Frequency of Unscheduled Visits to the Obstetrical Triage Assessment Unit by Pregnant Adolescents in an Urban Canadian Centre Compared with a Matched Cohort of Pregnant Women.

OBJECTIVES: People from marginalized and vulnerable populations present more frequently for unscheduled, emergency obstetrical services at labour and delivery triage units. Based on our clinical experience, pregnant adolescents visit the obstetrical triage assessment units (OTAU) more often than adults do. This study was designed to assess this phenomenon by quantifying and describing the frequency of unscheduled visits to the OTAU by pregnant adolescents (age <20 y) compared with a matched cohort of adult pregnant patients (age ≥20 y). METHODS: A retrospective database review was performed for data on all adolescent patients that delivered at our institution at ≥20 weeks gestation between January 1, 2013, and December 31, 2017. Adolescent pregnant patients were matched in a 1:1 ratio with adult pregnant patients. Demographic and clinical characteristics as well as the number of visits to the OTAU were recorded. RESULTS: A total of 162 adolescent pregnant patients visited the OTAU during the study period. The mean number of visits to the OTAU by adolescents was 2.77 ± 2.40 compared with 1.96 ± 1.80 visits in the adult cohort (P = 0.0001). Adolescents were 63% more likely than adults to access triage services (incidence rate ratio [IRR] 1.63; 95% CI 1.09-2.44, P = 0.017). Diagnosis of a mental health condition was the only identified risk factor for accessing OTAU, irrespective of age (IRR 1.64; 95% CI 1.05, 2.55, P = 0.029). CONCLUSIONS: Adolescent pregnant patients tend to visit the OTAU on an unscheduled basis more often than do adult patients. The presence of a mental health condition was identified as an important predictor of unscheduled visits to OTAUs for adolescent patients.

Pediatric and Adolescent Gynecology Practices: A National Survey of Canadian Gynecologists.

OBJECTIVE: To identify 1) the current state of pediatric and adolescent gynecology (PAG) provision of care; 2) barriers to practicing PAG; and 3) the need for increased PAG training in residency and continuing medical education (CME). METHODS: Obstetricians and gynecologists (OB/GYNs) across Canada who currently practice gynecology were asked to complete an anonymous, self-administered, Internet-based survey. RESULTS: One-hundred and forty-seven OB/GYNs across Canada responded to the survey, and after applying exclusion criteria (retired gynecologists, medical students, postgraduate trainees, gynecologists who do not currently practice gynecology, PAG specialists, or OB/GYNs seeing predominantly pregnant adolescent women), 135 were included. Seventy-six percent of survey respondents stated that they care for pediatric and adolescent patients in their practice. The pathologies and surgeries they are comfortable managing are those that are similar to the adult population, such as intrauterine device insertion in the office/OR, adnexal detorsion, laparoscopy in patients over 12 years of age, examination under anesthesia, and hymenectomy. Respondents who stated wanting to learn more about PAG preferred either online learning modules (85%) or CME workshops at regional meetings (91%). CONCLUSION: Canadian OB/GYNs provide PAG care with very little training to support their work. Attention must be given to better training for our residents via available curriculums and teaching modalities, as well as increased access to CME for OB/GYNs.

Where Have the Periods Gone? The Evaluation and Management of Functional Hypothalamic Amenorrhea

Functional hypothalamic amenorrhea (FHA) is a common cause of amenorrhea in adolescent girls. It is often seen in the setting of stress, weight loss, or excessive exercise. FHA is a diagnosis of exclusion. Patients with primary or secondary amenorrhea should be evaluated for other causes of amenorrhea before a diagnosis of FHA can be made. The evaluation typically consists of a thorough history and physical examination as well as endocrinological and radiological investigations. FHA, if prolonged, can have significant impacts on metabolic, bone, cardiovascular, mental, and reproductive health. Management often involves a multidisciplinary approach, with a focus on lifestyle modification. Depending on the severity, pharmacologic therapy may also be considered. The aim of this paper is to present a review on the pathophysiology, clinical findings, diagnosis, and management approaches of FHA in adolescent girls.

Non-visualization of the ovaries on pediatric transabdominal ultrasound with a non-distended bladder: Can adnexal torsion be excluded?

