Oral Abstracts / J Pediatr Adolesc Gynecol (2013) e47ee53
4 gonadoblastomas were found in patients with female external genitalia,
we were unable to calculate the association between external genitalia and
gonadal tumor. A total of 27 gonads were removed from 16 patients. Of
these gonads, 7 (26.0%; 95%CI12.1-44.7%) contained gonadoblastoma.
Gonadoblastoma was detected in 6 of 21 (28.7%; CI12.5-50.2%) abdom-
inal gonads and 1 in 5 (20.0%; 95%CI1.0-66.6%) inguinal gonads. One
scrotal gonad was removed and did not contain gonadal tumor. Although
not statistically signicant, abdominal gonads had higher rate of gonadal
tumor as compared to inguinal or scrotal gonads (OR2.0, 95%CI0.2-55.1;
p0.63). No malignant tumors were found.
Conclusions: In this study, the overall rate of gonadoblastoma in patients
with 45,X/46,XY mosaicism was 36%. While this study is limited by small
sample size, the rate was highest (50%) in patients with normal female
external genitalia, which is in contrast to existing literature. Prophylactic
gonadectomy should be considered for patients with 45,X/46,XY mosai-
cism and female external genitalia, given the lack of gonadal function and
the risk of gonadal tumor.
6. Assessing Azithromycin Efcacy in Treatment of Chlamydia
Trachomatis
Rebecca M. Beyda MD, Laura J. Benjamins MD, MPH, Elaine Symanski PhD,
Michael Swartz PhD, William L. Risser MD, PhD, Mona Eissa MD, MPH,
PhD
The University of Texas Health Science Center at Houston, Houston, TX
Background: The 2010 Center for Disease Control guidelines recommend
one dose of azithromycin for the treatment of uncomplicated chlamydia
infections based on 97% cure rate with azithromycin. A recent study found
an 8% failure rate of azithromycin treatment in adolescents. This
prospective study evaluated treatment efcacy in a sample of detained
youth.
Methods: We conducted a prospective study beginning April, 2012 in the
Harris County Juvenile Justice Center (HCJJC) medical department. Study
subjects were detainees with positive urine NAAT tests for chlamydia on
intake. We recruited subjects after they received their test results. After we
obtained informed consent, patients completed an enrollment question-
naire and then received 1 gram of azithromycin at lunch under direct
observation. If the patient vomited, the dose was repeated with an anti-
emetic. Each patient returned to the medical clinic in 1 e 2 days to assess
medication tolerance, provided a urine sample 3 weeks later for a chla-
mydia test of cure (TOC), and returned to the medical clinic in 4 weeks to
discuss TOC results. During this period, the patients had no opportunity for
sexual activity. Those with treatment failure (positive TOC) receive doxy-
cycline for seven days. Exclusion criteria included co-infection with
gonorrhea, signs and symptoms requiring treatment for pelvic inam-
matory disease or epididymitis/orchitis prior to the TOC. Potential
predictors of treatment failure with azithromycin include symptomatic
infections. The studys primary outcome was the incidence of azithromycin
treatment failure dened by a positive TOC. Secondary outcome was the
incidence of adverse effects of azithromycin administration: vomiting,
abdominal pain and/or nausea. We performed statistical analysis using
STATA software. The Institutional Review Boards from the University of
Texas Health Science Center at Houston and the HCJJC approved this study.
Results: Of the sixty-two patients enrolled, most were male (71%) with
a mean age of 15.7 years (range 14 e 17 years). Three subjects (5%, CI 1% e
13%) tested positive for Chlamydia at 3 weeks. Two of those patients
complained of persistent (dysuria) or worsening symptoms (testicular
pain) at the 3 week follow-up visit. Four patients (6.5%) experienced
vomiting within 3 hours or less after azithromycin ingestion, requiring
a repeat dose and 20 patients (32%) reported abdominal pain and/or
nausea after azithromycin ingestion.
