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Pregnant Adolescents Admitted to an Inpatient Child and Adolescent Psychiatric Unit: An Eight-Year Review
Original Study Pregnant Adolescents Admitted to an Inpatient Child and Adolescent Psychiatric Unit: An Eight-Year Review Teresa M. Fletcher MSN, RN, CPNP 1,*, Laura A. Markley MD 2, Dana Nelson MN, RN, CNS 3, Stephen S. Crane MD, FACOG, MBA 3, James J. Fitzgibbon MD 1 1
Department of Adolescent Medicine, Akron Children's Hospital Medical Center of Akron, Akron, Ohio Department of Psychiatry, Akron Children's Hospital Medical Center of Akron, Akron, Ohio 3 Department of Maternal Fetal Medicine, Akron Children's Hospital Medical Center of Akron, Akron, Ohio 2
a b s t r a c t Study Objective: To assess patient outcomes and describe demographic data of pregnant adolescents admitted to an inpatient child and adolescent psychiatric unit, as well as to determine if it is safe to continue to admit pregnant adolescents to such a unit. Design, Setting, and Participants: A descriptive retrospective chart review conducted at a free-standing pediatric hospital in northeast Ohio of all pregnant adolescents aged 13 to 17 years admitted to the inpatient child and adolescent psychiatric unit from July 2005 to April 2013. Main Outcome Measures: Data collection included details on demographic, pregnancy status, and psychiatric diagnoses. Results: Eighteen pregnant adolescents were admitted to the psychiatric unit during the time frame. Sixteen of those were in the first trimester of pregnancy. Pregnancy was found to be a contributing factor to the adolescent's suicidal ideation and admission in 11 of the cases. Admission to an inpatient psychiatric facility did not lead to adverse effects in pregnancy. Conclusion: Pregnant adolescents did not have negative pregnancy outcomes related to admission to an inpatient psychiatric unit. Results of this study suggest that it is safe to continue to admit uncomplicated pregnant adolescents in their first trimester to an inpatient child and adolescent psychiatric unit for an acute stay. Key Words: Pregnancy, Adolescents, Depression, Inpatient psychiatric care, Suicidal ideation
Introduction
Antenatal depression has been shown to be a frequent and serious problem for the pregnant adolescent, occurring with a prevalence of almost twice that of pregnant adults and nonpregnant teens.1e3 Depression during pregnancy has been associated with several adverse outcomes, including low birth weight (LBW) infants and preterm delivery, which are the 2 leading causes of infant morbidity and neonatal mortality in the United States.4 Pregnant adolescents with suicidal ideation are at an even higher risk of delivering an LBW infant than are pregnant adolescents with depression and no suicidal ideation.4 It is apparent from the literature that adequate mental health and prenatal care are paramount in the prevention of these complications. However, there are few resources that address the particular issue of treating the acutely suicidal pregnant adolescent. There are articles that address the use of various treatment modalities, primarily therapy for the depressed, pregnant adolescent, and some outline the decision-making process and considerations for the use of psychotropic medication in this population.2 No research has explored the safety and management considerations that interplay in the care of the suicidal adolescent patient
The authors indicate no conflicts of interest. * Address correspondence to: Teresa M. Fletcher, MSN, RN, CPNP, Akron Children's Hospital, Adolescent Medicine, One Perkins Square, Akron, OH 44308; Phone: þ1 (330) 543-4928; fax: þ1 (330) 543-3687 E-mail address: tfl[email protected] (T.M. Fletcher).