BACKGROUND: The pediatric reproductive organs are optimally imaged with a full bladder. The filling of the bladder, however, often leads to significant delay in diagnosis and can subject the patient to invasive bladder catheterization. As the key imaging feature in ovarian torsion is unilateral ovarian enlargement, we suspected that a torsed ovary is large enough to be visualized even if the bladder is not well distended. OBJECTIVE: The purpose of this study was to retrospectively investigate if clinically suspected adnexal torsion can be excluded based on non-visualization of the ovaries on transabdominal ultrasound (US) with a non-distended bladder in pediatric patients. MATERIALS AND METHODS: This retrospective study comprised 349 girls (1-19 years old) between Jan. 1, 2013, and July 30, 2018. Three hundred and forty-one of the girls were referred to transabdominal US to assess for adnexal torsion and/or appendicitis, and the ovaries were initially not visualized on US. Their bladders were subsequently filled and rescanned with a distended bladder showing the ovaries. Ovarian volumes and time between US scans were documented. The ratio of the volume of the larger ovary to the smaller one was calculated. Nine girls had surgically proven adnexal torsion and a preoperative transabdominal US with a non-distended bladder. There was an overlap of one girl between the two groups. The negative predictive value (NPV), positive predictive value (PPV), and sensitivity and specificity for exclusion of adnexal torsion based on non-visualization of the ovaries on US with a non-distended bladder were calculated. RESULTS: One of the girls (1/341) who had a US study done with a non-distended bladder in which the ovaries were not visualized had a positive diagnosis of adnexal torsion. In eight of the nine girls who had surgically proven adnexal torsion, the torted ovary was identified with a non-distended bladder. The NPV and PPV for exclusion of adnexal torsion with a non-distended bladder was 1.0 and 0.8, respectively. The specificity and sensitivity were 99.4% and 88.9%, respectively. The mean and median time difference between the initial scan and the scan after bladder filling was 105.1 min (standard deviation [SD] -65.8) and 89.0 min (interquartile range [IQR]- 59.0, 130.5), respectively. CONCLUSION: Non-visualization of the ovaries with a non-distended bladder on transabdominal US study can help exclude clinically suspected adnexal torsion, alleviating the need for bladder filling and prolonging the wait time in the emergency department. Inclusion of non-visualization of the ovaries as one of the features in a predictive score for adnexal torsion should be considered.

Where Are We in Terms of Sexual Health Education? An Ontario Perspective.

In the present study, sexual health educators in schools in the catchment area for the Children's Hospital of Eastern Ontario were surveyed to determine whether sexual health education programs were available to youth, whether the structure and content of sexual health education programs followed the guidelines, the instructors' qualifications and level of comfort with the material, and the need for additional resources that could be offered by health care professionals. Survey results showed that only 85% of participating schools had a sexual health education program in place. Only one-third of educators stated they had formal training on the topic of sexual health. Some schools still taught mostly about abstinence or advocated condom use for contraception. The results showed that many of these schools did not follow established Canadian guidelines for sexual health education. Nonetheless, 80% of Canadian adolescents report school as their most valuable source of information on sexuality.

Ecthyma Gangrenosum: Vulvar Ulcers, Pseudomonas, and Pancytopenia: A Case Report of an 18-Month-Old Female Toddler.

BACKGROUND: An 18-month-old female toddler presented with severe vulvar ulcers and pancytopenia with investigations revealing Pseudomonas aeruginosa bacteremia. CASE: A previously healthy 18-month-old female toddler presented with 6 days of fevers, vulvar rash, and ulcers. Vulvar cultures showed Staphylococcus aureus and P aeruginosa. Bloodwork showed pancytopenia and P aeruginosa bacteremia. She started receiving broad-spectrum antibiotics. Bone marrow aspirate revealed a hypocellular marrow with erythroid dysplasia. Vulvar ulcers progressed rapidly, therefore magnetic resonance imaging was performed to rule out necrotizing fasciitis. She was diagnosed with ecthyma gangrenosum (EG). Three months after initial presentation, she was diagnosed with precursor B-cell acute lymphoblastic leukemia. SUMMARY AND CONCLUSION: This case highlights that health care providers should suspect EG when severe vulvar ulcers are present with P aeruginosa infection and neutropenia. Because EG poses significant morbidity and mortality, its presence should prompt aggressive antimicrobial therapy and mobilization of a multidisciplinary team to initiate workup for an underlying immunodeficiency syndrome or malignancy. This case also illustrates that surgical debridement might be avoided in certain patients with EG as long as meticulous wound care and close monitoring with a multidisciplinary team are in place.

Resident Education Curriculum in Pediatric and Adolescent Gynecology: The Short Curriculum 2.0.

The degree of exposure to pediatric and adolescent gynecology (PAG) varies across residency programs in obstetrics and gynecology and pediatrics. Nevertheless, these programs are responsible for training residents and providing opportunities within their programs to fulfill PAG learning objectives. To that end, the North American Society for Pediatric and Adolescent Gynecology has taken a leadership role in PAG resident education by creating and systematically updating the Short Curriculum. This curriculum outlines specific learning objectives that are central to PAG education and lists essential resources for learners' reference. This updated curriculum replaces the previous 2014 publication with added content, resources, and updated references. Additionally, attention to the needs of learners in pediatrics and adolescent medicine is given greater emphasis in this revised North American Society for Pediatric and Adolescent Gynecology Short Curriculum 2.0.

Improving Resident Knowledge in Pediatric and Adolescent Gynecology: An Evaluation of the North American Society for Pediatric and Adolescent Gynecology Short Curriculum.

