Approach to the Woman with an Unplanned Pregnancy

Shana L. Birnbaum

Approximately one half of the pregnancies that occur in the United States are unintended, with rates highest in lower income and minority women. Just greater than one fourth of these pregnancies occur in women who are not using contraception, with the rest due to incorrect or inconsistent use or failure of a contraceptive method. More than half of the women who had a pregnancy termination in a recent year were using some form of contraception during the month they got pregnant. The majority of women had an identifiable episode for which emergency contraception could have been used to decrease the risk of pregnancy.

Slightly higher proportions of unintended pregnancies end in birth than in abortion (e.g., 48% vs. 43% in a recent year). The woman who suspects an unplanned or unwanted pregnancy often calls on her primary care clinician to confirm the diagnosis and review her options. To provide support and assistance, one must first accurately diagnose the pregnancy. Because an unwanted pregnancy may be a crisis in a woman’s life, the clinician needs skill in sensitively counseling a woman about her options without judgment or censure. Awareness of and attention to the patient’s social and cultural environment, including her beliefs and individual circumstances, are essential to lending appropriate support and arranging care that is consistent with her wishes and needs, including referral to community services for prenatal care, adoption, or medical and surgical options for abortion. If the clinician feels his or her personal beliefs may interfere with objectively reviewing the full range of management options or facilitating patient-desired referral, then transferring care to another clinician should be arranged.

CLINICAL PRESENTATIONS (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12)

Women presenting with unplanned pregnancies have highly variable experiences. Responses to the diagnosis, coping mechanisms, and capacity to take responsibility for decision making may differ greatly from woman to woman. Most women cite multiple reasons for their decisions on what to do about an unplanned pregnancy. These range from social hardship to serious illness.

Psychosocial Hardship

A pregnancy may be untimely or unwanted because of the hardship a child would create. A limited single or dual income may be insufficient to support either a first or an additional child. Older women who believed that they had completed their childbearing years may not have the emotional, physical, or financial resources for another child. For younger women, a pregnancy may hinder opportunities for education and career advancement. Lack of a stable, long-term relationship and a feeling of being unready to parent are frequent issues. Some women who desire children may have a partner opposed to parenting or may need family or social support that is lacking. These factors may conflict with the woman’s desire for motherhood (more than half of the women who undergo abortion intend to have a child in the future) or a moral opposition to abortion, creating great ambivalence.

Teenage pregnancy has been a problem of epidemic proportions, though starting to decline substantially. While over 500,000 adolescents in the United States became pregnant each year, the number is down by more than 50% from the 1990 peak. About 25% of those pregnancies end in abortion. Although the teen pregnancy rate in the United States has declined substantially, it remains double or triple that of most developed countries. Consequences for the future of teenage mothers may be
immense. Pregnancy may lead to dropping out of school, limited job opportunities, and dependence on the welfare system. The majority of adolescent pregnancies, 82%, are unplanned. Adolescents may exhibit risk-taking behavior in response to peer pressure, to experiment, or to test parental limits. Some lonely adolescents see a child as a companion who will provide them with unconditional love. Failure to use contraception may result from lack of adequate information or availability, as well as a sense of invincibility. Risk factors for teen pregnancy include early onset of sexual activity, lower socioeconomic status, poor educational performance, coming from a single-parent family or one with a history of teen pregnancy, and other high-risk behaviors such as substance use. Teenagers may present for prenatal care at a later gestational age because of denial or lack of information about how to get help, resulting in increased morbidity and mortality from the pregnancy or termination. Children born to adolescent parents are at higher risk of cognitive and behavioral problems.

Sexual abuse is particularly important because of their psychosocial circumstances. In both rural and urban areas, sexual abuse (including rape and incest) persists to a greater extent than most professional people assume. It may occur between father and daughter, but frequently involves another known adult male, such as uncle, older brother, or boyfriend. The victim may be repulsed at the thought of a baby inside her from such a traumatic experience and may not present for care until later in the pregnancy. In most states, the physician is mandated to report sexual abuse involving minors.