on an inpatient child and adolescent psychiatric unit. There also is a lack of information as to whether admission to an inpatient psychiatric unit has been related to increased morbidity or mortality with respect to the adolescent mother or fetus. In 2005, in response to increased requests to admit pregnant adolescents to an inpatient child and adolescent psychiatric unit at a free-standing children's hospital, the medical staff developed a policy addressing the care of these patients. That policy stated that in order for a pregnant adolescent to be admitted to the psychiatric unit, an obstetrics/gynecology (OB/GYN) provider, from an outside adult hospital, had to assess the patient's pregnancy status in the emergency department and determine if the patient's pregnancy is in a stable condition. The purpose of this study was to describe demographic data of pregnant adolescents admitted to an inpatient child and adolescent psychiatric unit, to assess those patient outcomes while admitted, and to describe the effectiveness and adherence of the policy. Patient safety was assessed for this patient cohort. Methods
The design of this study was a descriptive retrospective chart review conducted from 2005 to 2013 of all pregnant patients admitted to an inpatient child and adolescent psychiatric unit at a free-standing pediatric hospital in Ohio. The top 5 diagnoses for the study site in 2013 (N 5 932) were Depressive disorder, Not Otherwise Specified (NOS)
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2015.01.005
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(n 5 309, 33.15%), Unspecific Episodic Mood disorder (n 5 276, 29.61%), Major Depressive disorder; Single Episode, Severe Without Psychotic Behavior (n 5 107, 11.48%), Major Depressive disorder, Recurrent Episode, Severe Without Mention of Psychotic Behavior (n 5 55, 5.9%), and Major Depressive disorder, Single Episode, Moderate (n 5 21, 2.28%). In 2013, the study site admitted 588 female patients ranging in age from 13 to 16 years, with a mean age of 14.6 years. The study sample included 18 pregnant adolescents aged 13 to 17 years admitted to the unit from July 2005 to April 2013, and their charts were reviewed. Data collection included details on demographics, pregnancy status, and psychiatric diagnoses. Adverse pregnancy outcomes assessed included miscarriage, hypertension, bleeding, and abdominal pain during the admission. Pregnancy complications before admission were noted. Descriptive statistics were calculated using R 3.0.2 Ó statistical software.5 Results
Eighteen pregnant adolescents were admitted to the inpatient child and adolescent psychiatric unit from July 2005 to April 2013. The sample demographics are presented in Table 1. Descriptive data were gathered through a chart review of the medical record. Pregnancy problems before Table 1 Sample Patient Characteristics Variable
Pregnancy Data 2005-2013 Study Group N 5 18
Age Mean (SD) Median IQR Weight (kg) Mean (SD) Median IQR Gestational age (wks) Mean (SD) Median IQR Gender, n (%) Female Male Race, n (%) African American Asian/Oriental Hispanic/Latino Middle Eastern Non-Hispanic Other White Unknown Insurance, n (%) Medicaid Private Government/other Medicaid HMO Unknown Admit diagnosis, n (%) Depressive disorder NOS Adjustment disorder Intermitent explosive disorder Major depressive disorder Post-traumatic stress disorder Mood disorder NOS
15.7 (1.4) 16.0 (15.3-17.0) 65.5 (13.3) 63.6 (56.0-72.7) 10.4 (4.6) 9.7 (7.4-13.4) 18 (100) N/A 10 (55.6) 1 (5.6) 0 0 0 0 7 (38.9) 0 5 (27.8) 5 (27.8) 0 7 (38.9) 1 (5.6) 6 (33.3) 4 (22.2) 1 (5.6) 2 (11.1) 1 (5.6) 4 (22.2)
admission and pregnancy complications and management while admitted were noted. Specific notable events included 1 patient with neither documented abdominal pain nor vaginal bleeding before admission, who had a confirmed miscarriage while on the unit. Another patient experienced abdominal cramping and vaginal spotting, which, according to documentation, may have been explained by implantation or a possible abnormal pregnancy. The patient was discharged before a repeat human chorionic gonadotropin level could be completed to confirm pregnancy status, but a follow-up appointment with OB/GYN was made before discharge. Two patients experienced nausea to the point of requiring medication for symptom relief. Three patients had a urinary tract infection diagnosed while on the unit, and 1 of those patients had a vaginal yeast infection. All of the pregnant adolescents had an OB/GYN consultation ordered, and 17 (94.4%) were completed. Thirteen (72.2%) of the consultations were