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Katherine J Gold; Sheila M Marcus

Many pregnant women experience psychiatric disorders in their childbearing years. Emerging research
shows mental illness not only affects the mother's well-being but may also have significant effects on fetal
outcomes. This review details what is known about the prevalence of mental illness during pregnancy as
well as how such disorders may influence pregnancy outcomes. Maternal depression during pregnancy is
an independent risk factor for low fetal birthweight and premature delivery, but other illnesses, such as
anxiety disorders, eating disorders and psychotic illness, may also predict adverse birth outcomes.
Possible behavioral, genetic and neuroendocrine mechanisms for these relationships are presented.
Principles of treatment for psychiatric disorders during pregnancy are also discussed, with an emphasis
on the role of the obstetrical provider.

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¦early half of Americans will have a mental illness in their lifetime, and one out of four experiences a
psychiatric disorder in any given year.[1,2] Since the majority of these illnesses start before or during the
child-bearing years, many pregnant women have significant psychiatric comorbidity ( Table 1 ). Most
research has focused on the impact of stress, anxiety and depression on the developing fetus, but newer
studies indicate that a wide variety of mental disorders can pose a risk for adverse pregnancy outcomes.
In order to make appropriate decisions regarding whether, and how, to treat psychiatric symptoms during
pregnancy, providers must understand what is known about the impact of untreated illness on the
pregnancy and weigh these risks against potential risks from psychiatric medications used for treatment.

Preterm delivery (PTD) and low birthweight (LBW) continue to be significant risk factors for fetal and
infant death and complications. If mental health affects timing of delivery or fetal growth there might be
new approaches to improving perinatal outcomes. Despite widespread recognition that postpartum
depression and postpartum psychosis present substantial risks for infant and child outcomes, the impact
of antenatal mental illness on the fetus is less well understood. This review summarizes how psychiatric
illness during pregnancy affects fetal outcomes and how obstetrical practitioners might use this
information to provide optimal patient care. The review also highlights the current research and gaps in
understanding relationships between mental health and pregnancy outcomes and proposes key areas
where additional research is needed.

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ary M. Aruda, PhD, R¦, P¦P-BC; Kathleen Waddicor, R¦, BS¦; Liesl Frese, MSW, LICSW; Joanna C.M. Cole, PhD;
Pamela Burke, PhD, R¦, F¦P, P¦P-BC

Health care providers are faced with many challenges when working with adolescents. Vague symptoms,
unreliable menstrual history, and adolescent reluctance to disclose sexual activity present challenges to
early diagnosis. When pregnancy is suspected, clinicians need skills for accurate diagnosis, conducting
comprehensive assessments, and providing options counseling. Complexities of providing confidential
care while balancing the needs of the adolescent and family may deter some clinicians. A clinical case
scenario illustrates important elements of care. Through sharing lessons learned from 10 years of working
in a Pregnancy Follow-up Clinic, the authors hope to empower other clinicians as they care for
adolescents during this critical time.

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The adolescent birth rate in the United States rose in 2006 for the first time in 14 years (Hamilton, Martin,
& Ventura, 2007). Current estimates are that one third of teens become pregnant by age 20 years,
producing rates in the United States that are still the highest among fully industrialized nations (The
¦ational Campaign, 2008). According to the latest American Academy of Pediatrics clinical report on
adolescent pregnancy, by 2010 the population of female adolescents ages 15 to 19 years is expected to
increase by 10%; thus, there will be increasing demand for adolescent reproductive health services
(Klein, 2005). Clinicians will need the knowledge and skills to provide quality care to adolescents during
the early phase of pregnancy.

This article will explore issues surrounding the diagnosis of an adolescent pregnancy, including
psychosocial and physical assessment, options counseling, referral to termination or prenatal care, and
follow up. We draw from our extensive clinical experience and use a typical case study of "MJ" to highlight
challenges and opportunities for providing developmentally sensitive interventions and coordinated care
to adolescents in early pregnancy. Clinicians often find it helpful to view adolescence in three
psychosocial stages: early adolescence (11±14 years), middle adolescence (15±17 years), and late
adolescence (18±21 years), similar to the way health visit guidelines have been organized in the current
Bright Futures Guidelines (Hagan, Shaw, & Duncan, 2008).

