See Genital Anatomy in Pregnant Adolescents: “Normal” Does Not Mean “Nothing Happened” Pediatrics, January 2004, volume 113, pages e67-e69.
The purpose of this study was to summarize the medical history and genital examination findings in 36 adolescents who were pregnant at the time of, or shortly before, their sexual abuse examination. The medical history and photocolposcopic slides were reviewed; patient age, history of consensual sexual contact, gestational age of the fetus, and written documentation of the examination findings were analyzed. All the authors reviewed all the images jointly and were blinded to medical history other than pregnancy status; reviewers indicated their interpretation as “nonspecific,” “suggestive evidence of penetrative genital trauma,” or “definitive evidence of penetrative genital trauma.” Nonspecific examination findings included variations of normal anatomy and hymenal configurations, notches or irregularities in the hymenal rim that extended to less than half of the width of the hymenal rim, and apparently enlarged hymenal openings surrounded by normal hymenal rims. Suggestive evidence of penetrative genital trauma included deep notches in the posterior half of the hymen that extended almost to the base of the hymen and clearly visible scars. Definitive evidence of penetrative genital trauma included clefts in the posterior half of the hymen that extended through to the base of the hymen. These interpretations were based on an evidence-based classification system.11 If the written documentation of the findings was not discernable in the photographs or there was a lack of consensus among reviewers, those cases were interpreted as “inconclusive.”
The average age of the subjects was 15.1 years (range: 12.3–17.8 years). Pregnancy was confirmed during the clinic visit, before the visit by another clinician, or subsequent to the visit by a qualitative β human chorionic gonadotropin urine or serum sample or pelvic ultrasound. One adolescent was pregnant with her second infant (the first was also the product of a rape and was delivered by caesarian section), 1 had a miscarriage and dilatation and curettage procedure 2 weeks before her examination, and 1 had an abortion 2 months before her examination. All 3 of these adolescents had normal examinations. One 13-year-old adolescent, ∼6 months pregnant, received the first confirmation that she was pregnant during the sexual assault examination. Fig 1 shows a normal examination in the 13.8-year-old adolescent who is 8 weeks pregnant with her second child. Overall, 22 (64%) had normal or nonspecific examination findings, 8 (22%) had inconclusive findings, 4 (8%) had suggestive findings, and 2 (6%) had definite evidence of penetrating trauma. All but 1 of the inconclusive cases were patients examined >4 years ago. The photographs for these patients either failed to demonstrate a documented cleft with a second examination technique such as balloon-covered swab or with the prone knee-chest position, or the documented cleft appeared to be a shallow notch in the photograph. When the inconclusive category was eliminated, 82% of the examinations were normal, 11% were suggestive, and 7% were definitive for penetrating trauma. Fifty-six percent (N = 20) of pregnancies were a result of sexual abuse, 41% (N = 15) were a result of consensual sexual contact, and in 1 patient (3%) it was unknown whether the pregnancy was a result of abuse or consensual sexual contact. By date of the last menstrual period or by pelvic ultrasound, 39% were ≤8 weeks pregnant, 28% were 9 to 18 weeks pregnant, and 19% were >18 weeks pregnant. The duration of pregnancy was undetermined in 5 subjects (14%). Six (17%) presented for examinations within 4 weeks of their last sexual contact; only 1 subject was examined within 2 weeks of her most recent sexual contact. Overall, the average time between the most recent sexual contact and the examination was 3.1 month for the normal group, 2.9 months for the inconclusive group, 1.75 months for the suggestive group, and 1 month for the definitive group.
Despite definitive evidence of sexual contact (pregnancy), only 2 of 36 adolescents had genital changes that were diagnostic of penetrating trauma.