STUDY OBJECTIVE: Resident education in pediatric and adolescent gynecology (PAG) is challenging. It encompasses patients from neonates to young adults with different disorders involving multiple subspecialties. Residents have inadequate exposure to PAG topics and report lack of knowledge in this area. The objective of this study was to determine if the North American Society for Pediatric and Adolescent Gynecology (NASPAG) Short Curriculum improves self-reported knowledge in PAG among obstetrics and gynecology (ObGyn), family medicine, and pediatric residents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Participants were 47 US ObGyn, family medicine, and pediatric residency training programs across a 4-month study window, from September to December 2016. The NASPAG Short Curriculum was distributed to them with a request to complete a retrospective pre- and post-test survey. Primary outcome measure was improvement in self-perceived knowledge after exposure to the curriculum. RESULTS: Forty-eight programs responded to the study comprising a total of 1130 residents. One program was excluded because of logistical barriers to the distribution of study incentive. In total, 1080 residents were invited and 103 chose to participate (10% response rate); 68 residents completed all survey questions to be included in the final analysis. After completing the curriculum, self-reported knowledge improved in all 10 learning objectives, across all 3 specialties (47% [32/68] to 82% [56/68]; P < .01). Pre-test knowledge correlated with previous clinical exposure to PAG patients, but did not correlate with year of residency training, type of residency, or previous PAG lectures. CONCLUSION: Significant deficiencies exist regarding self-reported knowledge of core PAG topics among ObGyn, family medicine, and pediatric residents. Use of the NASPAG Short Curriculum improves self-reported knowledge in PAG trainees across all 3 specialties.

Creation and Dissemination of a Multispecialty Graduate Medical Education Curriculum in Pediatric and Adolescent Gynecology: The North American Society for Pediatric and Adolescent Gynecology Resident Education Committee Experiences.

STUDY OBJECTIVE: The goal was to develop a multispecialty committee to address deficiencies in pediatric and adolescent gynecology (PAG) resident education through curricular development under the auspices of the North American Society for Pediatric and Adolescent Gynecology. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A multispecialty North American committee was organized to develop short as well as long curricula in PAG through a combination of conference calls and face-to-face meetings. Content was guided by objectives of national accrediting organizations. The curricula used print as well as interactive electronic resources. RESULTS: After publication of the short and long curricula, a dissemination strategy was developed to present the information at national meetings. A curricular study was performed after introduction of the curriculum to evaluate its efficacy. Long-term plans for further curricular components and expansion of educational tools are ongoing. CONCLUSION: We gathered a diverse multispecialty group of doctors to collaborate on a unified educational goal. This committee developed and disseminated resident PAG curricula using a variety of learning tools. This curricular development and implementation can occur with a minimal financial burden.

Tubo-Ovarian Abscess in a Virginal Adolescent with Labial Agglutination Due to Lichen Sclerosus.

BACKGROUND: We describe an unusual presentation of lichen sclerosus in a postmenarchal, virginal girl. CASE: A 14-year-old girl first presented with acute urinary retention due to labial agglutination and developed bilateral tubo-ovarian abscesses in 10 days of the conservative management period. Abscesses were treated with antibiotherapy and percutaneous drainage; simple division of the labial agglutination and vulvar biopsies were performed with a preliminary diagnosis of lichen sclerosus. Postoperative follow-up with antibiotherapy and clobetasol propionate 0.05% ointment was uneventful. SUMMARY AND CONCLUSION: Lichen sclerosus should be considered in cases of labial agglutination with atypical presentations. Finally, this case reminds us that pelvic inflammatory disease and tubo-ovarian abscess must be kept in mind even in virginal adolescents, especially in the presence of obstructive lesions of the genital tract.

Treat Me But Don't Judge Me: A Qualitative Examination of Health Care Experiences of Pregnant and Parenting Youth.

STUDY OBJECTIVE: To share pregnant and parenting youth's experiences with health care to inform recommendations for promoting youth-friendly medical encounters. DESIGN: This exploratory study used a qualitative descriptive approach. SETTING: Three urban centers that service pregnant youth and young parents in a large Canadian city. PARTICIPANTS: A convenience sample of 26 participants (mean age of 18.7 years) was recruited across sites. INTERVENTIONS: Five focus groups were conducted. MAIN OUTCOME MEASURES: Focus groups were audio recorded, transcribed verbatim, and analyzed thematically. Analysis involved the independent, open coding of data by 2 qualitative researchers to identify and compare emerging themes. RESULTS: Three major themes emerged regarding their experiences with health care providers: characteristics of negative health care encounters, the emergence of contemporary stereotypes during these encounters, and characteristics of positive health care encounters. Negative encounters often resulted from perceived judgmental attitudes of providers and were shown to contribute to a general sense of mistrust and fear. Positive health care encounters tended to feature mutual respect, support, open dialogue, and nonjudgmental attitudes. CONCLUSION: Pregnant and parenting youth in our study have experienced many negative health care encounters that have contributed to disengagement and mistrust of the health care system. To engage this high-risk population in health care, practitioners are encouraged to consider their own biases when servicing this population and work toward fostering positive, nonjudgmental interactions, and supportive environments.

Photovoice: A Strategy to Better Understand the Reproductive and Sexual Health Needs of Young Mothers.