Each clinical setting is unique. The authors are based in an inner-city adolescent clinic within a large
pediatric tertiary care hospital in the ¦ortheast. Based on a review of 6 years of quality improvement data
for pregnant adolescent patients (¦ = 601) diagnosed with a pregnancy between January 2000 and
December 2005, 45.8% decided to terminate the pregnancy, 48.2% opted to continue their pregnancy,
and 6% had a miscarriage (Aruda, McCabe, Litty, & Burke, 2008). While percentages fluctuated slightly
from year to year, overall there was a relatively even distribution of those who opted to continue the
pregnancy and those who chose to terminate it. ¦one of these pregnant patients who chose to continue
their pregnancy were interested in exploring options for adoption at the time of pregnancy diagnosis.

This article includes forms that we developed, which clinicians are free to adapt for their own practice.
The Confidential Pregnancy Intake Form (Figure 1) is an interview guide that is completed by the clinician
who is assessing a newly diagnosed pregnant adolescent.
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C. Bottomley; V. Van Belle; F. Mukri; E. Kirk; S. Van Huffel; D. Timmerman; T. Bourne

£
 The objective of this study was to determine the optimal gestational age at which to
establish the location and viability of an early pregnancy using transvaginal ultrasonography (TVS).

  This was a prospective study of 1442 women undergoing initial TVS at no more than 84 days
gestation. Logistic regression analysis was performed to determine the relationship between gestational
age and the ability to confirm viability or non-viability, in women with and without symptoms of pain and
bleeding.
 The commonest TVS finding prior to 35 days was a pregnancy of unknown location, from 35 to
41 days an early intrauterine pregnancy of uncertain viability and from 42 days a viable intrauterine
pregnancy. Miscarriage could only be diagnosed on initial TVS after 35 days. There was no difference
between the ability to make a diagnosis for women with certain or uncertain dates (÷ = 0.719). The
chance of confirming viability increased rapidly per day of gestation until 49 days and thereafter
plateaued. Of the 29 ectopic pregnancies diagnosed, 72% presented prior to 49 days gestation and all of
these women presented with pain, bleeding or a previous ectopic pregnancy history.

 The ability to confirm viability or non-viability is significantly related to gestational age. In
asymptomatic women with no previous ectopic pregnancy TVS should be delayed until 49 days. Our data
suggest that this would reduce the number of inconclusive scans, without an associated increase in
morbidity from missed ectopic pregnancies.

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Transvaginal ultrasonography (TVS) is commonly performed during the early first trimester of pregnancy
to confirm pregnancy location, viability or gestational age (Bigrigg and Read, 1991). The optimal timing of
such an early first trimester ultrasound scan is unclear. As commercially available human chorionic
gonadotrophin (hCG) assays can detect pregnancy from the time of a missed period there seems to be a
trend for women to present earlier for ultrasound assessment. There is also a tendency for asymptomatic
women to undergo routine scans for viability in the early first trimester. However this may be associated
with an increase in the rate of inconclusive ultrasound findings (Jauniaux 
., 2005).

Performing an ultrasound assessment in pregnancy too early may lead to the finding of a pregnancy of
unknown location (PUL) or an intrauterine pregnancy of uncertain viability (IPUVI) with the need for serial
serum hCG measurements and further ultrasound assessment (Banerjee 
., 1999; Elson 
., 2003;
Falco 
., 2003; Condous 
., 2004). Conversely, if ultrasound assessment is deferred based on
arbitrary limits for gestation, there may be physical or psychological morbidity or mortality associated with
a delay in the diagnosis of a spontaneous early pregnancy loss (¦ikcevic 
., 1998) or an ectopic
pregnancy (Mol and van der Veen, 1997; Lewis, 2007).

The first objective of this study was to test the hypothesis that there is a positive association between
gestational age and the ability to make a definitive diagnosis of viability or non-viability at first TVS
assessment in a general Early Pregnancy Unit (EPU) population. The second objective was to determine
whether there is an optimal time for an ultrasound scan to be performed, in both asymptomatic and
symptomatic women, in order to limit the number of PUL and IPUVI findings while giving a definitive
answer regarding viability and identifying the majority of women with pathology present within the cohort
studied.
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