MD Total
Table VIII. length
1 2 1 0 0 T
Mean of labor
birth
weights
and
16 and Birth weight (grams) Length of labor (hours)
16
Over
under
2,944.3
i!,923.8
lR.‘?l
12.24
Table IX. Mean birth weights and lengths of labor in the under 17 age group according to height Ifeight CJnder 61
Birth weight (grams ) Length of labor (hours)
“,797.89 13.71
(in.)
I 61-64
1’,987.69 11.06
I
64 and ouer
2.9.30.73 1227
birth in both cases. Abruptio placentae and placenta previa were rare before the age of 25 years. Spontaneous premature rupture of the membranes, defined as rupture before 37 completed weeks and before the onset of labor, occurred less frequently in the teenagers than in the other primigravidas. Anemia was not common in the teenage group, agreeing with the reports of Coates? and Roopnarinesingh,” whereas Israel and Woutersz? and Salzmann and associates4 reported an increased incidence.
38
Hay
and
Boyd
Postpartum hemorrhage, defined as 500 1111. or greater, \vas very common in the young ,group, despite the higher incidence of elective cesarcan sections in these patients. This confirms Koopnarinesingh’s’ findings but is contrary to other reports.“. 7. ‘b “3 In The incidence of both mcconiunl staining of the amniotic fluid and fetal heart vrariations and irregularities was low in the young paticnts~ which vvas contrary to the findings of Battaglia” but Ivas reflected in the good Apgar scores of the majority of babies after the first minute of life. Prolonged labor of more than 24 hours \vas only half as common in the young teenagers as in the other group. Other authors:, 11. 12 have reported no increase in incidence of prolonged labor in young tecn1”, 1a all reported an inagers whereas others’, creased incidence of this problem. The low operative delivery rate, and in particular the low cesarean section rate, conflict with other reports.“. ‘1 i The latter’s population was identical to that of this study and is a reminder of the inadequacy of the statistical survey as opposed to a population study. Our results support those of Briggs and Israel and Woutersz” and colleagues’ but our cesarean section rate is even higher than that of Wong and Clark.‘” Prematurity influenced the perinatal mortality rate, the rate being four times higher
in babies weighing less than 2,500 grams, and vvas responsible for many of the perinatal deaths. Prematurity and pre-eclampsia were associated with 34 (64.1 per cent) of the 53 deaths. The incidence of prenlaturt infants \vas higher in the teenage ,qroup in this series, as in others.“, ‘3 I’. I:’ but was contrary to the reports of Coates’ and Israel and Woutersz.” The perinatal mortality rate in the teenage patients \\as slightly higher than in the older group brrt we could find no justification for Koopnarinesingh’s” suggestions that earlier cesarean section would improve fetal sur\:iv.al or quality in young teenagers more than in the older age group. Our results show, a remarkable constancy of birth weight and length of labor (Table VIII) in both groups. The young teenager was one inch shorter on average than her older sister but this had little effect on her obstetric performance. There ivas no evidence that she compensated for lack of inches by producing significantly lighter babies but in the under 17 age group (Table IX1 it is apparent that the girl under 61 inches tall requires a longer labor to effect delivery. Attention to good antenatal care. the proper management of labor. and research into the problems of pre-eclampsia and prematurity are problems of all ages and parities.
REFERENCES
1. 2.
Harris, J. W.: 12, 1922. Israel, S. L.,
4. 5. 6. 7. 8.
Johns
Hopkins
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33:
Woutersz, T. B.: AM. J. 85: 659, 1963. Marchetti, A., and Manakerj J. S.: AM. J. OBSTET. GYNECOL. 59: 1013. 1950. Salzmann, B., Keating, W. ‘J., and Head, T.: Curr. Med. Dig. 24: 108, 1957. Semmens, J. B., and McGlamory, J. C.: Obstet. Gvnecol. 16: 31. 1960. Roopnarinesingh, S.’ S.: J, Obstet. Gynecol. Br. Commonw. 77: 424, 1970. Coates, J. B.: AM. J. OBSTET. GYNECOL. 108: 68, 1970. Briggs, R. M., Herren, R. R., and Thompson, W. B.: AM. J. OBSTET. GYNECOL. 84: 436, 1962. OBSTET.
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and
GYNECOL.
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Battaglia, M.: Pediatrics 32: 902, 1963. Bochner, K.: AM. J. OBSTET. GYNECOL. 53: 260, 1962. Donnelly, J. F., Abernathy, J. R., Creadick, R. N., Flowers, C. E., Greenberg, B. C., and Wells, H. B.: AM. J. OBSTET. GYNECOL. 80: 663, 1960. Hulka, Z., and Schaaf, F.: Obstet. Gynecol. 23: 678, 1964. Montagu, M. F. A.: The Reproductive DeveloDment of the Female. New York. 1957. Julian Press Inc. Mu&o, T. j.: AM. J. OBSTET. Gun-ECOI.. 84: 442, 1962. Wong, J. A., and Clark, J. F. J.: J. Natl. Med. Assoc. 63: 125, 1971. I
14. 15.