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The Potential Impact of Welfare Reform on Pregnant Teenagers
208
Poster Presentations
THE USE OF ULTRASOUND IN THE GYNECOLOGICAL CARE OF WOMEN WITH MENTAL RETARDATION. Elisabeth H. Ouint M.D., Yolanda R. Smith, M.D., Rachel Hertzberg, B.S., Richard A. Bowerman, M.D. University of Michigan Medical Center, Ann Arbor, Ml. BACKGROUND: Satisfactory gynecological examination in women with mental retardation can be very difficult or impossible. Transabdominal ultrasonography is a helpful adjunct in the care of women that cannot tolerate a pelvic examination. This study was undertaken to evaluate the scan use, scan quality and clinical outcomes in a group of women with mental retardation, upon whom pelvic ultrasounds were performed. METHODS: A retrospective chart analysis was performed on all women with mental retardation who underwent pelvic ultrasonography by our Radiology Department between November 1992 and May 1997. During this time 154 patients underwent 292 scans. Available charts (n=145) were screened for patient age, level of retardation, indication for ultrasound, scan quality and outcome. RESULTS: The average age was 39 years. Level of retardation was as follows: 82 severe, 10 moderate and 3 mild retarded women. Indications for the scans included annual exam due to inability to examine, 174 patients (60%); abnormal bleeding, 25 (9%); pelvic mass or abnormal exam, 13 (4%); follow up for a previous scan, 55 (19%) and miscellaneous, 10 (3%). The patient data was not available for 15 scans. Overall scan quality was adequate in 103 (35%) of cases, suboptimal in 140 (48 %) and nondiagnostic in 49 (17%). Suboptimal exams were due to poor bladder filling, 49 (35%); lack of patient cooperation, 20 (20%) and unspecified causes in 63 (45%) of scans. The nondiagnostic scans were mostly due to poor bladder filling, 36 (73%) and limited patient cooperation, 8 (16%). Fifty patients (32%) had an abnormal scan. Abnormalities included fibroids, 26 (52%); simple cysts, 15 (30%); complex cysts, 3 (6%) and miscellaneous, 6 (12%). Of the 174 scans done for annual exam 16 % revealed fibroids and 10 % had simple cysts on one or both ovaries. As a result of the sonographic findings surgical procedures were performed in two patients. One had an ovarian cancer (scan indication: anemia) and the other patient had a laparoscopy for a paratubal cyst (indication: annual). CONCLUSIONS: Ultrasonography can be successfully performed in a majority of women with mental retardation and is therefore a useful adjunct in the gynecological evaluation of patients with mental retardation. Pathologic findings were detected in 32% of patients, however surgical intervention was only employed in two cases. Since yearly ultrasonography exams have a low yield of significant abnormalities, a scan every two-three years in asymptomatic women that cannot be examined may be appropriate.
NATURAL PROGRESSION OF POSSIBLE IN-UTERO OVARIAN TORSION. I jsa R Dynn M P Marc R. Laufer, M.D. Division of Gynecology, Department of Surgery, Division of AdolescentIYoung Adult Medicine, Department of Medicine, Children's Hospital; Division of Reproductive Endocrinology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital; Harvard Medical School, Boston. MA. BACKGROUNp' Fetal intra abdominal cystic masses can be detected by routine antenatal ultrasound. The differential diagnosis most commonly includes masses related to the genitourinary (kidney or ovary) or gastrointestinal tract. The most common types of ovarian cysts are follicular and theca-lutein cysts, and the risk of malignancy in this age group is extremely unlikely. Complications of a fetal uyarian cyst include torsion, hemorrhagc, intestinal obstruction, and bi...u~ Jystoda. ~ A 25 year-old gravida-4 para-3 with an uncomplicated prenatal course presented for an ultrasound at 32.9 weeks gestation due to fundal height greater than dates and a previous child with congenital anomalies. The survey was normal except for a 4.0 cm x 2.8 cm x 3.8 cm cystic structure in the left fetal pelvis, separate from the bladder and kidney, thought to be consistent with an ovarian cyst. A healthy female (10 pounds 12 ounces) was delivered vaginally at term. The ovarian cyst was asymptomatic. as the baby had normal feeding and growth. At 4 months of age, an ultrasound showed a 1.8 cm x 2.9 cm hypoechoic lesion with internal echoes in the left upper quadrant, consistent with an ovarian cystic lesion that may have torsed or bled; the left ovary was not visualized in the pelvis, and the right ovary appeared normal. At 5 months a repeat ultrasound showed a homogenous hypoechoic mass of similar dimensions with internal echogenicity in the right lower quadrant, thought to be consistent with a mobile ovarian cyst. At 6 months, the