A CASE REPORT OF PEDIATRIC PREGNANCY IN A PRECOCIOUS CHILD COMPLICATED BY

VIRAL INFECTIONS
ABSTRACT

Data regarding local incidence of precocious puberty is unknown. Precocious puberty is the

onset of secondary sex characteristics in children earlier than normal. It is secondary to various

causes including normal variant, cranial and ovarian tumors, endocrine disorders and much more.

Additionally, many cases of childhood pregnancy in the country is left undocumented. Prenatal care

for this patient population requires more effort because it is associated with a lot of pregnancy

complications. Moreover, teratogenic exposure during pregnancy makes it further critical.

Pregnancy in a precocious child atop with exposure to viral infections with possible fetal effects

poses a great challenge in management. We are presented with a case of a nine-year-old with sexual

precocity, pregnant at an early age and is further complicated by Rubeola and Varicella infections.

Keywords: pediatric pregnancy, precocious puberty, Rubeola, sexual precocity, Varicella

INTRODUCTION

Precocious puberty is generally defined as the appearance of secondary sex characteristics

before age 8 years in girls (or menarche before age 9 years) and before 9 years in boys. The overall

incidence of sexual precocity is estimated to be 1:5,000 to 1:10,000 children. The female-to-male ratio

is approximately 10:1. (1)

The etiologies of precocious puberty may be subdivided into GnRH-dependent and GnRH-

independent causes. GnRH-dependent precocious puberty, often called central precocious puberty,

results from activation of the hypothalamic-pituitary-gonadal axis by a variety of central nervous

system abnormalities among others, brain tumors, trauma, infection or could be idiopathic. The

etiologies of GnRH-independent peripheral precocious puberty include production of sex steroids by

the gonad in an unregulated fashion, such as in McCune-Albright syndrome (MAS), ovarian cyst,
estrogen-secreting adrenal tumor, exogenous estrogen exposure, Peutz-Jegher syndrome, primary

hypothyroidism and aromatase excess. (2) Diagnosis and management of precocious puberty

depends on the pathology identified.

There are only few reported cases of pregnancy occurring in girls with sexual precocity. Among

these was a 10-year-old as discussed in the case report by T.E.C. Jr. in 1834 who delivered to a

healthy term baby. (3) Another case is the Peruvian woman who is the youngest confirmed mother in

medical history, giving birth at the age of five years. (4) Today, many cases of pregnancy in children

remain unreported because of social stigma on this matter.

Pregnancy in young children have a higher risk for adverse outcomes. Furthermore, exposure

to viral infections could further complicate the condition.

GENERAL OBJECTIVE

To discuss a case of pregnancy in a precocious child complicated by Measles infection.

Specific Objectives

1. To discuss precocious puberty.

2. To discuss pregnancy in children and its possible outcomes.

3. To discuss possible effects of rubeola and varicella infections on pregnancy.

This paper is significant because this is the first documentation of pregnancy in a precocious child

in the Philippines. This will help future cases in diagnosing precocious puberty and its causes. It will

also aid future studies to identify the problems encountered in pregnancy in young children especially

those who are victims of sexual abuse.

CASE REPORT

This is a case of A.C. a 9 year- old Gravida 1 Para 0 who was admitted with a chief complaint

of intermittent fever for 3 days.

History of present illness started 2 days prior to admission as on and off fever with the highest

temperature recorded as 40 ° Celsius accompanied by vomiting, productive cough with yellowish

phlegm, and colds. No associated skin lesions noted. Persistence of the said symptoms prompted

consult to a private hospital where she was diagnosed with Upper Respiratory Tract Infection and was

then transferred to a tertiary hospital for further management.

The patient’s mother did not have any prenatal checkup nor took any prenatal supplements

during pregnancy. Her mother did not have any illness during pregnancy. The patient was delivered

fullterm by spontaneous vaginal delivery a traditional birth attendant at home without fetomaternal

complications. The patient did not receive any immunization when she was younger.

At 3 months of life, she was diagnosed with a heart problem which according to the mother

was detected in a hospital in Manila and was given unrecalled medications. No other history of

childhood illness.

Family history revealed maternal bronchial asthma. No other history of illnesses such as

hypertension, diabetes, heart disease, thyroid disease, and malignancy.

She is a grade 4 student with academic honor in school. She has a good relationship with her

mother.

Menarche started at 7 years old with regular intervals lasting for 5 days using 2 to 3 moderately

soaked pads per day with no associated dysmenorrhea. Last normal menstrual period was December

18, 2018. Breast development was noticed 1 year prior to menarche.

Patient was sexually abused since January 7, 2019 by her stepfather. Sexual exploitation

happened 2 times at home. She has no history of foul-smelling vaginal discharge. Presently, the

patient is under the protective custody of a sector caring for abused women and girls.
 For her pregnancy, prenatal check up is done at the local health center and in a tertiary

hospital with the aid of Teen Parents’ Clinic. She is regularly taking OB Multivitamins, Ferrous Sulfate,

and Calcium tablet once a day.