STUDY OBJECTIVE: Adolescent women face significant sexual and reproductive health challenges and are more vulnerable than their male peers. Photovoice methodology might allow them to provide more meaningful and accurate representations of the health challenges they encounter. Our objectives were to: (1) use Photovoice to understand how young mothers frame reproductive and sexual health within the context of their lives; (2) explore how they define reproductive and sexual health; (3) identify youth perspectives on how their life situations influence their ability to affect their health; and (4) connect their perspectives to social determinants of health framework to facilitate implementation of effective programs and policies to address their needs. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This was a prospective qualitative community-based participatory research study involving young women (ages 15-25 years) recruited from a local youth outreach center. A 9-step validated qualitative participatory approach that combined documentary photography with focus groups was used. Qualitative analysis was conducted with NVivo version 10 software (QSR International Inc., Burlington, MA, USA). Data were coded and themes were developed. RESULTS: Thirty women were recruited and nine women completed the study. Key themes included: personal sexual health practices and coping skills, influence of poverty, physical environments, community resources and sexual health services, education, and stigma of pregnancy. Participating in community-based participatory research empowered participants to advocate for their own health. CONCLUSION: Photovoice methodology contributes to understanding complex factors influencing sexual and reproductive health of young mothers. This participatory-based methodology highlights their individual situations, allowing us to seek connections, create analytical perspectives from which to relate their situations to root causes, and consider strategies for change.

Does an Advanced Pelvic Simulation Curriculum Improve Resident Performance on a Pediatric and Adolescent Gynecology Focused Objective Structured Clinical Examination? A Cohort Study.

STUDY OBJECTIVE: To determine the effect of an advanced pelvic simulation curriculum on resident performance on a pediatric and adolescent gynecology (PAG) focused objective structured clinical examination (OSCE). DESIGN: Obstetrics and gynecology residents in a single academic Canadian center participated in a PAG simulation curriculum. An OSCE on prepubertal vaginal bleeding was administered at the biannual OSCE examination 2 months before the simulation curriculum and again 3 months after the simulation curriculum. SETTING: Academic half-day at the University of Ottawa Skills and Simulation Centre. PARTICIPANTS: Obstetrics and gynecology residents from the University of Ottawa. INTERVENTIONS: Participants completed 4 stations teaching PAG-appropriate history-taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion, and approach to the child and/or adolescent. Advanced pelvic models were used for procedure-specific stations. MAIN OUTCOME MEASURES: The primary outcome measure was change in mean score on a prepubertal vaginal bleeding OSCE station. Secondary outcome measures were changes in individual component scores. RESULTS: Fourteen residents completed the simulation curriculum and the PAG OSCE at the 2 separate time points (before and after simulation curriculum). The mean OSCE score before the simulation curriculum was 54.6% (20.5 of 37) and mean score after the curriculum was 78.1% (28.9 of 37; P < .001). Significant score increases were found in history-taking, examination, differential diagnosis, identification of organism, surgical procedures, and identification of foreign body (P < .01 for all). CONCLUSION: This innovative PAG simulation curriculum significantly increased residents' knowledge in PAG history-taking, examination skills, operative procedures, and approach to the child and/or adolescent. Obstetrics and Gynecology Program Directors should consider incorporating PAG simulation training into their curriculum to ensure that residents meet their learning objectives and increase their knowledge and confidence, which will ultimately benefit patient care.

Adolescent Pregnancy Guidelines.