Conclusions: Upon preliminary analysis, we found that azithromycin
was 95% effective in treatment of uncomplicated Chlamydia trachomatis in
our sample of detained youth. The advantage of this controlled setting
includes observed medication delivery and exclusion of re-infection. These
ndings suggest azithromycins efcacy may be decreasing and a test of
cure should be considered after oral azithromycin, especially in symp-
tomatic patients. Adverse effects of azithromycin were common and
counseling on the side effects should be a component of care in the
e49
treatment of chlamydia. Further research studying the etiology of azi-
thromycin treatment failure and its risk factors in a larger adolescent
population is needed to conrm our ndings.
7. Violence in Pregnant Canadian Adolescents: A Prospective Study
Diane Belder-Preston MD, Amanda Black MD, MPH, Tammy Hewson RN,
Nathalie Fleming MD
Childrens Hospital of Eastern Ontario and The Ottawa Hospital, University
of Ottawa, Ottawa, Ontario, Canada
Background: Adolescent pregnancy represents an important societal
concern in the developed world. It is a vulnerable period often associated
with increased risk of violence. To date there is no Canadian data on the
prevalence of violence in pregnant adolescents. The objective of this
prospective cohort study is to determine the prevalence and type of
violence (past or current) in adolescent pregnancies.
Methods: A REB approved, prospective cohort study was conducted
between November 2009 and May 2012. A total of 100 women, 14-20 years
of age, attending a multidisciplinary adolescent prenatal community
outreach clinic in Ottawa, Canada were recruited. A validated questionnaire
on abuse was administered to collect data at the initial visit (Survey 1) and
re-administered at 34-35 weeks gestation (Survey 2). Prevalence of violence
was the primary outcome measured. Secondary outcomes included corre-
lation of violence with socio-demographic variables. In addition to descrip-
tive statistics, a combination of shers exact test, chi-square goodness of t
test, and the McNaemars chi-square test were used to derive p-values, while
logistic regression was used to calculate crude and adjusted odds ratios.
Results: 100 adolescents with mean age 17.5 years (range 14-20 years)
were recruited into the study. Approximately 88% of adolescents felt safe
when initially recruited compared with 96% at 34-35 weeks (p0.505).
The proportion of adolescents who experienced any type of violence was
as high as 40% in our patient population. Generally, there was a decrease in
the proportion of adolescents who experienced violence upon recruitment
to the study compared to end of pregnancy. Specically, when comparing
responses in survey 1 and 2, there was a reduction in the proportion of
adolescents who reported being afraid of their current or past partner/
family member in the previous 6 months (34% vs. 16%, p0.0095), the
proportion of adolescents who reported being a victim of domestic
violence (40% vs. 23%, p0.0056), physical violence (21% vs. 8%, p0.0098)
and sexual violence (7% vs. 2.7%, p0.25). The ex-partner was reported
most commonly to be the abuser. Adolescents reply to being afraid of their
current or past partner/family member in the previous 6 months signi-
cantly predicted the prevalence of violence (p<0.0001). Adolescents who
used drugs were up to three fold more likely to report any type of violence
during their pregnancy (OR 2.9, 95% CI 1.2-7.6).
Conclusion: This is the only prospective study to date looking at violence
in Canadian pregnant adolescents and conrms the high prevalence of
violence amongst this population. However, a reduction was observed
during the course of the pregnancy. This reduction may reect the
supportive programming and environment present in our multidisci-
plinary adolescent clinic. Finally, our study highlights the importance of
screening for violence in adolescent pregnancies and supports the need to
offer pregnant adolescents comprehensive multidisciplinary adolescent
prenatal care in order to mitigate the inherent risks.
8. Trends in Standard Workup Performed by Pediatric Subspecialists
for the Diagnosis of Adolescent PCOS
S. Powers 1, R. Mehra 2, S. Sullivan 3, L. Tuchman 2, N. Uliassi 4,
V. Gomez-Lobo 2
1
Georgetown University School of Medicine
2
Childrens National Medical Center
3
MedStart Washington Hospital Center
4
New York-Presbyterian Hospital Weill Cornell Medical College
Background: Adolescents with polycystic ovarian syndrome (PCOS) may
present to an endocrinologist, gynecologist, or adolescent medicine specialist.