On physical examination vital signs were as follows: 100/60 mmHg, Cardiac rate 93 bpm,

respiratory rate of 20 cpm, temperature of 38.5°C, Height 147 cm, Weight 45.5 kg. She has fair skin

complexion, no lesions appreciated. On chest examination, heart rate is normal and regular, no

murmur appreciated. No chest wall deformity, with symmetrical chest expansion, clear breath

sounds. The abdomen is flat, soft nontender. Sexual maturity rating revealed Tanner stage 5 for the

breasts (Figure 1) and stage 4 for the pubic hair (Figure 2). Internal examination findings are cervix

closed, no blood per examining finger. Pregnancy is compatible with 11 6/7 weeks age of gestation by

measurement of crown rump length on ultrasound (Figure 3).

Admitting impression was: Gravida 1 Para 0 Pregnancy uterine 10 6/7 weeks age of gestation;

Community-Acquired Pneumonia- Low Risk; To Consider Congenital Heart Disease.

The patient was admitted for 3 days and was actively co-managed with Pediatric service.

Laboratory examination such as CBC, urinalysis, serum Na, K, Dengue NS1, 12-L ECG, blood culture

and sensitivity, and Chest X-ray were all normal (Tables1, 2). She was started on Ceftriaxone 2g IV

once a day. On hospital day 3, eruption of generalized maculopapular lesions was noticed on the

face down to the chest and extremities with the diagnosis of Measles. She was then transferred to

San Lazaro Hospital where she was admitted for another 5 days and was sent home improved.

Subsequent prenatal check up was done at a local health center. At 22 weeks age of gestation,

she followed up at Teen Parents’ Clinic. She was seen by the Dental, Nutrition and Psychology

services as well. She had no subjective complaints. Fetal movement could be perceived and was

started to be felt at 20 weeks age of gestation. On examination, fundic height was 21 cm (Figure 4)

with good fetal heart tone of 155 beats per minute best heard at the hypogastric area (Figure 5, 6).
 At 24 weeks age of gestation, congenital anomaly scan was done with unremarkable result.

Two days after, she developed vesicular lesions all over the body with associated lymphadenopathy

(Figure 7). The skin lesions subsided after 1 week with no other complications noted. At 29 weeks

age of gestation, she followed up at Teen Parents’ Clinic. She had no subjective complaints. Fundic

height was 29 cm with good fetal heart tone of 148 beats per minute at the right lower quadrant. Plain

cranial MRI was done after 2 days with no significant findings (Figure 8). FT4, TSH results were

normal as well (Table 3). Presently, her pregnancy is at 31 6/7 weeks age of gestation.

DISCUSSION

Precocious puberty is defined as the onset of pubertal development at an age that is 2 to 2.5

standard deviations (SD) earlier than population norms. Incidence of precocious puberty in the

Philippines is not yet reported. The cause of precocious puberty may range from a variant of normal

development (eg, isolated premature adrenarche or isolated premature thelarche) to pathologic

conditions with a significant risk of morbidity and even death (eg, malignant germ-cell tumor and

astrocytoma). (5) The pathophysiology identified is increased kisspeptin secretion from the arcuate

nucleus and the anteroventral paraventricular nucleus of the hypothalamus. (2). In the study of Siamak

et al, data of 106 girls (82.2%) and 23 boys (17.8%) with precocious puberty were analyzed and

revealed 73 out of 129 subjects (56.6%) were due to normal variants of puberty, 87.5% of subjects

with central precocious puberty were idiopathic. (6) Diagnosis of type of precocious puberty includes

Cranial MRI to identify any neurologic lesions, pelvic/ abdominal ultrasound to detect ovarian mass,

thyroid hormone determination, other hormonal analyses such as luteinizing hormone, estradiol,

testosterone, human chorionic gonadotrophin, cortisol, DHEAS and 17-OHP.

The advanced onset of puberty in a child has an immense effect on her especially adjustment

from a child to a reproductively- capable individual. As in the case of our patient, puberty at the young

age of 6 has a huge impact on her. Breast development was started to be noticed at this age.
Menstruation started a year after. The physical, emotional and social effects of this matter could have

disturbed the way the child see herself. Confounded with the occurrence of pregnancy at this young

age, the complexity is even graver as seen in this case. The cause of precocious puberty in this case

is not known because of lack of investigation. An important part of the management includes the

inquiry of the cause of sexual precocity. Because of her pregnancy, hormonal evaluation will not be

helpful and should be reserved postpartum. Cranial MRI will be valuable in determining presence of

tumor and fortunately, is not present in our patient as revealed in the result of her imaging. Ovarian

mass is ruled out because of absence of it on pelvic ultrasound.