OBJECTIVE: To describe the needs and evidence-based practice specific to care of the pregnant adolescent in Canada, including special populations. OUTCOMES: Healthy pregnancies for adolescent women in Canada, with culturally sensitive and age-appropriate care to ensure the best possible outcomes for these young women and their infants and young families, and to reduce repeat pregnancy rates. EVIDENCE: Published literature was retrieved through searches of PubMed and The Cochrane Library on May 23, 2012 using appropriate controlled vocabulary (e.g., Pregnancy in Adolescence) and key words (e.g., pregnancy, teen, youth). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to English or French language materials published in or after 1990. Searches were updated on a regular basis and incorporated in the guideline to July 6, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, national and international medical specialty societies, and clinical practice guideline collections. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS/HARMS/COSTS: These guidelines are designed to help practitioners caring for adolescent women during pregnancy in Canada and allow them to take the best care of these young women in a manner appropriate for their age, cultural backgrounds, and risk profiles. RECOMMENDATIONS: 1. Health care providers should adapt their prenatal care for adolescents and offer multidisciplinary care that is easily accessible to the adolescent early in the pregnancy, recognizing that adolescents often present to care later than their adult counterparts. A model that provides an opportunity to address all of these needs at one site may be the preferred model of care for pregnant adolescents. (II-1A) 2. Health care providers should be sensitive to the unique developmental needs of adolescents through all stages of pregnancy and during intrapartum and postpartum care. (III-B) 3. Adolescents have high-risk pregnancies and should be managed accordingly within programs that have the capacity to manage their care. The unique physical risks of adolescent pregnancy should be recognized and the care provided must address these. (II-1A) 4. Fathers and partners should be included as much as possible in pregnancy care and prenatal/infant care education. (III-B) 5. A first-trimester ultrasound is recommended not only for the usual reasons for properly dating the pregnancy, but also for assessing the increased risks of preterm birth. (I-A) 6. Counselling about all available pregnancy outcome options (abortion, adoption, and parenting) should be provided to any adolescent with a confirmed intrauterine gestation. (III-A) 7. Testing for sexually transmitted infections (STI) (II-2A) and bacterial vaginosis (III-B) should be performed routinely upon presentation for pregnancy care and again in the third trimester; STI testing should also be performed postpartum and when needed symptomatically. a. Because pregnant adolescents are inherently at increased risk for preterm labour, preterm birth, and preterm pre-labour rupture of membranes, screening and management of bacterial vaginosis is recommended. (III-B) b. After treatment for a positive test, a test of cure is needed 3 to 4 weeks after completion of treatment. Refer partner for screening and treatment. Take the opportunity to discuss condom use. (III-A) 8. Routine and repeated screening for alcohol use, substance abuse, and violence in pregnancy is recommended because of their increased rates in this population. (II-2A) 9. Routine and repeated screening for and treatment of mood disorders in pregnancy is recommended because of their increased rates in this population. The Edinburgh Postnatal Depression Scale administered in each trimester and postpartum, and more frequently if deemed necessary, is one option for such screening. (II-2A) 10. Pregnant adolescents should have a nutritional assessment, vitamins and food supplementation if needed, and access to a strategy to reduce anemia and low birth weight and to optimize weight gain in pregnancy. (II-2A) 11. Conflicting evidence supports and refutes differences in gestational hypertension in the adolescent population; therefore, the care usual for adult populations is supported for pregnant adolescents at this time. (II-2A) 12. Practitioners should consult gestational diabetes mellitus (GDM) guidelines. In theory, testing all patients is appropriate, although rates of GDM are generally lower in adolescent populations. Practitioners should be aware, however, that certain ethnic groups including Aboriginal populations are at high risk of GDM. (II-2A) 13. An ultrasound anatomical assessment at 16 to 20 weeks is recommended because of increased rates of congenital anomalies in this population. (II-2A) 14. As in other populations at risk of intrauterine growth restriction (IUGR) and low birth weight, an ultrasound to assess fetal well-being and estimated fetal weight at 32 to 34 weeks gestational age is suggested to screen for IUGR. (III-A) 15. Visits in the second or third trimester should be more frequent to address the increased risk of preterm labour and preterm birth and to assess fetal well-being. All caregivers should be aware of the signs and symptoms of preterm labour and should educate their patients to recognize them. (III-A) 16. It should be recognized that adolescents have improved vaginal delivery rates and a concomitantly lower Caesarean section rate than their adult counterparts. (II-2A) As with antenatal care, peripartum care in hospital should be multidisciplinary, involving social care, support for breastfeeding and lactation, and the involvement of children's aid services when warranted. (III-B) 17. Postpartum care should include a focus on contraceptive methods, especially long-acting reversible contraception methods, as a means to decrease the high rates of repeat pregnancy in this population; discussion of contraception should begin before delivery. (III-A) 18. Breastfeeding should be recommended and sufficient support given to this population at high risk for discontinuation. (II-2A) 19. Postpartum care programs should be available to support adolescent parents and their children, to improve the mothers' knowledge of parenting, to increase breastfeeding rates, to screen for and manage postpartum depression, to increase birth intervals, and to decrease repeated unintended pregnancy rates. (III-B) 20. Adolescent women in rural, remote, northern, and Aboriginal communities should be supported to give birth as close to home as possible. (II-2A) 21. Adolescent pregnant women who need to be evacuated from a remote community should be able to have a family member or other person accompany them to provide support and encouragement. (II-2A) 22. Culturally safe prenatal care including emotional, educational, and clinical support to assist adolescent parents in leading healthier lives should be available, especially in northern and Aboriginal communities. (II-3A) 23. Cultural beliefs around miscarriage and pregnancy issues, and special considerations in the handling of fetal remains, placental tissue, and the umbilical cord, must be respected. (III).