The imprecise nature of the diagnostic criteria for PCOS in adolescents may
lead to inconsistencies in the approach to diagnosis and treatment.
e50 Oral Abstracts / J Pediatr Adolesc Gynecol (2013) e47ee53
Methods: Electronic medical records at Childrens National Medical Center
(CNMC) in endocrinology, gynecology and adolescent medicine were
queried for patients who underwent diagnostic work up for PCOS. Female
patients between ages 10 and 18 who were assigned at least one of the
following ICD-9 codes between June 2009 and October 2011 were included:
hirsutism, irregular menses, oligomenorrhea, hypersecretion of ovarian
androgens, amenorrhea, or PCOS. This study was approved by CNMCs IRB.
Results: Data was collected on 261 patientsd144 in endocrinology, 9 in
gynecology, and 108 in adolescent pediatrics. Patient ages at the time of
work-up were 15.31.60 years old.
Of the evaluations for PCOS, endocrinologists were most likely to
evaluate glucose homeostasis with HbA1c levels for 32.6% (n47) of
patients evaluated, and fasting insulin for 23.6% (n34). Gynecologists
ordered HbA1c and fasting insulin for 22.2% (n2). Adolescent medicine
specialists ordered HbA1c for 26.9% (n29) and fasting insulin for 19.2%
(n21). Adolescent medicine specialists were more likely to collect lipid
data (49.1% n53), compared to gynecologists (22.2% n2) and endocri-
nologists (16.0% n23). Gynecologists ordered pelvic ultrasounds for 88.9%
(n8) of patients compared to 9.3% (n10) in adolescent medicine and
23.6% (n34) in endocrinology.
Out of the 261 patients who received diagnostic work up, 187 met
Rotterdam criteria for PCOSd133 in endocrinology, 7 in gynecology, and
67 in adolescent medicine. Of these patients 39.0% were diagnosed with
PCOS, 42.8% were diagnosed PCOS with a qualication, and 18.2% were not
diagnosed with PCOS. A diagnosis with qualication means that the
physician qualied their diagnosis, for example; likely PCOS, mild PCOS, or
suspected PCOS.
Upon chart documentation review, irregular menses along with clinical
and biochemical evidence of hyperandrogenism were used most often as
justication for a PCOS diagnosisd 73.5% for irregular menses, 37.6% for
clinical and 57.3% for biochemical hyperandrogenism. 22.8% of justica-
tions included insulin resistance or obesity and 21.4% included an elevated
LH/FSH ratio.
Endocrinologists were most likely to treat patients who met diagnostic
criteria with metformin (58.4%, n66), compared to adolescent medicine
(29.9% n20) and gynecology (14.3% n1). Adolescent medicine specialists
were most likely to treat with oral contraceptive pills (58.2%, n39),
compared to endocrinology (23.9% n27) and gynecology (42.9% n3).
Conclusions: Inconsistent PCOS diagnostic and treatment practices
between specialties are evident. This may be a reection of provider
comfort within their specialty and how their specialty approaches this
constellation of symptoms. Standardizing diagnosis and treatment of PCOS
in adolescents and measuring outcomes depending on diagnostic and
therapeutic approaches are important next steps.
9. Intrauterine Devices and Adolescents: A Comparative Study of
Contraceptive Failure, Expulsion and Discontinuation Rates Stratied
by Age
J.M. Aoun MD, D.W. Stovall MD, V.A. Dines BS, R. Darolia MD,
V. Gomez-Lobo MD
Riverside Regional Medical Center, Newport News, VA Washington
Hospital Center, Washington, DC
Background: Approximately 80% of teen pregnancies are unplanned.
Intrauterine devices (IUDs) are among the most effective reversible
methods of birth control. As limited data has been published regarding the
effectiveness and efciency of IUDs in adolescents, we elected to test the
hypothesis that adolescents have higher IUD expulsion, failure, and
discontinuation rates as compared to adults. Our goal was to provide
female healthcare practitioners with new information to enhance their
practice and improve their patient counseling regarding the use of IUDs.
Methods: This was a retrospective, multicenter chart review study. All
women between the ages of 13 and 35 who had an IUD inserted between
6/2008 and 6/2011 at the two clinical research centers were eligible for the
study. Adolescence was dened as < 21 years. Patients with incomplete
data for analysis or loss to follow-up after IUD insertion were excluded.