left ovary measured I cm x 2 cm x 1.9 cm and contained multiple punctate internal calcifications, with a more dense calcification medial to the left ovary; these findings were consistent with a history of prenatal ovarian torsion, although the scan was unable to exclude the possibility of a teratoma. A scan at 8 months demonstrated an ovoid mass of mixed echogenicity measuring 3.2 cm x 2.1 cm x 3.2 cm in the left lower quadrant: the hyperechoic portion seen previously was still prominent and demonstrated posterior shadowing. The most likely possibility to explain these findings was once again thought to be a history of in-utero ovarian torsion. Abdominal x-ray films obtained at that time showed no pelvic calcifications. At I year of age, the mass was unchanged in size, with note made of a calcification along the anterior surface. An 18 month scan showed that the calcified left ovarian lesion, presumably representing an old torsion of the ovary, was unchanged. At 2 years of age, the panially calcified left ovary was seen with what appeared to be normal ovarian tissue. measuring 2.7 cm x l.l cm x 2.1 cm. Venous now was obtained in the normalappearing tissue. This finding was thought to be more suggestive of an ovarian dermoid rather thaJ} torsion. Repeat abdominal x-ray films were obtained, and again did not demonstrate pelvic calcifications. At 3 years of age. a normal left ovary. measuring 1.5 cm x 1.1 cm was noted to be adjacent to a stable linear calcification in the left adnexa. measuring 1.7 cm. The most recent scan. obtained at 3 years and ~ months of age. showed a calcified left ovary measuring 1.5 cm x 1.6 cm x 1.6 cm. The calcification appeared to be surrounded by normal ovarian tissue. without change from previous ultrasounds. and thought to most likely represent possible in-utero ovarian torsion. CONC! (lSIONS' A fetal ovarian cyst complicated by possible in-lItero torsion does not require intervention if it is asymptomatic and not increasing in size. As the cyst is asymptomatic and the risk of malignancy is extremely small, intervention is not necessary.
THE POTENTIAL IMPACf OF WELFARE REFORM ON PREGNANT TEENAGERS. Janette Walker MD, Roxanne Protasovicki, BS, Jan Paradise, MD, Sarah Crane, MD, Boston Medical Center, Boston, MA. BACKGROUND: Massachusetts instituted welfare reform in September 1996 stating that pregnant teenagers must either live with a parent or legal guardian or in an approved group home in order to be eligible to receive Aid to Families with Dependent Children (AFDC). Previous studies have confmned that there is a high prevalence of dysfunctional humes among pregnant adolescents, especially those on public assistance, and adequate long-term housing for pregnant teens is lacking. We suspect that there is a sub-population of pregnant teenagers displaced from their parent's1guardian's home and thus required to move frequently, and that this group may correspond to those individuals most likely to be on welfare. This pilot study was undertaken to examine whether pregnant adolescents receiving AFDC were more likely to move during pregnancy and whether welfare reform was likely to have an impact on their situations. METIiOPS: Thiny seven teenagers «18 years) identified from the binh log of an urban teniary care center over a 14 month period were interviewed during their post-partum stay. Chart reviews were also perfonned to collect data on pregnancy course and binh outcome. Data is mainly presented with descriptive statistics due to limited subject number (all P>O.I). ~ : Twenty of the 37 (54%) subjects received AFDC benefits. Eight subjects (40%) on AFDC and 7(41%) not on AFDC moved during pregnancy. Three (15%) on AFDC and 1 (6%) not on AFDC moved more than once during pregnancy. Two of the fonner group were unable to live at home due to parental eviction and abuse. Due to a deficiency of approved living situations, these teens were forced to move more frequently in order to receive AFDC. Fony five percent of those on AFDC were aware of the reform regulations compared to 35% of those not receiving benefits. All patients receiving AFDC and a large majority (94%) of those not on AFDC denied that the new regulations would impact their future reproductive choices. Poor maternal weight gain, preterm delivery, and low birth weight occurred at similar rates in both groups. CONCLUSIONS: This study confirmed a high rate of mobility among pregnant teenagers. The subset of teens moving frequently during pregnancy moved secondary to external causes, not by choice, and the new welfare regulations caused some of these patients to change locations more often. The subjects denied the impact of reform on their future plans and, although a clearly subjective measure, this response may be of interest to legislators if proven consistent.