Objectif : Décrire les besoins des adolescentes enceintes au Canada (y compris celles qui sont issues de populations particulières) et les pratiques factuelles propres aux soins qui doivent être offerts à ces femmes. Issues : Grossesses saines chez les adolescentes au Canada; offre de soins sûrs au plan culturel et adaptés à l'âge pour assurer l'obtention des meilleures issues possibles pour ces jeunes femmes, leurs enfants et leur famille; et réduction des taux de grossesse à répétition. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PUBMED et The Cochrane Library le 23 mai 2012, au moyen d'un vocabulaire contrôlé (p. ex. « Pregnancy in Adolescence ¼) et de mots clés (p. ex. « pregnancy ¼, « teen ¼, « youth ¼) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Les résultats ont été limités aux articles publiés en anglais ou en français à partir de 1990. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'au 6 juillet 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : La présente directive clinique a été conçue pour aider les praticiens canadiens à offrir aux adolescentes enceintes des soins optimaux qui sont adaptés à leur âge, à leur contexte culturel et à leurs profils de risque. Recommandations 1. Les professionnels de la santé devraient adapter leurs services prénataux aux besoins des adolescentes et leur offrir des soins multidisciplinaires dont elles pourront facilement se prévaloir tôt dans le cadre de la grossesse, en tenant ainsi compte du fait que les adolescentes sollicitent souvent des soins plus tard que leurs homologues adultes. Un modèle de soins permettant de répondre à tous ces besoins en un seul et même endroit pourrait constituer le modèle à privilégier pour les adolescentes enceintes. (II-1A) 2. Les fournisseurs de soins devraient être sensibles aux besoins développementaux particuliers des adolescentes tout au long de la grossesse, ainsi que dans le cadre des soins intrapartum et postpartum. (III-B) 3. Chez les adolescentes, la grossesse est exposée à des risques élevés et devrait faire l'objet d'une prise en charge adaptée en conséquence dans le cadre de programmes disposant des capacités nécessaires. Les risques physiques propres à la grossesse chez une adolescente doivent être pris en considération et les soins offerts doivent s'y adapter. (II-1A) 4. La participation des pères et des partenaires aux cours prénataux (soins à prodiguer à la mère et à l'enfant) devrait être favorisée autant que possible. (III-B) 5. La tenue d'une échographie au cours du premier trimestre est recommandée non seulement aux fins de la datation adéquate de la grossesse (soit la raison habituellement invoquée pour la tenue d'une telle intervention), mais également pour l'évaluation des risques accrus d'accouchement préterme. (I-A) 6. Des services de counseling traitant de toutes les options disponibles en ce qui concerne la grossesse (avortement, adoption et parentage) devraient être offerts à toutes les adolescentes chez qui la présence d'une grossesse intra-utérine a été confirmée. (III-A) 7. Un dépistage visant les infections transmissibles sexuellement (II-2A) et la vaginose bactérienne (III-B) devrait être mené systématiquement dans le cadre de la première consultation prénatale et, une fois de plus, au cours du troisième trimestre; un dépistage visant les infections transmissibles sexuellement devrait également être mené pendant la période postpartum et lorsque la présence de symptômes en justifie la mise en œuvre. a. Puisque les adolescentes enceintes sont intrinsèquement exposées à des risques accrus de travail préterme, d'accouchement préterme et de rupture prématurée des membranes préterme, elles constituent un « groupe exposé à des risques élevés ¼ : le dépistage et la prise en charge de la vaginose bactérienne s'avèrent donc recommandée. (III-B) b. À la suite d'un traitement mis en œuvre en raison de l'obtention d'un résultat positif au dépistage, la tenue d'un test de contrôle post-traitement s'avère requise de trois à quatre semaines à la suite de la fin du traitement. L'orientation du partenaire vers des services de dépistage et de traitement s'avère également requise. Les fournisseurs de soins devraient profiter de l'occasion pour discuter de l'utilisation de condoms avec leurs patientes. (III-A) 8. La mise en œuvre systématique et répétée d'un dépistage de la consommation d'alcool, de la consommation de substances psychoactives et de la violence pendant la grossesse est recommandée, en raison de leurs taux accrus au sein de cette population. (II-2A) 9. La mise en œuvre systématique et répétée d'un dépistage et d'une prise en charge des troubles de l'humeur pendant la grossesse est recommandée, en raison des taux accrus de ces troubles au sein de cette population. L'administration de l'Échelle de dépression postnatale d'Édimbourg à chaque trimestre et pendant la période postpartum (et plus fréquemment, lorsque cela semble nécessaire) constitue une option pour la mise en œuvre d'un tel dépistage. (II-2A) 10. Les adolescentes enceintes devraient faire l'objet d'une évaluation nutritionnelle et d'une supplémentation en vitamines et en aliments (au besoin), ainsi qu'obtenir accès à une stratégie visant l'optimisation du gain pondéral pendant la grossesse et la baisse des risques d'anémie et de faible poids de naissance. (II-2A) 11. Des données contradictoires soutiennent et réfutent la présence de différences en matière d'hypertension gestationnelle au sein de la population adolescente; ainsi, nous soutenons pour l'instant l'offre, aux adolescentes enceintes, des soins qui sont habituellement offerts aux populations adultes. (II-2A) 12. Les praticiens devraient consulter les lignes directrices traitant du diabète sucré gestationnel. En théorie, le dépistage de toutes les patientes s'avère approprié, et ce, bien que les taux de diabète sucré gestationnel soient généralement moindres chez les populations adolescentes. Les praticiens devraient cependant être avisés que certains groupes ethniques (dont les populations autochtones) sont exposés à des risques élevés de diabète sucré gestationnel. (II-2A) 13. La tenue d'une échographie d'évaluation anatomique à 16-20 semaines est recommandée, en raison des taux accrus d'anomalies congénitales au sein de cette population. (II-2A) 14. Tout comme dans le cas d'autres populations exposées à des risques de retard de croissance intra-utérin et de faible poids de naissance, la tenue d'une échographie visant à évaluer le bien-être fœtal et à estimer le poids fœtal à un âge gestationnel de 32-34 semaines est suggérée pour le dépistage du retard de croissance intra-utérin. (III-A) 15. Au cours du deuxième ou du troisième trimestre, les consultations devraient être plus fréquentes pour traiter des risques accrus de travail et d'accouchement prétermes, et pour évaluer le bien-être fœtal. Tous les fournisseurs de soins devraient connaître les symptômes du travail préterme et former leurs patientes de façon à ce qu'elles puissent les reconnaître. (III-A) 16. On se doit de souligner que les adolescentes comptent des taux d'accouchement vaginal supérieurs et (de façon concomitante) des taux de césarienne inférieurs, par comparaison avec leurs homologues adultes. (II-2A) Tout comme dans le cas des soins prénataux, les soins peripartum prodigués à l'hôpital devraient être de nature multidisciplinaire, mettre en jeu le milieu social, soutenir l'allaitement et la lactation, et solliciter la participation des services de protection de l'enfance, lorsque cela s'avère justifié. (III-B) 17. Les soins postpartum devraient comprendre une composante traitant des modes de contraception (particulièrement des contraceptifs réversibles à action prolongée), dans le but d'abaisser les taux élevés de nouvelle grossesse chez les adolescentes; les discussions au sujet de la contraception devraient débuter avant l'accouchement. (III-A) 18. L'allaitement devrait être recommandé et du soutien suffisant devrait être offert à cette population exposée à des risques élevés d'abandon. (II-2A) 19. Des programmes de soins postpartum visant la hausse des connaissances parentales et des taux d'allaitement, le dépistage et la prise en charge de la dépression postpartum, le prolongement des intervalles entre les grossesses et la réduction des taux de grossesse non souhaitée à répétition devraient être offerts pour soutenir les parents adolescents et leurs enfants. (III-B) 20. Au sein des collectivités autochtones, rurales, éloignées et du Nord, les adolescentes devraient bénéficier du soutien nécessaire à la tenue de l'accouchement le plus près possible de leur foyer. (II-2A) 21. Les adolescentes enceintes qui doivent être évacuées d'une collectivité éloignée devraient pouvoir se faire accompagner par un membre de la famille (ou toute autre personne de leur choix) à des fins de soutien et d'encouragement. (II-2A) 22. Des soins prénataux sûrs au plan culturel (y compris des mesures de soutien affectif, pédagogique et clinique aidant les parents adolescents à mener une vie leur assurant la santé) doivent être offerts, et ce, particulièrement au sein des collectivités autochtones et du Nord. (II-3A) 23. Les croyancesculturelles (entourant la fausse couche et les problèmes de la grossesse) et les considérations particulières (en ce qui concerne la manipulation des restes fœtaux, des tissus placentaires et du cordon ombilical) doivent être respectées. (III).