done in the emergency department (per hospital policy), and 4 (22.2%) were done on the psychiatric unit. One significant issue observed was that due to the need to wait for an outside obstetrician to present to the emergency department for consultation, there were admission delays compared with the nonpregnant patient. However, due to specific data on arrival time, assessment time, and admission time, the length of the delay was not able to be quantified in this study. Seven (38.9%) of the pregnant adolescents admitted had an ultrasound performed to determine the status of the pregnancy, while 11 (61.1%) did not. Fifteen (83.3%) had prenatal vitamins ordered. Eleven (61.1%) of the pregnant adolescents reported that being pregnant was a contributing factor to having suicidal ideation. Discussion
Our findings suggest that pregnant adolescents receiving psychiatric care on an inpatient child and adolescent psychiatric unit were not adversely affected with regard to their pregnancy outcomes. All except 1 patient had an OB/ GYN consultation in the emergency department or on the psychiatric unit. There was no prenatal care protocol for these adolescents (ie, ultrasounds and prenatal vitamins being ordered). More than half of these pregnant adolescents thought that their pregnancy was a contributing factor to their suicidal ideation. A case-control study from Brazil6 demonstrated that pregnant teens had a far greater prevalence of depression (26.3% vs 13.6%), anxiety (43.6% vs 28.0%), and attempted suicide (20.0% vs 6.3%) than age- and socioeconomic statusematched peers. This study noted that adolescent pregnancy and suicidal behaviors shared several overlapping risk factors, including symptoms of depression and anxiety, abuse of alcohol and drugs, exposure to violence and physical and sexual abuse, low levels of social support, tense family relationships, lack of recreational activities, repetition of a year at school, and impoverished socioeconomic circumstances.6 Another study looking at characteristics of adolescent mothers who had reported suicide attempts following pregnancy noted that “venereal disease” and pregnancy complications were associated with suicidal
T.M. Fletcher et al. / J Pediatr Adolesc Gynecol 28 (2015) 477e480
ideation and attempt.7 This study, from 1970, noted a relationship between adolescent pregnancy and suicide, concluding that “the rate of attempted suicide amongst teenage mothers is in excess of expected with the general urban adolescent population.”7 “Spontaneous abortion occurs in 15% of clinically established pregnancies. When cardiac activity has been demonstrated, the miscarriage rate is reduced to 2% to 3% in asymptomatic low-risk women.”8 One patient had a confirmed miscarriage while on the unit, which is 5.56% of the study population and unlikely associated with admission to the unit. This is significantly lower than the general population's clinically established pregnancy spontaneous abortion rate and should not deter pregnant patients from being admitted to a psychiatric unit. The mean age of the pregnant adolescents in this study is slightly higher than the mean age of the 2013 unit data: 15.7 years compared to 14.3 years. In 2010, Ohio's teen pregnancy rate for 10- to 19-year-olds is 29 per 1000 females. The pregnancy rate for 15- to 19-year-olds in Ohio is much higher at 55.3 per 1000 females.9 The pregnancy rate (roughly 30 per 1000) for our study sample aged 14 to 17 years (mean 5 15.7 years) is representative of Ohio's general adolescent pregnancy population. Several articles stress the importance of adequate mental health and prenatal care in the prevention of serious complications for mother and fetus, including suicidal behavior and attempt, as well as premature delivery and poor antenatal growth.1e4,6 This study's aim was to consider the safety and management considerations that interplay in the care of the suicidal adolescent patient on an inpatient child and adolescent psychiatric unit, especially when on-site obstetrical care is not readily available. It was found that there was no noted increase in adverse events for the adolescent mother or fetus incurred during an acute inpatient psychiatric stay when a protocol to determine health and potential risk of admission was implemented. In a review of research completed by Siegel and Brandon,10 they examined psychopathology in adolescent pregnancy and the postpartum period. It was found that pregnant and postpartum adolescents are at higher risk of depression than their adult counterparts, but when comparing the pregnant adolescents with nonpregnant