WHAT DO ADOLESCENTS REALLY KNOW ABOUT SEXUALLY TRANSMITTED DISEASES? Gayllyn Fayst-RakQs pO, Carolyn Scott, MO, Andrea Waxman, MD, lames Reed, PhD. Lehigh Valley Hospital and S1. Luke's Hospital, AlIentown, PA BACKGROUND Adolescents are at high risk for contracting sexually transmitted diseases (STDs). Three million adolescents contract an STD each year accounting for 25% of all new STD cases annually. The highest rate of gonorrhea and chlamydia infections occurs in the adolescent population and sexually active adolescent girls have an HPV prevalence rate of 50%. This study was designed to assess the general knowledge ofSTDs among the adolescent population.
ME.I.HQ.IlS. An anonymous questionnaire of 56 true or false questions was administered evaluating adolescent knowledge of STDs. An additional section included demographic characteristics of the respondents. Questions concerning the recognition, risks, symptoms, transmission, diagnosis, treatment, confidentiality and cure were asked.
B.E.S.ULIS One hundred sixty-nine questionnaires were returned representing students ages 13 through 19. Ninety-one percent described were Caucasian with an equal number of males and females. The majority (88%) had received education in school about STDs. Despite this the overall percent of correct answers was only 65.9%. Students scored best in questions regarding the risk of transmission of HIV with a greater than 90% correct response rate. Student misconceptions of STDs were wide ranging, including factors associated with cervical cancer, the belief in nonsexual transmission of STDs and curability of genital warts. Sixty-five to 88% responses were correct for the most common signs and symptoms of STDs as well as sequelae. While 88% of students were aware that latex condoms could prevent transmission of STDs, up to 42% believed that tubal sterilizaton procedures and depo-provera to do the same. Fifty-three percent of the students falsely believed that the pap smear is a screening test for STDs. CONCI USIONS Even though adolescents undergo formal education during the high school years, the overall factual knowledge of STDs is disturbing. Without this knowledge, the risk of STD transmission in adolescents and its longterm sequelae is increased.
Poster Presentations
THE USE OF ULTRASOUND IN THE GYNECOLOGICAL CARE OF WOMEN WITH MENTAL RETARDATION. Elisabeth H. Ouint M.D., Yolanda R. Smith, M.D., Rachel Hertzberg, B.S., Richard A. Bowerman, M.D. University of Michigan Medical Center, Ann Arbor, Ml. BACKGROUND: Satisfactory gynecological examination in women with mental retardation can be very difficult or impossible. Transabdominal ultrasonography is a helpful adjunct in the care of women that cannot tolerate a pelvic examination. This study was undertaken to evaluate the scan use, scan quality and clinical outcomes in a group of women with mental retardation, upon whom pelvic ultrasounds were performed. METHODS: A retrospective chart analysis was performed on all women with mental retardation who underwent pelvic ultrasonography by our Radiology Department between November 1992 and May 1997. During this time 154 patients underwent 292 scans. Available charts (n=145) were screened for patient age, level of retardation, indication for ultrasound, scan quality and outcome. RESULTS: The average age was 39 years. Level of retardation was as follows: 82 severe, 10 moderate and 3 mild retarded women. Indications for the scans included annual exam due to inability to examine, 174 patients (60%); abnormal bleeding, 25 (9%); pelvic mass or abnormal exam, 13 (4%); follow up for a previous scan, 55 (19%) and miscellaneous, 10 (3%). The patient data was not available for 15 scans. Overall scan quality was adequate in 103 (35%) of cases, suboptimal in 140 (48 %) and nondiagnostic in 49 (17%). Suboptimal exams were due to poor bladder filling, 49 (35%); lack of patient cooperation, 20 (20%) and unspecified causes in 63 (45%) of scans. The nondiagnostic scans were mostly due to poor bladder filling, 36 (73%) and limited patient cooperation, 8 (16%). Fifty patients (32%) had an abnormal scan. Abnormalities included fibroids, 26 (52%); simple cysts, 15 (30%); complex cysts, 3 (6%) and miscellaneous, 6 (12%). Of the 174 scans done for annual exam 16 % revealed fibroids and 10 % had simple cysts on one or both ovaries. As a result of the sonographic findings surgical procedures were performed in two patients. One had an ovarian cancer (scan indication: anemia) and the other patient had a laparoscopy for a paratubal cyst (indication: annual). CONCLUSIONS: Ultrasonography can be successfully performed in a majority of women with mental retardation and is therefore a useful adjunct in the gynecological evaluation of patients with mental retardation. Pathologic findings were detected in 32% of patients, however surgical intervention was only employed in two cases. Since yearly ultrasonography exams have a low yield of significant abnormalities, a scan every two-three years in asymptomatic women that cannot be examined may be appropriate.