Data regarding pregnancy among young children less than 10 years old is limited. Extensive

local literature review was done regarding pregnancy in precocious girls but there was no

documented case found. The World Health Organization summarized the health, economic and social

consequences of adolescent pregnancy. Pregnancy and childbirth complications are the leading

cause of death among 15 to 19-year-old girls globally, with low and middle-income countries

accounting for 99% of global maternal deaths of women ages 15 to 49 years. Adolescent mothers

(ages 10 to 19 years) face higher risks of eclampsia, puerperal endometritis, and systemic infections

than women aged 20 to 24 years. In low- and middle-income countries, babies born to mothers under

20 years of age face higher risks of low birthweight, preterm delivery, and severe neonatal conditions.
(7) The study of Salihu et al analyzed 17.8 million singletons and 337,904 individual twins that occurred

in children (10-14 years old) in the United States from 1989 to 2000. The absolute and relative risks of

stillbirth were identified by using 15- to19-year-old and 20- to 24-year-old mothers as comparison

groups. It was found out that pediatric mothers exhibited significantly elevated risk for stillbirth in both

singleton and twin pregnancies. (8) Thus, with this in regard, the possible health risks of pregnancy

should always be anticipated and reiterated to young parents, such as our patient. Active

management together with Dental, Nutrition and Psychology services is essential in order to address

every need of the young mother. On her first follow up in Teen Parents’ Clinic, her understanding and

coping with her situation was assessed. She is still anxious that people might abuse her and trusts
only a few. But the good thing is that she takes full responsibility of her pregnancy. She is fully aware

of the possible complications and feels worried about it. Counselling regarding her condition was

done. Dental and nutrition consults was done as well, which were both unremarkable.

Long term effects of sexual abuse should also be a focus in the management of this patient.

The patient should also be referred to a mental health professional in order to evaluate the depth of

damage caused by the traumatic event. According to American College of Obstetricians and

Gynecologists, the primary aftereffects of childhood sexual abuse include the following: emotions

such as fear, shame humiliation, guilt and self-blame which can lead to anxiety and depression;

symptoms of posttraumatic stress such as recurring thoughts of abuse; and distorted self- perception

which can lead to self-destructive relationships.(9) All these issues should be tackled in order to

restore the patient’s self-esteem and prevent any long term detrimental psychological effect to her.

On the other side, pregnant women are among the population high risk for developing measles

complication. These complications include pneumonia, encephalitis, subacute sclerosing

panencephalitis and death. Rasmussen and Jamieson reviewed reports with 20 or more measles

cases during pregnancy that included data on effects of measles on pregnant women or pregnancy

outcomes. It concluded that women with measles were significantly more likely to have spontaneous

abortion, intrauterine fetal demise, or neonates with low birth weight than women without measles. (10)

As in the case of our patient, she was infected by Measles early in pregnancy. Supportive treatment

was given to her during the time of illness. She was also transferred in another institution with

isolation facilities where possible complications of the virus were observed. Fortunately, she was

discharged improved. Prenatal care includes congenital anomaly scan which was done at 24 weeks

age of gestation to detect any effect of the virus to fetal development. In this case, congenital anomaly

scan had unremarkable result.

Before 24 weeks gestation, vertical transmission of Varicella Zoster Virus to the fetus has been

detected clinically/serologically and by PCR in approximately 24% and 8% of cases of virologically

confirmed maternal chickenpox respectively. Intrauterine growth restriction (IUGR) occurs in

approximately 23% of cases and low birth weight is virtually universal. Primary Varicella Zoster Virus

infection in the first two trimesters of pregnancy results in intrauterine infection in up to 25% of cases,

and congenital anomalies described in the Congenital Varicella Syndrome can be expected in

approximately 12% of infected fetuses. Maternal chickenpox in the first 20 weeks of pregnancy was

associated with an incidence of Congenital Varicella Syndrome of 0.91% (13 cases of Congenital

Varicella Syndrome in 1423 live births).(11) As in this case, she contracted Varicella infection at 24

weeks age of gestation. The odds of this patient acquiring fetal complications is further intensified.

Fetal biometry every prenatal visit should be included in the management to document fetal growth

and detect intrauterine growth restriction.

In order to address the needs of young mothers, the Department of Health (DOH) has initiated

several adolescent youth and reproductive health interventions that use a multidisciplinary approach

and promote partnership among schools, communities and hospitals. One of these interventions is

the hospital-based center for teens. (12) With the Teen Parents’ Clinic, our patient has been given

appropriate prenatal care for her situation. Her case is being handled sensitively, making sure all

issues are addressed properly in a way that has been tailored to her condition.