adolescents, the depression rates are similar. There was also an association between the social support adolescents received while pregnant and postpartum and depressive symptoms. There is a decrease of depressive symptoms in adolescents who report a good quality of social support received. Experiences with their own parents, beliefs about themselves, and their socioeconomic status also affected depressive symptoms. The research states that adults with psychiatric illness have a negative impact for the mother and the baby. Depression during pregnancy is associated with problems with bonding, infant behavior, and maternal suicide. There were limitations to this study. The small sample size produced limited data points. Data could not easily be compared with the unit data because the study sample was obtained during an 8-year period and the unit data were available only for 2013. Data sets were gathered from a retrospective review. These data were collected at a defined
479
geographic area and may not be generalizable to other populations outside the Midwest United States. Implications for Practice
Pregnant adolescents in their first trimester can be admitted to an inpatient child and adolescent psychiatric unit to receive mental health and prenatal care. The development and implementation of institutional policy that specifies the criteria for admission facilitate incorporation of this practice. After review of these data, the institution updated their pregnant patient policy. Lack of consistent pregnancy care led to a prior-to-admission checklist to be completed while in the emergency department. The policy is now as follows: “Uncomplicated” pregnant adolescents may be admitted to the child and adolescent psychiatric unit from the emergency department if they meet designated criteria: positive pregnancy test, no abdominal pain, fundus examination palpable below the umbilicus, last menstrual period places pregnancy within the first 14 weeks' gestational age, vital signs stable, and no chronic medical problems. Providers from the hospital's maternal-fetal medicine department (rather than from an outside facility) will be contacted by the emergency department and approve the patient's admission to the hospital. The maternal-fetal providers will then see and assess the patient within 24 hours of admission and will implement a standard protocol including labs and ultrasound as indicated for the pregnancy care of these patients, and outpatient care will be arranged. If acute obstetric complications occur on the unit, the maternal-fetal providers will arrange transport under their care to an obstetric facility and provide ongoing care to ensure the safety of the patient and her pregnancy. The patients in this study had depressive symptoms and were pregnant. Pregnancy can be an added stressor for any female and maternal depression can increase the rate of maternal suicide. These suicidal pregnant adolescents need adequate psychiatric care in order to thrive as potential adolescent parents. If adult psychiatric facilities only admit patients over the age of 18, then child and adolescent psychiatric units may need to admit these patients for their psychiatric concern, but many child and adolescent psychiatric facilities are not co-located in an institution that offers obstetrical care. In the future, we plan to replicate the study with the revised pregnant patient policy. We will assess if there are any different patient outcomes compared with this study. This study could be replicated in other institutions that allow pregnant adolescents to be admitted to a child and adolescent psychiatric unit. Conclusion
Pregnant adolescents did not have any increase in noted adverse events during an admission to an inpatient psychiatric unit. Admitting these pregnant adolescents with suicidal ideation or attempt for adequate psychiatric care and prenatal care can result in and improve the ultimate outcome of the pregnancy. We recommend that it is safe to
480
T.M. Fletcher et al. / J Pediatr Adolesc Gynecol 28 (2015) 477e480
admit uncomplicated pregnant adolescents, within the aforementioned parameters, to an inpatient child and adolescent psychiatric unit for an acute stay. References 1. Pinheiro R, da Cunha Coelho F, da Silva R, et al: Suicidal behavior in pregnant teenagers in southern Brazil: social, obstetric and psychiatric correlates. J Affect Disord 2012; 136:520 2. McClanahan K: Depression in pregnant adolescents: considerations for treatment. J Pediatr Adolesc Gynecol 2009; 22:59 3. Bunevicius R, Kusminskas L, Bunevicius A, et al: Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynecol Scand 2009; 88:599 4. Hodgkinson S, Colantuoni E, Roberts D, et al: Depressive symptoms and birth outcomes among pregnant teenagers. J Pediatr Adolesc Gynecol 2010; 23:16