NATURAL PROGRESSION OF POSSIBLE IN-UTERO OVARIAN TORSION. I jsa R Dynn M P Marc R. Laufer, M.D. Division of Gynecology, Department of Surgery, Division of AdolescentIYoung Adult Medicine, Department of Medicine, Children's Hospital; Division of Reproductive Endocrinology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital; Harvard Medical School, Boston. MA. BACKGROUNp' Fetal intra abdominal cystic masses can be detected by routine antenatal ultrasound. The differential diagnosis most commonly includes masses related to the genitourinary (kidney or ovary) or gastrointestinal tract. The most common types of ovarian cysts are follicular and theca-lutein cysts, and the risk of malignancy in this age group is extremely unlikely. Complications of a fetal uyarian cyst include torsion, hemorrhagc, intestinal obstruction, and bi...u~ Jystoda. ~ A 25 year-old gravida-4 para-3 with an uncomplicated prenatal course presented for an ultrasound at 32.9 weeks gestation due to fundal height greater than dates and a previous child with congenital anomalies. The survey was normal except for a 4.0 cm x 2.8 cm x 3.8 cm cystic structure in the left fetal pelvis, separate from the bladder and kidney, thought to be consistent with an ovarian cyst. A healthy female (10 pounds 12 ounces) was delivered vaginally at term. The ovarian cyst was asymptomatic. as the baby had normal feeding and growth. At 4 months of age, an ultrasound showed a 1.8 cm x 2.9 cm hypoechoic lesion with internal echoes in the left upper quadrant, consistent with an ovarian cystic lesion that may have torsed or bled; the left ovary was not visualized in the pelvis, and the right ovary appeared normal. At 5 months a repeat ultrasound showed a homogenous hypoechoic mass of similar dimensions with internal echogenicity in the right lower quadrant, thought to be consistent with a mobile ovarian cyst. At 6 months, the left ovary measured I cm x 2 cm x 1.9 cm and contained multiple punctate internal calcifications, with a more dense calcification medial to the left ovary; these findings were consistent with a history of prenatal ovarian torsion, although the scan was unable to exclude the possibility of a teratoma. A scan at 8 months demonstrated an ovoid mass of mixed echogenicity measuring 3.2 cm x 2.1 cm x 3.2 cm in the left lower quadrant: the hyperechoic portion seen previously was still prominent and demonstrated posterior shadowing. The most likely possibility to explain these findings was once again thought to be a history of in-utero ovarian torsion. Abdominal x-ray films obtained at that time showed no pelvic calcifications. At I year of age, the mass was unchanged in size, with note made of a calcification along the anterior surface. An 18 month scan showed that the calcified left ovarian lesion, presumably representing an old torsion of the ovary, was unchanged. At 2 years of age, the panially calcified left ovary was seen with what appeared to be normal ovarian tissue. measuring 2.7 cm x l.l cm x 2.1 cm. Venous now was obtained in the normalappearing tissue. This finding was thought to be more suggestive of an ovarian dermoid rather thaJ} torsion. Repeat abdominal x-ray films were obtained, and again did not demonstrate pelvic calcifications. At 3 years of age. a normal left ovary. measuring 1.5 cm x 1.1 cm was noted to be adjacent to a stable linear calcification in the left adnexa. measuring 1.7 cm. The most recent scan. obtained at 3 years and ~ months of age. showed a calcified left ovary measuring 1.5 cm x 1.6 cm x 1.6 cm. The calcification appeared to be surrounded by normal ovarian tissue. without change from previous ultrasounds. and thought to most likely represent possible in-utero ovarian torsion. CONC! (lSIONS' A fetal ovarian cyst complicated by possible in-lItero torsion does not require intervention if it is asymptomatic and not increasing in size. As the cyst is asymptomatic and the risk of malignancy is extremely small, intervention is not necessary.