Factors Associated with Breastfeeding Initiation in Adolescent Pregnancies: A Cohort Study.

PURPOSE: Adolescent mothers have a lower breastfeeding rate than adult women. The objective is to determine the association between multiple high-risk characteristics of pregnant adolescents with intention and initiation of breastfeeding. METHODS: We conducted a retrospective population-based cohort study in Ontario (2006-2012) using the Better Outcomes Registry & Network (BORN) database. Breastfeeding outcomes of adolescent women (younger than 20 years) with a singleton live-born infant at term gestation (37 weeks or greater) were analyzed. The χ(2) and independent-sample t tests were used where appropriate. A multivariate logistic regression analysis was also performed. RESULTS: This study included 22,023 adolescent women with complete breastfeeding information. Almost half (48.8%, n = 10,749) exclusively breastfed their infant at time of hospital discharge. Breastfeeding was significantly more likely in the older adolescents (odds ratio 1.10); other factors significantly associated with breastfeeding included intention to breastfeed, prenatal classes attendance, living in a higher-income neighborhood, having a spontaneous vaginal delivery, being a nonsmoker, not using substances during pregnancy, and not having any preexisting health problems or obstetrical complications (P < .0001). A significant interaction between smoking and intention to breastfeed was identified. Intention to breastfeed was found to be protective against the reduction in breastfeeding seen with smoking. CONCLUSION: This large-cohort study confirms that high-risk factors are associated with lower breastfeeding in Canadian adolescent term singleton births. Breastfeeding intention is a very important driver of breastfeeding. These findings highlight the importance of early multidisciplinary adolescent pregnancy care targeting these risks factors and education in order to improve breastfeeding rates in this population.

HPV awareness in higher-risk young women: the need for a targeted HPV catch-up vaccination program.

OBJECTIVE: To determine levels of HPV awareness and knowledge in higher-risk young women and their attitudes toward HPV vaccination and catch-up programs. METHODS: An anonymous, cross-sectional, Internet-based, self-reported questionnaire was completed by women ages 13 to 25 attending two outreach clinics. Primary outcomes were HPV infection/vaccine awareness, vaccination rates, and catch-up program acceptability. Chi-square, Fisher exact test, and logistic regression analyses were performed. RESULTS: Of 105 respondents (mean age 19.32), 66.7% received social assistance and 54.3% relied on walk-in clinics. Overall HPV awareness was 81.0% and vaccine awareness was 76.2%. HPV awareness was significantly higher in women < 20 years old (P = 0.032) and with past sexually transmitted infection (STI) history (P = 0.039) but didn't differ by education level. Vaccine awareness differed significantly with STI history (P = 0.031) but not by age or education level. Awareness of HPV's association with genital warts and cervical cancer was low (30.0%, 41.9%) and didn't differ by education level or sexually transmitted infection history. Thirty percent had been vaccinated (of those, 42% had received 3 doses), mainly in school-based programs (71%). Odds of vaccination were significantly higher in those with a family doctor (OR 8.08). Reasons for not being vaccinated included: "Did not know about it"(28.5%) and "Don't know" (28.5%). Catch-up program acceptability was high (92.8%, 95.2% if free) and did not differ significantly by age or education level. CONCLUSION: Higher-risk young women may have high levels of HPV infection/vaccine awareness but lack knowledge of HPV consequences. Those who missed or did not complete HPV vaccination opportunities would support free catch-up vaccination programs in accessible, youth-friendly centres.