5. R Core Team: R: A language and environment for statistical computing. Vienna, Austria, R Foundation for Statistical Computing, 2014. Available: http://www. R-project.org/; 2014. Accessed November 15, 2014. 6. Freitas G, Cais C, Stefanello S, et al: Psychosocial conditions and suicidal behavior in pregnant teenagers: a case-control study in Brazil. Eur Child Adolesc Psychiatry 2008; 17:336 7. Gabrielson I, Klerman L, Currie J, et al: Suicide attempts in a population pregnant as teen-agers. Am J Public Health Nations Health 1970; 60:2289 8. Tongsong T, Srisomboom J, Wanapirak C, et al: Pregnancy outcome of threatened abortion with demonstrable fetal cardiac activity: a cohort study. J Obstet Gynecol 1995; 21:331 9. Ohio Department of Health, Center for Public Health Informatics and Statistics. Estimated teen pregnancies at rates over 1,000 females, by counties and age groups, 2010. Available: http://www.odh.ohio.gov/healthStats/disparities/ pregnancy.aspx. Accessed July 16, 2014. 10. Siegal R, Brandon A: Adolescents, pregnancy, and mental health. J Pediatr Adolesc Gynecol 2014; 27:138
Department of Adolescent Medicine, Akron Children's Hospital Medical Center of Akron, Akron, Ohio Department of Psychiatry, Akron Children's Hospital Medical Center of Akron, Akron, Ohio 3 Department of Maternal Fetal Medicine, Akron Children's Hospital Medical Center of Akron, Akron, Ohio 2
a b s t r a c t Study Objective: To assess patient outcomes and describe demographic data of pregnant adolescents admitted to an inpatient child and adolescent psychiatric unit, as well as to determine if it is safe to continue to admit pregnant adolescents to such a unit. Design, Setting, and Participants: A descriptive retrospective chart review conducted at a free-standing pediatric hospital in northeast Ohio of all pregnant adolescents aged 13 to 17 years admitted to the inpatient child and adolescent psychiatric unit from July 2005 to April 2013. Main Outcome Measures: Data collection included details on demographic, pregnancy status, and psychiatric diagnoses. Results: Eighteen pregnant adolescents were admitted to the psychiatric unit during the time frame. Sixteen of those were in the first trimester of pregnancy. Pregnancy was found to be a contributing factor to the adolescent's suicidal ideation and admission in 11 of the cases. Admission to an inpatient psychiatric facility did not lead to adverse effects in pregnancy. Conclusion: Pregnant adolescents did not have negative pregnancy outcomes related to admission to an inpatient psychiatric unit. Results of this study suggest that it is safe to continue to admit uncomplicated pregnant adolescents in their first trimester to an inpatient child and adolescent psychiatric unit for an acute stay. Key Words: Pregnancy, Adolescents, Depression, Inpatient psychiatric care, Suicidal ideation
Introduction
Antenatal depression has been shown to be a frequent and serious problem for the pregnant adolescent, occurring with a prevalence of almost twice that of pregnant adults and nonpregnant teens.1e3 Depression during pregnancy has been associated with several adverse outcomes, including low birth weight (LBW) infants and preterm delivery, which are the 2 leading causes of infant morbidity and neonatal mortality in the United States.4 Pregnant adolescents with suicidal ideation are at an even higher risk of delivering an LBW infant than are pregnant adolescents with depression and no suicidal ideation.4 It is apparent from the literature that adequate mental health and prenatal care are paramount in the prevention of these complications. However, there are few resources that address the particular issue of treating the acutely suicidal pregnant adolescent. There are articles that address the use of various treatment modalities, primarily therapy for the depressed, pregnant adolescent, and some outline the decision-making process and considerations for the use of psychotropic medication in this population.2 No research has explored the safety and management considerations that interplay in the care of the suicidal adolescent patient
The authors indicate no conflicts of interest. * Address correspondence to: Teresa M. Fletcher, MSN, RN, CPNP, Akron Children's Hospital, Adolescent Medicine, One Perkins Square, Akron, OH 44308; Phone: þ1 (330) 543-4928; fax: þ1 (330) 543-3687 E-mail address: tfl[email protected] (T.M. Fletcher).