THE POTENTIAL IMPACf OF WELFARE REFORM ON PREGNANT TEENAGERS. Janette Walker MD, Roxanne Protasovicki, BS, Jan Paradise, MD, Sarah Crane, MD, Boston Medical Center, Boston, MA. BACKGROUND: Massachusetts instituted welfare reform in September 1996 stating that pregnant teenagers must either live with a parent or legal guardian or in an approved group home in order to be eligible to receive Aid to Families with Dependent Children (AFDC). Previous studies have confmned that there is a high prevalence of dysfunctional humes among pregnant adolescents, especially those on public assistance, and adequate long-term housing for pregnant teens is lacking. We suspect that there is a sub-population of pregnant teenagers displaced from their parent's1guardian's home and thus required to move frequently, and that this group may correspond to those individuals most likely to be on welfare. This pilot study was undertaken to examine whether pregnant adolescents receiving AFDC were more likely to move during pregnancy and whether welfare reform was likely to have an impact on their situations. METIiOPS: Thiny seven teenagers «18 years) identified from the binh log of an urban teniary care center over a 14 month period were interviewed during their post-partum stay. Chart reviews were also perfonned to collect data on pregnancy course and binh outcome. Data is mainly presented with descriptive statistics due to limited subject number (all P>O.I). ~ : Twenty of the 37 (54%) subjects received AFDC benefits. Eight subjects (40%) on AFDC and 7(41%) not on AFDC moved during pregnancy. Three (15%) on AFDC and 1 (6%) not on AFDC moved more than once during pregnancy. Two of the fonner group were unable to live at home due to parental eviction and abuse. Due to a deficiency of approved living situations, these teens were forced to move more frequently in order to receive AFDC. Fony five percent of those on AFDC were aware of the reform regulations compared to 35% of those not receiving benefits. All patients receiving AFDC and a large majority (94%) of those not on AFDC denied that the new regulations would impact their future reproductive choices. Poor maternal weight gain, preterm delivery, and low birth weight occurred at similar rates in both groups. CONCLUSIONS: This study confirmed a high rate of mobility among pregnant teenagers. The subset of teens moving frequently during pregnancy moved secondary to external causes, not by choice, and the new welfare regulations caused some of these patients to change locations more often. The subjects denied the impact of reform on their future plans and, although a clearly subjective measure, this response may be of interest to legislators if proven consistent.
WHAT DO ADOLESCENTS REALLY KNOW ABOUT SEXUALLY TRANSMITTED DISEASES? Gayllyn Fayst-RakQs pO, Carolyn Scott, MO, Andrea Waxman, MD, lames Reed, PhD. Lehigh Valley Hospital and S1. Luke's Hospital, AlIentown, PA BACKGROUND Adolescents are at high risk for contracting sexually transmitted diseases (STDs). Three million adolescents contract an STD each year accounting for 25% of all new STD cases annually. The highest rate of gonorrhea and chlamydia infections occurs in the adolescent population and sexually active adolescent girls have an HPV prevalence rate of 50%. This study was designed to assess the general knowledge ofSTDs among the adolescent population.
ME.I.HQ.IlS. An anonymous questionnaire of 56 true or false questions was administered evaluating adolescent knowledge of STDs. An additional section included demographic characteristics of the respondents. Questions concerning the recognition, risks, symptoms, transmission, diagnosis, treatment, confidentiality and cure were asked.
B.E.S.ULIS One hundred sixty-nine questionnaires were returned representing students ages 13 through 19. Ninety-one percent described were Caucasian with an equal number of males and females. The majority (88%) had received education in school about STDs. Despite this the overall percent of correct answers was only 65.9%. Students scored best in questions regarding the risk of transmission of HIV with a greater than 90% correct response rate. Student misconceptions of STDs were wide ranging, including factors associated with cervical cancer, the belief in nonsexual transmission of STDs and curability of genital warts. Sixty-five to 88% responses were correct for the most common signs and symptoms of STDs as well as sequelae. While 88% of students were aware that latex condoms could prevent transmission of STDs, up to 42% believed that tubal sterilizaton procedures and depo-provera to do the same. Fifty-three percent of the students falsely believed that the pap smear is a screening test for STDs. CONCI USIONS Even though adolescents undergo formal education during the high school years, the overall factual knowledge of STDs is disturbing. Without this knowledge, the risk of STD transmission in adolescents and its longterm sequelae is increased.