Adolescent Gynecology and Pregnancy

1. Adolescent Gynecology and Pregnancy Katrina R. Davis, MD Assistant Professor Obstetrics and Gynecology UAMS

2. Adolescent Obstetrical and Gynecological Care • Barriers • Guidelines • Resources

3. Barriers to Care of Adolescents • Parental Permission • Payment • Lack of Education • Fear

4. Parental Permission • HIPPA General Rule- Health care providers must safeguard an individual’s protected health information (PHI). A parent guardian or other person in loco parentis with authority under local law to make health care decisions about an unemancipated minor shall be treated as the minor’s personal representative.

5. Exceptions to General Rule • Parents consent to independence • When applicable state/local law permits independent consent • Applicable law permits third part consent

6. Arkansas Law • Minor may exercise independent consent for: • Contraceptive services • Prenatal Services • STD/HIV services • Alcohol/Drug Abuse Treatment • Mental Health Services • General Medical Health Services

7. Exceptions Where Parental Consent Required for Unemancipated Minor • Sterilization of a Minor • Abortion

8. Definitions • Unemancipated Minor- A person who is under the age of majority and has not exercised his or her right to independence from parental authority if any under applicable state law.

9. Definitions (cont.) • Emancipated Minor: • Marriage • 16 and lives separately from parents • Veterans entitled to benefits • Spouses of such veterans • Married to an adult • Military active duty • Minor parent may consent to treatment of their own child

10. Abortion • No abortion may be performed on an unemancipated minor until 48 hours after written notice given to parents

11. Exceptions Regarding Abortion Consent by Unemancipated Minor • To prevent minor’s death • Written authorization from parents • Victim of child abuse or neglect • Parent out of contact for at least one year • Parent has committed incest, rape, or sexual abuse

12. Consent for Surgical Procedures • Independent consent from a minor acceptable if: • Married • Pregnant seeking treatment in connection with pregnancy or childbirth except for elective abortion • Emancipated • Incarcerated • Treatment for STD • Otherwise must have substituted consent

13. Incompetent Patients • Determination of incompetence • Alternate consent for incompetent patients

14. Determination of Incompetence • Unable to understand all relevant facts related to condition and/or proposed treatment • Made by attending physician in consultation with another physician: • May be temporary or permanent • Not based solely upon refusal of medical care • Attending must document bases of finding in chart

15. Alternate Consent for Incompetent Patients • Advanced directives • Substituted consent

16. Substituted consent • Court appointed guardian, conservator, or custodian • Spouse • Any parent • Maternal grandparent if parents not available • Adult child • Adult sibling • Person standing in loco parentis, whether formally serving or not

17. Health Care Guidelines • First Visit • Cervical Cancer Screening

18. First Visit • A young woman’s first visit to an OB/GYN for primary and preventive health care should take place sometime around the ages of 13-16 (ACOG 1998) • Initial visit is a visit and not necessarily a pelvic exam • Opportunity to meet gynecologist and ask any questions • Opportunity to obtain medical and family history (parent can be an asset)

19. Sexual Activity • 50% of teens have become sexually active by age 17 • 20% of 15 year-olds have already had intercourse

20. Issues for First Visit • Menstrual Irregularity or cramps • Pubertal development • Sexuality • Sexual orientation • Sexual development • Sexual activity • STD education and screening • Mental health issues • Substance abuse

21. Cancer Screening Guidelines • Three years after the onset of vaginal intercourse or no later than age 21 years. (American Cancer Society 2002)

22. STD Screening Guidelines • HIV and syphilis if history of : STD’s; multiple sexual partners or high-risk sexual partner, exchange of sex for drugs or money, IV drug use, blood transfusion before 1985 (HIV only); admittance to jail or other detention facility; live in areas with high prevalence of HIV and syphilis • Gonorrhea and Chlamydia screening annually once sexually active • ACOG Committee Opinion October 2004

23. Resources • Health Department • Planned Parenthood • Florence Crittendon Home • Medicaid • Family Planning Funds • “Tool Kit for Teen Care”

24. Tool Kit for Teen Care • Order from ACOG • Making office adolescent friendly • Tools for adolescent assessment • ACOG educational materials

25. Tools to Make Your Office Adolescent Friendly • Sample letters • Suggested responses to common telephone questions • Talking with teens

26. Tools for Adolescent Assessment • Blood pressure/Height-for-Age Percentiles • Body Mass Index by Age • Tanner Staging • ACOG Adolescent Visit Record and Adolescent Visit Questionnaire

27. CPT Coding Information • Quick reference on CPT Coding • Billing and Coding Issues in Adolescent Reproductive Health

28. ACOG Educational Materials • Patient education pamphlets: menstruation, eating disorders, teaching your children about sexuality • Fact sheets: acne, acquaintance and date rape, contraception, lesbian teens, violence and teens, etc.

29. Florence Crittendon Home • Provides the only residential home where single teenage mothers can live, learn and grow while awaiting the birth of their babies • Arkansas • Pregnant, unmarried teenagers opting to give birth to the conception are eligible • Educational assistance, adoption assistance, vocational training, parenting training, financial planning and assistance, prenatal care through hospital delivery, etc.

30. Financial Resources • Family Planning waiver Medicaid: gyn visit and contraception • AR Kids: covers prenatal care and delivery as well as all other health care • Sobra Medicaid- covers pregnancy only