on an inpatient child and adolescent psychiatric unit. There also is a lack of information as to whether admission to an inpatient psychiatric unit has been related to increased morbidity or mortality with respect to the adolescent mother or fetus. In 2005, in response to increased requests to admit pregnant adolescents to an inpatient child and adolescent psychiatric unit at a free-standing children's hospital, the medical staff developed a policy addressing the care of these patients. That policy stated that in order for a pregnant adolescent to be admitted to the psychiatric unit, an obstetrics/gynecology (OB/GYN) provider, from an outside adult hospital, had to assess the patient's pregnancy status in the emergency department and determine if the patient's pregnancy is in a stable condition. The purpose of this study was to describe demographic data of pregnant adolescents admitted to an inpatient child and adolescent psychiatric unit, to assess those patient outcomes while admitted, and to describe the effectiveness and adherence of the policy. Patient safety was assessed for this patient cohort. Methods
The design of this study was a descriptive retrospective chart review conducted from 2005 to 2013 of all pregnant patients admitted to an inpatient child and adolescent psychiatric unit at a free-standing pediatric hospital in Ohio. The top 5 diagnoses for the study site in 2013 (N 5 932) were Depressive disorder, Not Otherwise Specified (NOS)
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2015.01.005
478
T.M. Fletcher et al. / J Pediatr Adolesc Gynecol 28 (2015) 477e480
(n 5 309, 33.15%), Unspecific Episodic Mood disorder (n 5 276, 29.61%), Major Depressive disorder; Single Episode, Severe Without Psychotic Behavior (n 5 107, 11.48%), Major Depressive disorder, Recurrent Episode, Severe Without Mention of Psychotic Behavior (n 5 55, 5.9%), and Major Depressive disorder, Single Episode, Moderate (n 5 21, 2.28%). In 2013, the study site admitted 588 female patients ranging in age from 13 to 16 years, with a mean age of 14.6 years. The study sample included 18 pregnant adolescents aged 13 to 17 years admitted to the unit from July 2005 to April 2013, and their charts were reviewed. Data collection included details on demographics, pregnancy status, and psychiatric diagnoses. Adverse pregnancy outcomes assessed included miscarriage, hypertension, bleeding, and abdominal pain during the admission. Pregnancy complications before admission were noted. Descriptive statistics were calculated using R 3.0.2 Ó statistical software.5 Results
Eighteen pregnant adolescents were admitted to the inpatient child and adolescent psychiatric unit from July 2005 to April 2013. The sample demographics are presented in Table 1. Descriptive data were gathered through a chart review of the medical record. Pregnancy problems before Table 1 Sample Patient Characteristics Variable
Pregnancy Data 2005-2013 Study Group N 5 18
Age Mean (SD) Median IQR Weight (kg) Mean (SD) Median IQR Gestational age (wks) Mean (SD) Median IQR Gender, n (%) Female Male Race, n (%) African American Asian/Oriental Hispanic/Latino Middle Eastern Non-Hispanic Other White Unknown Insurance, n (%) Medicaid Private Government/other Medicaid HMO Unknown Admit diagnosis, n (%) Depressive disorder NOS Adjustment disorder Intermitent explosive disorder Major depressive disorder Post-traumatic stress disorder Mood disorder NOS
15.7 (1.4) 16.0 (15.3-17.0) 65.5 (13.3) 63.6 (56.0-72.7) 10.4 (4.6) 9.7 (7.4-13.4) 18 (100) N/A 10 (55.6) 1 (5.6) 0 0 0 0 7 (38.9) 0 5 (27.8) 5 (27.8) 0 7 (38.9) 1 (5.6) 6 (33.3) 4 (22.2) 1 (5.6) 2 (11.1) 1 (5.6) 4 (22.2)
admission and pregnancy complications and management while admitted were noted. Specific notable events included 1 patient with neither documented abdominal pain nor vaginal bleeding before admission, who had a confirmed miscarriage while on the unit. Another patient experienced abdominal cramping and vaginal spotting, which, according to documentation, may have been explained by implantation or a possible abnormal pregnancy. The patient was discharged before a repeat human chorionic gonadotropin level could be completed to confirm pregnancy status, but a follow-up appointment with OB/GYN was made before discharge. Two patients experienced nausea to the point of requiring medication for symptom relief. Three patients had a urinary tract infection diagnosed while on the unit, and 1 of those patients had a vaginal yeast infection. All of the pregnant adolescents had an OB/GYN consultation ordered, and 17 (94.4%) were completed. Thirteen (72.2%) of the consultations were done in the emergency department (per hospital policy), and 4 (22.2%) were done on the psychiatric unit. One significant issue observed was that due to the need to wait for an outside obstetrician to present to the emergency department for consultation, there were admission delays compared with the nonpregnant patient. However, due to specific data on arrival time, assessment time, and admission time, the length of the delay was not able to be quantified in this study. Seven (38.9%) of the pregnant adolescents admitted had an ultrasound performed to determine the status of the pregnancy, while 11 (61.1%) did not. Fifteen (83.3%) had prenatal vitamins ordered. Eleven (61.1%) of the pregnant adolescents reported that being pregnant was a contributing factor to having suicidal ideation. Discussion
