CASE REPORT
Adolescent Pregnan
Current concern about adolescent pregnancy ie based
largely on its ne@ive hnpad on the social, develop
mental, and economic proepecte of the mother and her
infant. The issur~ of +&scen~ pngnancy are mollo com-
plex when the mother nas a seven heart defect. Our case
uustrates the problems that can lr@e in the pressure of
associated medical ptiblems. Although the patients be-
havior kontributed substantially to a tragic outcome, we
believe greater prof+sional awareness and sensitiv-
ity regarding the needs of such adolescent patient8might
iiave produced a more favorableoutcome.
KEY wonDs:
7
Pregnan
Heart de ect
Adolescent pregnancy is viewed as medically and
socially undesirable (1,2). Medically, the pregnant
adolescent appears to be at greater risk than the
older woman of having a premature delivery, a low-
birthweight (< Wx, gm) infant, or an infant who
dies during the first year of life (3,4). Even when
adolescent pregnancy proceeds favorably, there may
be undesirable psychosocial consequences. A young
mother, who has not finished her own growing up,
now has a major responsibility for the care of a child.
We present a case of an adolescer,t pregnancy in the
context of a severe medical problem that, during
--
Frvn~the Universityof KentuckyCofIec of Medicine,Lexington.
Address reprint requests to: Eugene B. Eallagher, Fh.D., University
of KmhUky college of Medicine, DPpartrnentof Behavioral Science,
cdlege of Me&itu ma? Building, kxington, KY 405364086.
h4anuxript atcepted Mnxmber 20,1986.
Q society for Adolescent Medkine, 1988
Publisheh by Elsevier Sdence Pu~lishb.g CL Inc., 52 Vanderbilt Ave., New York, NY 10017
e Heart
pregnancy, posed major and ultimately fatal com-
plications. Our case is extreme in that the outcome
of adolescent pregnancy is rarely so dire (5-i). this
case does, however, demonstrate frequently occur-
ring issues regarding the balance of responsibility
between the medical t.;rcfessional, patient, and fam-
ily that adolescence accentuates.
Case Report
The patient was the first-bornchild of a working-class
family living in a northeasternmetropolis.A heart mur-
mur had been discovered at birth. At 4 months old, she
was diagnosed as having congenital aortic stenosis. At 5
years old, she had open-heart aortic valve surgery, which
significantly improved her cardiac status. Her entry into
grade school was uneventful.
At 8 years of age hzr parents divorced, after whi21 she
and her younger sistrr lived with their mother. Their eco-
nomic position markedly declined. Resider&l moves,
along with associated school changes, may have contib-
uted to her later loss of interest in school. Her familys
low economic status subsequently affected their ability to
afford medications, but the patient2 main medical ex-
penses were met by the state Medicaid and Aid to De-
pendent Children.
At 13 years old, she was hospitalized for persistent
chest pain. An electrocardiogram showed myocardiil is-
chemia and cardiac catheterization indicated severe aortic
insufficiency. She underwent successful open heart sur-
geerywith a Bjork-Shiley mechanical valve replacement.
Chronic anticoag&tion was then required to prevent em-
bolization. She did well following the sqery and expe-
rienced some catch-up growth during the next year.
Nevertheless, she remained short for her age.
In the 7th grade, her interest in school started to de-
cline. She began to skip classes, saying she didnt feel
well. Her surge;eryoccurredearly in 8th grade and caused
her to miss four weeks of school. Despite her physical
growth and greater energy postoperatively, however, her
161
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162 GALLAGHERAND FARRALI.
truancy continued. She failed the 8th grade, and arrange-
ments were made for her to repeat it in a different school.
At age 15 years, she became sexually active, and she
asked for birth control pills. They were prescribed reluc-
tantly by her physician due to a concern about the possible
m- with her anticoagulation. The patient how-
ever, did not return to receive the medication. In Novem-
ber of that year she came to the pediatric clinic for possible
pregnancy. She was 6 weeks pregnant and was transferred
to the obstetrics clinic. Her anticoagulant was changed
from oral warfarin to subcutaneous heparin. This change
was made because of the high risk of fetal damage with
warfarin (8,9). She was taught to inject the hepatin herself.