Objectif : Déterminer le niveau de sensibilisation au VPH et l'état des connaissances à ce sujet chez des jeunes femmes exposées à des risques accrus, ainsi que les attitudes de ces dernières envers la vaccination anti-VPH et les programmes de rattrapage. Méthodes : Un questionnaire Web d'autoévaluation anonyme et transversal a été rempli par des femmes (âges : 13-25 ans) fréquentant deux cliniques destinées à des groupes mal desservis. La sensibilisation à l'infection au VPH / à la vaccination anti-VPH, les taux de vaccination et l'acceptabilité des programmes de rattrapage constituaient les critères d'évaluation principaux. Le test de chi carré, le test exact de Fisher et des analyses de régression logistique ont été menés. Résultats : Parmi les 105 répondantes (âge moyen : 19,32), 66,7 % recevaient de l'aide sociale et 54,3% avaient recours aux services de cliniques sans rendez-vous. Le taux global de sensibilisation au VPH était de 81,0 % et le taux de sensibilisation à la vaccination était de 76,2 %. La sensibilisation au VPH était considérablement accrue chez les femmes de moins de 20 ans (P = 0,032) et chez celles qui présentaient des antécédents d'infection transmissible sexuellement (ITS) (P = 0,039); toutefois, elle n'était pas affectée par le niveau de scolarité. La sensibilisation à la vaccination variait considérablement en fonction des antécédents d'ITS (P = 0,031), mais non pas en fonction de l'âge ou du niveau de scolarité. La sensibilisation à l'association entre le VPH et les verrues génitales et le cancer du col utérin était faible (30,0 %, 41,9 %) et ne variait ni en fonction du niveau de scolarité ni en fonction des antécédents d'ITS. Trente pour cent des répondantes avaient été vaccinées (chez celles-ci, 42 % avaient reçu trois doses), principalement dans le cadre de programmes scolaires (71 %). La probabilité d'une vaccination était considérablement accrue chez les répondantes qui pouvaient compter sur les services d'un médecin de famille (RC, 8,08). Parmi les raisons expliquant le fait de ne pas avoir été vaccinée, on trouvait les suivantes : « Je n'étais pas au courant ¼ (28,5 %) et « Je ne sais pas ¼ (28,5 %). L'acceptabilité des programmes de rattrapage était élevée (92,8 %, 95,2 % si l'accès était gratuit) et ne variait pas de façon considérable en fonction de l'âge ou du niveau de scolarité. Conclusion : Les jeunes femmes exposées à des risques accrus pourraient disposer d'une sensibilisation élevée à l'infection au VPH / à la vaccination anti-VPH, tout en présentant un manque de connaissances quant aux conséquences du VPH. Celles qui n'ont pu se prévaloir d'occasions de se faire vacciner contre le VPH (ou qui n'ont pu terminer un cycle de vaccination anti-VPH) seraient en faveur de l'offre de programmes gratuits de rattrapage de la vaccination au sein de centres accessibles et axés sur la jeunesse.

Enhancing postgraduate training in pediatric and adolescent gynecology: evaluation of an advanced pelvic simulation session.

STUDY OBJECTIVE: To describe and evaluate a Canadian simulation session designed to teach pediatric and adolescent gynecology (PAG) history taking, examination and operative skills, and an approach to the child and adolescent. DESIGN: Obstetrics and gynecology residents in a single academic center participated in a PAG simulation session and rated their gain in knowledge on 6 aspects of PAG care. SETTING: Academic half-day at the University of Ottawa Skills and Simulation Centre. PARTICIPANTS: Twenty-four Obstetrics/Gynecology residents at the University of Ottawa. INTERVENTIONS: Participants completed 4 stations teaching PAG-appropriate history taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion, and approach to the child/adolescent. Advanced pelvic models were used for procedure specific stations. Participants completed an anonymous evaluation form at the end of the session. MAIN OUTCOME MEASURE: Self-perceived increase in knowledge and PAG specific skills after the simulation session. RESULTS: Twenty-four residents completed the simulation session and post-session evaluation. All residents (100%) agreed that they had gained knowledge in PAG history taking, examination techniques, office procedures, operative skills, approach to child, and approach to the adolescent. Qualitative feedback stressed the excellence of instruction, interaction, immediate feedback, and hands-on experience. All residents (100%) stated the PAG simulation session should continue. CONCLUSIONS: This advanced PAG simulation session increased resident self-perceived knowledge. Other obstetrics/gynecology training programs should consider implementing advanced PAG simulation sessions to increase resident knowledge and confidence in delivering care to the pediatric/adolescent patient.