Our findings suggest that pregnant adolescents receiving psychiatric care on an inpatient child and adolescent psychiatric unit were not adversely affected with regard to their pregnancy outcomes. All except 1 patient had an OB/ GYN consultation in the emergency department or on the psychiatric unit. There was no prenatal care protocol for these adolescents (ie, ultrasounds and prenatal vitamins being ordered). More than half of these pregnant adolescents thought that their pregnancy was a contributing factor to their suicidal ideation. A case-control study from Brazil6 demonstrated that pregnant teens had a far greater prevalence of depression (26.3% vs 13.6%), anxiety (43.6% vs 28.0%), and attempted suicide (20.0% vs 6.3%) than age- and socioeconomic statusematched peers. This study noted that adolescent pregnancy and suicidal behaviors shared several overlapping risk factors, including symptoms of depression and anxiety, abuse of alcohol and drugs, exposure to violence and physical and sexual abuse, low levels of social support, tense family relationships, lack of recreational activities, repetition of a year at school, and impoverished socioeconomic circumstances.6 Another study looking at characteristics of adolescent mothers who had reported suicide attempts following pregnancy noted that “venereal disease” and pregnancy complications were associated with suicidal
T.M. Fletcher et al. / J Pediatr Adolesc Gynecol 28 (2015) 477e480
ideation and attempt.7 This study, from 1970, noted a relationship between adolescent pregnancy and suicide, concluding that “the rate of attempted suicide amongst teenage mothers is in excess of expected with the general urban adolescent population.”7 “Spontaneous abortion occurs in 15% of clinically established pregnancies. When cardiac activity has been demonstrated, the miscarriage rate is reduced to 2% to 3% in asymptomatic low-risk women.”8 One patient had a confirmed miscarriage while on the unit, which is 5.56% of the study population and unlikely associated with admission to the unit. This is significantly lower than the general population's clinically established pregnancy spontaneous abortion rate and should not deter pregnant patients from being admitted to a psychiatric unit. The mean age of the pregnant adolescents in this study is slightly higher than the mean age of the 2013 unit data: 15.7 years compared to 14.3 years. In 2010, Ohio's teen pregnancy rate for 10- to 19-year-olds is 29 per 1000 females. The pregnancy rate for 15- to 19-year-olds in Ohio is much higher at 55.3 per 1000 females.9 The pregnancy rate (roughly 30 per 1000) for our study sample aged 14 to 17 years (mean 5 15.7 years) is representative of Ohio's general adolescent pregnancy population. Several articles stress the importance of adequate mental health and prenatal care in the prevention of serious complications for mother and fetus, including suicidal behavior and attempt, as well as premature delivery and poor antenatal growth.1e4,6 This study's aim was to consider the safety and management considerations that interplay in the care of the suicidal adolescent patient on an inpatient child and adolescent psychiatric unit, especially when on-site obstetrical care is not readily available. It was found that there was no noted increase in adverse events for the adolescent mother or fetus incurred during an acute inpatient psychiatric stay when a protocol to determine health and potential risk of admission was implemented. In a review of research completed by Siegel and Brandon,10 they examined psychopathology in adolescent pregnancy and the postpartum period. It was found that pregnant and postpartum adolescents are at higher risk of depression than their adult counterparts, but when comparing the pregnant adolescents with nonpregnant adolescents, the depression rates are similar. There was also an association between the social support adolescents received while pregnant and postpartum and depressive symptoms. There is a decrease of depressive symptoms in adolescents who report a good quality of social support received. Experiences with their own parents, beliefs about themselves, and their socioeconomic status also affected depressive symptoms. The research states that adults with psychiatric illness have a negative impact for the mother and the baby. Depression during pregnancy is associated with problems with bonding, infant behavior, and maternal suicide. There were limitations to this study. The small sample size produced limited data points. Data could not easily be compared with the unit data because the study sample was obtained during an 8-year period and the unit data were available only for 2013. Data sets were gathered from a retrospective review. These data were collected at a defined