Further plans for the patient include routine prenatal care and screening including HIV testing,

continued investigation of possible congenital heart disease by 2D Echocardiography, and exploration

of the cause of precocious puberty as previously discussed. Postpartum, patient will be given

childhood immunization including cervical cancer vaccine.

CONCLUSION

Prenatal care for this young patient should be highly individualized. In this case, cause of

precocious puberty should be identified by different diagnostics so that proper management could be

given, if indicated. Every single aspect including physical, emotional and psychosocial should be

properly addressed and issues should be handled with intricate care . Effects on pregnancy and

outcome of conception combined with possible consequences of Rubeola and Varicella should be
properly identified and managed. Multidisciplinary approach including obstetrician, pediatrician,

psychologist among others are required in order to deliver the utmost management warranted in this

sensitive case.
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1. Partsch CJ, Sippell WG. Pathogenesis and epidemiology of precocious puberty. Effects of

exogenous oestrogens. Hum Reprod Update. 2001 May-Jun;7(3):292-302.

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Endocrinology & Metabolism, Volume 98, Issue 6, 1 June 2013, Pages 2198–2207,

https://doi.org/10.1210/jc.2013-1024.

3. T. E. C., Jr. Report of a case of precocious puberty and pregnancy in 1834. Pediatrics. October

1972, Volume 50 / Issue 4.

4. The Telegraph. Six decades later, world’s youngest mother awaits aid [internet]. India: The

Telegraph; 2002. Available from: www.telegraphindia.com/world/six-decades-later-world-s-youngest-

mother-awaits-aid/cid/1560903.

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[internet]. USA: Up To Date ; 2018. Available from:

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puberty#references

6. Shiva S, Fayyazi A, Melikian A, Shiva S. Causes and types of precocious puberty in north-west

iran. Iran J Pediatr. 2012;22(4):487–492.

7. Ganchimeg T, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World

Health Organization multicountry study. Bjog. 2014;121(S Suppl 1):40-8.

8. Salihu HM, et al, Childhood pregnancy (10-14 years old) and risk of stillbirth in singletons and

twins. J Pediatr. 2006 Apr;148(4):522-6.

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Measles and Pregnancy. Obstet Gynecol. 2015;126(1):163–170.

doi:10.1097/AOG.0000000000000903.
11. Lamont, R. F., Sobel, J. D., Carrington, D., Mazaki-Tovi, S., Kusanovic, et al. (2011). Varicella-

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teen-centers-empower-pregnant-adolescents/
APPENDIX

Figure 1. Image shown displays Tanner stage 5 for the breasts. Her breasts show final
adult size, areola returns to the contour of the surrounding breast, with projecting
central papilla.

Figure 2. Image shown displays Tanner stage 4 for the pubic hair. It has adult-like hair
quality, extending across pubis but sparing medial thighs.
Figure 3. Transvaginal scan during admission revealing single intrauterine
pregnancy compatible with 11 6/7 weeks age of gestation.

Figure 4. Measurement of fundic height of 21 cm done at 22 weeks age of

gestation during the follow up at Teen Parents’ Clinic in the outpatient department
Figure 5. Pelvic scan done on her prenatal follow up at Teen Parents’ Clinic.
Single intrauterine pregnancy with good fetal heart activity with estimated
fetal weight of 541 g.

Figure 6. Pelvic scan showing good fetal cardiac activity of 155 beats per minute.
Figure 7. Shown is the patient’s back and upper extremity with vesicular lesions
characteristic of Varicella infection.

Figure 8. MRI result of patient showing unremarkable result.

 TABLE 1
COMPLETE BLOOD COUNT
Hospital Day 1 Hospital Day 3
Erythrocytes 4.73 (4.2-5.4) 4.25 (4.2-5.4)
Hemoglobin 135 (120-140) 121 (120-140)
Hematocrit 0.3487 (0.38-0.47) 0.347 (0.38-0.47)
Leukocyte 5.21(4.5-11) 4.93 (4.5-11)
Neutrophils 0.668 (0.37-0.72) 0.806 (0.37-0.72)
0.217 (0.20-0.50) 0.116 (0.20-0.50)
Lymphocytes
Monocytes 0.111 (0.0-0.14) 0.022 (0.0-0.14)
Eosinophils 0.000 (0.0-0.06) 0.004 (0.0-0.06)
Basophils 0.004 (0.0-0.01) 0.002 (0.0-0.01)
Thrombocytes 184(150-400) 138 (150-400)
*Normal value ( )

TABLE 2
Hospital Day 1
Na 132.1
K 3.51
Dengue NS1 Negative
Blood Culture and No growth
Sensitivity
12L ECG Sinus Rhythm
Chest X-ray with abdominal Unremarkable chest
shield study

TABLE 3
TSH 1.63 (0.4-5.5 )
Ft4 1.12 (0.78 -2.19)

*Normal value ( )