Detailed information on IUD expulsion, contraception failure, and
discontinuation were collected. Symptoms associated with IUD use and
reasons for discontinuation were also recorded. Demographic data as well
as data on the type of IUD used and the healthcare provider at time of
insertion were obtained. Chi-square was used to calculate differences
between groups. The study was IRB-approved at both institutions.
Results: A total of 1217 patients charts were reviewed, 159 were excluded
and the remaining 1058 patients were included in the study. Of these, 268
were adolescents, 284 were categorized as young adults (21-25 years), and
506 were categorized as older adults (26-35 years). As compared to older
adults, adolescents had a signicantly higher early discontinuation rate
(42.2% versus 32.8%, P 0.005). Among patients who prematurely
discontinued their IUDs, more than half did so within the rst year of use,
irrespective of age. The differences between groups with regards to preg-
nancy failure and expulsion rates were not signicant. Pain and bleeding
were the rst and second most common reasons for discontinuation in all
three age groups. Although the percentage of patients reporting pain with
the IUD was not signicantly different between the three groups, when
pain was experienced in the adolescent group it was more likely to lead to
discontinuation as compared to older adults (15% versus 10%, P 0.032).
The incidence of PID was signicantly higher in the adolescent group as
compared to the other age groups (4% versus 1%, P 0.001).
Conclusions: IUDs are a safe and effective method of contraception for
adolescents. The rates of expulsion as well as pregnancy failure are not
signicantly increased in this age group when compared to adults.
However, adolescents have a higher early discontinuation rate as
compared to older individuals and are more likely to discontinue their IUD
when they experience pain; therefore, they may benet from additional
counseling regarding symptoms associated with IUDs. PID is also more
common in adolescents requiring heightened awareness in the provider as
well as the patient.
(N.B: The study represents original work, and was not previously
presented or published.)
10. Safety of Long Acting Reversible Contraception for Adolescents
With Cardiovascular Disease
Anne-Marie Amies Oelschlager MD 1, Kate Debiec MD 1, Elizabeth Micks
MD 2, Tiana Nizamic 2, Malica Deepti Mantrala 2, Sarah Prager MD 2
1
Department of Obstetrics and Gynecology, University of Washington,
Seattle Childrens Hospital, Seattle, WA
2
Department of Obstetrics and Gynecology, University of Washington,
Seattle, WA
Background: Long-acting reversible contraceptive (LARC) methods,
including the levonorgestrel-releasing intrauterine system (LNG-IUS), the
copper intrauterine device (IUD) and etonogestrel (ETG) implant are rst-
line contraceptive options for adolescents given their high efcacy for
pregnancy prevention. In addition, the LNG-IUS is effective treatment for
heavy menstrual bleeding, endometriosis, and dysmenorrhea. LARC
methods have minimal interaction with other medications, do not exac-
erbate hypertension, and are not thrombogenic. However, there is little
data about the safety and efcacy of these methods in adolescents,
particularly those with congenital cardiac defects and cardiovascular
disease. The purpose of this study was to evaluate the safety and efcacy of
LARC methods in adolescents with cardiovascular conditions.
Methods: We completed a retrospective chart review of patients with
congenital cardiac anomalies or other cardiovascular disease under age 22
who had a LARC device placed at Seattle Childrens Hospital or the
University of Washington Medical Center between January 1, 2007 and
March 1, 2012. Patient characteristics, medical conditions, indications for
placement, and complications including perforation, pregnancy, expulsion
and pelvic infection were collected and analyzed. Institutional review
board approval was granted for this study.
Results: Thirty adolescents with congenital cardiac defects or other
cardiovascular conditions, including cardiomyopathy or coronary artery
disease, had a LARC device inserted during the study period: Three
patients (10%) opted for the ETG implant and 27 (90%) opted for the
LNG-IUS. The average age at insertion was 17.7 years (range 12-21). Twelve
patients had reported a previous pregnancy. The most common cardio-
vascular issues were complex congenital malformations (10/30) and septal
defects (6/30). The most common indications were contraception (22
patients, 73%), heavy menstrual bleeding (6 patients, 20%), and menstrual