479
geographic area and may not be generalizable to other populations outside the Midwest United States. Implications for Practice
Pregnant adolescents in their first trimester can be admitted to an inpatient child and adolescent psychiatric unit to receive mental health and prenatal care. The development and implementation of institutional policy that specifies the criteria for admission facilitate incorporation of this practice. After review of these data, the institution updated their pregnant patient policy. Lack of consistent pregnancy care led to a prior-to-admission checklist to be completed while in the emergency department. The policy is now as follows: “Uncomplicated” pregnant adolescents may be admitted to the child and adolescent psychiatric unit from the emergency department if they meet designated criteria: positive pregnancy test, no abdominal pain, fundus examination palpable below the umbilicus, last menstrual period places pregnancy within the first 14 weeks' gestational age, vital signs stable, and no chronic medical problems. Providers from the hospital's maternal-fetal medicine department (rather than from an outside facility) will be contacted by the emergency department and approve the patient's admission to the hospital. The maternal-fetal providers will then see and assess the patient within 24 hours of admission and will implement a standard protocol including labs and ultrasound as indicated for the pregnancy care of these patients, and outpatient care will be arranged. If acute obstetric complications occur on the unit, the maternal-fetal providers will arrange transport under their care to an obstetric facility and provide ongoing care to ensure the safety of the patient and her pregnancy. The patients in this study had depressive symptoms and were pregnant. Pregnancy can be an added stressor for any female and maternal depression can increase the rate of maternal suicide. These suicidal pregnant adolescents need adequate psychiatric care in order to thrive as potential adolescent parents. If adult psychiatric facilities only admit patients over the age of 18, then child and adolescent psychiatric units may need to admit these patients for their psychiatric concern, but many child and adolescent psychiatric facilities are not co-located in an institution that offers obstetrical care. In the future, we plan to replicate the study with the revised pregnant patient policy. We will assess if there are any different patient outcomes compared with this study. This study could be replicated in other institutions that allow pregnant adolescents to be admitted to a child and adolescent psychiatric unit. Conclusion
Pregnant adolescents did not have any increase in noted adverse events during an admission to an inpatient psychiatric unit. Admitting these pregnant adolescents with suicidal ideation or attempt for adequate psychiatric care and prenatal care can result in and improve the ultimate outcome of the pregnancy. We recommend that it is safe to
480
T.M. Fletcher et al. / J Pediatr Adolesc Gynecol 28 (2015) 477e480
admit uncomplicated pregnant adolescents, within the aforementioned parameters, to an inpatient child and adolescent psychiatric unit for an acute stay. References 1. Pinheiro R, da Cunha Coelho F, da Silva R, et al: Suicidal behavior in pregnant teenagers in southern Brazil: social, obstetric and psychiatric correlates. J Affect Disord 2012; 136:520 2. McClanahan K: Depression in pregnant adolescents: considerations for treatment. J Pediatr Adolesc Gynecol 2009; 22:59 3. Bunevicius R, Kusminskas L, Bunevicius A, et al: Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynecol Scand 2009; 88:599 4. Hodgkinson S, Colantuoni E, Roberts D, et al: Depressive symptoms and birth outcomes among pregnant teenagers. J Pediatr Adolesc Gynecol 2010; 23:16
5. R Core Team: R: A language and environment for statistical computing. Vienna, Austria, R Foundation for Statistical Computing, 2014. Available: http://www. R-project.org/; 2014. Accessed November 15, 2014. 6. Freitas G, Cais C, Stefanello S, et al: Psychosocial conditions and suicidal behavior in pregnant teenagers: a case-control study in Brazil. Eur Child Adolesc Psychiatry 2008; 17:336 7. Gabrielson I, Klerman L, Currie J, et al: Suicide attempts in a population pregnant as teen-agers. Am J Public Health Nations Health 1970; 60:2289 8. Tongsong T, Srisomboom J, Wanapirak C, et al: Pregnancy outcome of threatened abortion with demonstrable fetal cardiac activity: a cohort study. J Obstet Gynecol 1995; 21:331 9. Ohio Department of Health, Center for Public Health Informatics and Statistics. Estimated teen pregnancies at rates over 1,000 females, by counties and age groups, 2010. Available: http://www.odh.ohio.gov/healthStats/disparities/ pregnancy.aspx. Accessed July 16, 2014. 10. Siegal R, Brandon A: Adolescents, pregnancy, and mental health. J Pediatr Adolesc Gynecol 2014; 27:138