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Adolescent Pregnan e Heart

Current concern about adolescent pregnancy ie based pregnancy, posed major and ultimately fatal com-
largely on its ne@ive hnpad on the social, develop plications. Our case is extreme in that the outcome
mental, and economic proepecte of the mother and her of adolescent pregnancy is rarely so dire (5-i). this
infant. The issur~ of +&scen~ pngnancy are mollo com- case does, however, demonstrate frequently occur-
plex when the mother nas a seven heart defect. Our case
ring issues regarding the balance of responsibility
uustrates the problems that can lr@e in the pressure of
associated medical ptiblems. Although the patients be- between the medical t.;rcfessional, patient, and fam-
havior kontributed substantially to a tragic outcome, we ily that adolescence accentuates.
believe greater prof+sional awareness and sensitiv-
ity regarding the needs of such adolescent patient8might Case Report
iiave produced a more favorableoutcome.
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
KEY wonDs: years old, she had open-heart aortic valve surgery, which

Pregnan significantly improved her cardiac status. Her entry into
Heart de ect 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,
Adolescent pregnancy is viewed as medically and along with associated school changes, may have contib-
socially undesirable (1,2). Medically, the pregnant uted to her later loss of interest in school. Her familys
adolescent appears to be at greater risk than the low economic status subsequently affected their ability to
afford medications, but the patient2 main medical ex-
older woman of having a premature delivery, a low-
penses were met by the state Medicaid and Aid to De-
birthweight (< Wx, gm) infant, or an infant who pendent Children.
dies during the first year of life (3,4). Even when At 13 years old, she was hospitalized for persistent
adolescent pregnancy proceeds favorably, there may chest pain. An electrocardiogram showed myocardiil is-
be undesirable psychosocial consequences. A young chemia and cardiac catheterization indicated severe aortic
mother, who has not finished her own growing up, insufficiency. She underwent successful open heart sur-
now has a major responsibility for the care of a child. geerywith a Bjork-Shiley mechanical valve replacement.
We present a case of an adolescer,t pregnancy in the Chronic anticoag&tion was then required to prevent em-
context of a severe medical problem that, during 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-
Frvn~the Universityof KentuckyCofIec of Medicine,Lexington. cline. She began to skip classes, saying she didnt feel
Address reprint requests to: Eugene B. Eallagher, Fh.D., University well. Her surge;eryoccurredearly in 8th grade and caused
of KmhUky college of Medicine, DPpartrnentof Behavioral Science,
cdlege of Me&itu ma? Building, kxington, KY 405364086.
her to miss four weeks of school. Despite her physical
h4anuxript atcepted Mnxmber 20,1986. growth and greater energy postoperatively, however, her

Q society for Adolescent Medkine, 1988
Publisheh by Elsevier Sdence Pu~lishb.g CL Inc., 52 Vanderbilt Ave., New York, NY 10017 ol91W.50

truancy continued. She failed the 8th grade, and arrange- lacking in security and guidance, the typical adoles-
ments were made for her to repeat it in a different school. cent problems usually pose greater difficulties. The
At age 15 years, she became sexually active, and she risks that attend the entry of adolescents into adult-
asked for birth control pills. They were prescribed reluc- hood are further increased in the presence of sig-
tantly by her physician due to a concern about the possible nificant medical problems. The burden of decision
m- with her anticoagulation. The patient how-
making and guidance often shifts to outside agen-
ever, did not return to receive the medication. In Novem-
ber of that year she came to the pediatric clinic for possible
cies or groups - schoo1, health personnel, a court,
pregnancy. She was 6 weeks pregnant and was transferred or a social agency. Many bureaucratic or professional
to the obstetrics clinic. Her anticoagulant was changed experts lack day-today knowledge of the adoles-
from oral warfarin to subcutaneous heparin. This change cent, thus potentially impeding their ability to make
was made because of the high risk of fetal damage with wise decisions. Medical social workers and family
warfarin (8,9). She was taught to inject the hepatin herself. counselors are frequently in a position to understand
The patient was truant and living in a public housing the personal situation of the adolescent patient, al-
apartment with her sister, mother, stepfather, and step though nurses and physicians as well often possess
sister. The familys economic position required social work such knowledge.
intervention to assist in paying for the heparin. Consid- In our case, a particular point can be identified
eration was given to terminating the pregnancy; however,
at which a different course might have resulted in
her personal desire to proceed was honored. One month
later, she had a spontaneous abortion, which was com- a less catastrophic ending. Our hospitals obstetric
pleted by surgical dilatation and curettage. Warfarin was clinic has a special program - the Young Moth-
reinstituted and she was counseled against future preg- ers program - for the adolescent patient. Under
nancy, but no contraceptive was prescribed. this program, patients receive instruction and
The following March she presented 9 weeks pregnant. counseling regarding health care, infant care, and
She was again changed from warfarin to heparin. She contraception. They receive encouragement and
announced that she wanted to have the baby. Neverthe- practical facilitatior? to maintain their education.
less, she was apprehensive and told the social worker The program is staffed by nurses, social workers,
about a friend who had died during pregnancy. and obstetricians who provide the medical super-
At her prenatal visit 1 month later, she complained that
vision of pregnancy. The program also provides
her arms ached, that sometimes her fingers turned blue,
and that slight exertion made her short of breath. She also
periodic prenatal visits and small-sized nutrition
reported difficulty with her heparin; the injections bruised classes that create a favorable atmosphere for peer
her skin and she was not taking them as prescribed. Her acquaintance and friendship among these young
dose schedule was decreased to twice daily at that time. women. Although our patient was eligible for this
Two weeks later she complained of chest pain, and program, she was not offered the opportunity be-
the mechanical valves click could not be heard. A new cause she was also an obstetric heart patient. Be-
diastolic murmurwas present. A blood test showed in- cause her case required that she be seen by cardiac
adequate anticoagulation. She was immediately admit- as well as obstetric specialists, her prenatal visits
ted to the hospital, and high-dose intravenous heparin could not be conveniently accommodated within
was @ituted. Twenty-four hours after admission, she the group-appointment format of the Young
became nauseated, experienced severe chest pain, and
Mothers program.
then became comatose. The decision was made to oper-
ate and declot the mechanical valve. She could not be When pregnancy occurs in a young unmarried
weaned from the bypass machine and was pronounced teenager, it exists within a social and personal ma-
dead. trix that requires a special logic of professional as-
sessment and response. We believe that our
patient might have benefited from this program. It
mscussion appears, however, that she was regarded more as
This adolescent pregnancy had a worst case out- a heart-valve case than as an adolescent
come. It demonstrates the influence of the patients mother.
congenital heart disease on her life and pregnancy
despite continuous access to sophisticated medical
With chikihood behind them, adolescents are ea- References
ger for adult social independence, yet they are still 1. Boyce WT. Permanence and change: Psychosocial factors in
the outcome of adolescent pregnancy. Sot Sci Med
economically and emotionally dependent on th; 196;21:1279-87.
family. When adolescents face a family situation 2. Elster AB. The effect of maternal age, parity,and prenatalcare