The patient was truant and living in a public housing
apartment with her sister, mother, stepfather, and step
sister. The familys economic position required social work
intervention to assist in paying for the heparin. Consid-
eration was given to terminating the pregnancy; however,
her personal desire to proceed was honored. One month
later, she had a spontaneous abortion, which was com-
pleted by surgical dilatation and curettage. Warfarin was
reinstituted and she was counseled against future preg-
nancy, but no contraceptive was prescribed.
The following March she presented 9 weeks pregnant.
She was again changed from warfarin to heparin. She
announced that she wanted to have the baby. Neverthe-
less, she was apprehensive and told the social worker
about a friend who had died during pregnancy.
At her prenatal visit 1 month later, she complained that
her arms ached, that sometimes her fingers turned blue,
and that slight exertion made her short of breath. She also
reported difficulty with her heparin; the injections bruised
her skin and she was not taking them as prescribed. Her
dose schedule was decreased to twice daily at that time.
Two weeks later she complained of chest pain, and
the mechanical valves click could not be heard. A new
diastolic murmurwas present. A blood test showed in-
adequate anticoagulation. She was immediately admit-
ted to the hospital, and high-dose intravenous heparin
was @ituted. Twenty-four hours after admission, she
became nauseated, experienced severe chest pain, and
then became comatose. The decision was made to oper-
ate and declot the mechanical valve. She could not be
weaned from the bypass machine and was pronounced
dead.
mscussion
This adolescent pregnancy had a worst case out-
come. It demonstrates the influence of the patients
congenital heart disease on her life and pregnancy
despite continuous access to sophisticated medical
care.
With chikihood behind them, adolescents are ea-
ger for adult social independence, yet they are still
economically and emotionally dependent on th;
family. When adolescents face a family situation
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 9, No. 2
lacking in security and guidance, the typical adoles-
cent problems usually pose greater difficulties. The
risks that attend the entry of adolescents into adult-
hood are further increased in the presence of sig-
nificant medical problems. The burden of decision
making and guidance often shifts to outside agen-
cies or groups - schoo1, health personnel, a court,
or a social agency. Many bureaucratic or professional
experts lack day-today knowledge of the adoles-
cent, thus potentially impeding their ability to make
wise decisions. Medical social workers and family
counselors are frequently in a position to understand
the personal situation of the adolescent patient, al-
though nurses and physicians as well often possess
such knowledge.
In our case, a particular point can be identified
at which a different course might have resulted in
a less catastrophic ending. Our hospitals obstetric
clinic has a special program - the Young Moth-
ers program - for the adolescent patient. Under
this program, patients receive instruction and
counseling regarding health care, infant care, and
contraception. They receive encouragement and
practical facilitatior? to maintain their education.
The program is staffed by nurses, social workers,
and obstetricians who provide the medical super-
vision of pregnancy. The program also provides
periodic prenatal visits and small-sized nutrition
classes that create a favorable atmosphere for peer
acquaintance and friendship among these young
women. Although our patient was eligible for this
program, she was not offered the opportunity be-
cause she was also an obstetric heart patient. Be-
cause her case required that she be seen by cardiac
as well as obstetric specialists, her prenatal visits
could not be conveniently accommodated within
the group-appointment format of the Young
Mothers program.
When pregnancy occurs in a young unmarried
teenager, it exists within a social and personal ma-
trix that requires a special logic of professional as-
sessment and response. We believe that our
patient might have benefited from this program. It
appears, however, that she was regarded more as
a heart-valve case than as an adolescent
mother.
References
1. Boyce WT. Permanence and change: Psychosocial factors in
the outcome of adolescent pregnancy. Sot Sci Med
196;21:1279-87.
2. Elster AB. The effect of maternal age, parity,and prenatalcare
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