Chronic or Life-Threatening Illness

The woman who desires pregnancy but suffers from a chronic or lifethreatening illness such as diabetes, systemic lupus erythematosus, or cancer endures unique stress when she faces an unplanned pregnancy. The pregnancy may jeopardize her health and her ability to care for her family, and she may face conflicting opinions regarding termination. In addition, the effect of pregnancy on certain disease processes is not well understood.

HIV Infection

Many women of childbearing age are infected with HIV. The rate of transmission of HIV to the fetus in the pre-antiretroviral era was estimated to be 25% to 50%, but this has declined to less than 2% with combination antiretroviral therapy. Pregnancy does not appear to adversely affect the HIV disease process in the mother, although untreated women in the developing world have worse pregnancy outcomes. There is some evidence that women treated with combination antiretroviral therapy have a higher incidence of preterm labor than those on no therapy, but the overall benefits of well-controlled disease clearly outweigh the potential risks.

Substance Abuse

Substance abuse is most common among women of reproductive age, and estimates of substance use among pregnant women range from 0.4% to 27%, depending on the population surveyed. Cocaine use has been associated with lower birth weight and preterm labor along with higher rates of miscarriage. Heroin use during pregnancy can lead to a withdrawal syndrome in the infant along with pregnancy complications. In addition to toxic drug effects, poor pregnancy outcomes may result from transmission of disease, hazardous behavior to support a drug habit, malnutrition, and poor prenatal care. There may be polysubstance abuse with additive effects. Alcohol use also remains a significant problem during pregnancy. The fetal alcohol syndrome, considered part of the fetal alcohol spectrum disorder (FASD), is manifested by intrauterine growth retardation, microcephaly, and developmental abnormalities. Subtle deficits in development and attention, without the classic phenotype, are seen with lower levels of alcohol exposure. Estimates of the prevalence of fetal alcohol syndrome range from 0.3 to 2.2 per 1,000 live births, and FASD may be twice as prevalent, particularly among high-risk populations. Some substance abusers may respond to pregnancy with denial or indifference, whereas others may take the opportunity of pregnancy to engage in active substance abuse treatment. A multidisciplinary approach is most effective in caring for these patients.

Psychiatric Illness

Substance abuse frequently coincides with psychopathology, but any woman with a psychiatric illness presents concerns during pregnancy. Some evidence suggests that certain psychiatric disorders may worsen during pregnancy and yet remain undertreated.

Depression is a particular concern, being common before, during, and after pregnancy—some studies estimate a prevalence of depression during pregnancy at up to 20%. There has been controversy surrounding the safety of pharmacologic treatment of depression with selective serotonin reuptake inhibitors (SSRIs) during pregnancy (see Chapter 227). Although large meta-analysis of over 3,000 infants finds no association between the SSRI paroxetine and cardiac malformations, previously noted associations led to paroxetine being Food and Drug Administration (FDA) classified as a Pregnancy Category D agent. There have also been concerns raised regarding neonatal risk of transient tremor, tachypnea, and possible withdrawal symptoms with maternal third-trimester SSRI use, leading to an FDA warning. However, the risks of untreated maternal depression for both mother and child are significant and include long-term cognitive and language achievements, which generally outweigh the potential effects of medication exposure. Experts generally recommend treatment of depression during pregnancy. Psychotherapy is a reasonable option for mild to moderate depression, but more severe symptoms, particularly in women with a history of good response to medication, should be treated pharmacologically, with fluoxetine and sertraline having the most safety data.

Psychosis or mania that is severe or poorly controlled may lead to increased birth complications as a result of poor prenatal care, concurrent substance abuse, increased incidence of homelessness, or unrecognized physical illness. The primary care physician may be asked to provide counseling and to act as a liaison between obstetric and psychiatric providers.

Genetic Defects

Some patients undergoing amniocentesis or chorionic villus sampling to identify genetic abnormalities do so on the assumption that they will consider an induced abortion. A patient may look to her primary care provider for guidance with this difficult decision-making process, although often the assistance of a genetic counselor is indicated.