|Year : 2019 | Volume
| Issue : 1 | Page : 54-59
Spectrum of diseases in female children and adolescents admitted to the obstetrics and gynecology hospital, Shanghai, between 2003 and 2017
Hai-Xia Huang1, Ming-Xing Zhang1, Hong-Wei Zhang1, Meng Zhang1, Yi Yu1, Yu Kang2, Gui-Ling Li2, Cong-Jian Xu2
1 Department of Gynecology, Obstetrics and Gynecology, Hospital of Fudan University, Shanghai 200011, China
2 Department of Gynecology, Obstetrics and Gynecology, Hospital of Fudan University; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, China
|Date of Submission||17-Dec-2018|
|Date of Web Publication||11-Apr-2019|
Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 419 Fang-Xie Road, Shanghai 200011
Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 419 Fang-Xie Road, Shanghai 200011
Source of Support: None, Conflict of Interest: None
Objective: To investigate the spectrum of diseases in female children and adolescents hospitalized for obstetric and gynecological conditions.
Methods: This retrospective study included patients (age ≤19 years) admitted to the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, between January 2003 and December 2017. Their medical records – age, principal diagnosis, and treatment – were reviewed and analyzed. Diagnoses were divided into eight disease classifications. Comparison between groups was analyzed with Student's t-test.
Results: This study enrolled 4,628 inpatients. The number of inpatients increased each year, especially in the groups of gynecologic tumors, pregnancy-related conditions, and disorders of the breast. The mean age was 16.33 ± 2.42 years (range: 2–19 years). Of all the inpatients, 41.9% (n = 1,939) were hospitalized for gynecologic tumors, and 85.5% (n = 1,657) of the tumors were benign. Altogether, ovarian cysts (28.66%, n = 1,325) were the most common disease observed in this group. In addition, 32.9% (n = 1,524) of the inpatients were hospitalized for pregnancy, childbirth, and puerperium; within this group, 21.9% (n = 1,014) were hospitalized for artificial abortions.
Conclusions: The efforts of all stakeholders toward the implementation of government policies to promote sexual and reproductive health among children and adolescents in China have been effective.
Keywords: Children and Adolescents; Disease Attributes; Hospitalized; Reproductive Health Education
|How to cite this article:|
Huang HX, Zhang MX, Zhang HW, Zhang M, Yu Y, Kang Y, Li GL, Xu CJ. Spectrum of diseases in female children and adolescents admitted to the obstetrics and gynecology hospital, Shanghai, between 2003 and 2017. Reprod Dev Med 2019;3:54-9
|How to cite this URL:|
Huang HX, Zhang MX, Zhang HW, Zhang M, Yu Y, Kang Y, Li GL, Xu CJ. Spectrum of diseases in female children and adolescents admitted to the obstetrics and gynecology hospital, Shanghai, between 2003 and 2017. Reprod Dev Med [serial online] 2019 [cited 2019 Jun 16];3:54-9. Available from: http://www.repdevmed.org/text.asp?2019/3/1/54/255991
| Introduction|| |
In comparison with adult women, an increasing number of female children and adolescents are being admitted to obstetrics and gynecology hospitals for different types of disease/condition in many countries. Among this group of inpatients in China and European countries, issues related to pregnancy and childbirth are the most prominent.,, In China, an estimated 10 million induced abortions are performed in registered health facilities, excluding self-induced abortions using oral mifepristone and/or misoprostol, with approximately 25% being performed in unmarried women younger than 18 years., Early motherhood has long been a concern because of the negative consequences on the adolescent mothers and their children, along with the overall implication to the society., However, only a few studies have discussed the current events in China with regard to the efforts toward the implementation of government policies to promote sexual and reproductive health among children and adolescents.
The aim of this study was to investigate the disease spectrum observed in female children and adolescent inpatients at a specialized hospital in Shanghai, China. The findings from this study may be useful to health policymakers in China.
| Methods|| |
We retrospectively searched the electronic medical record database of the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, to identify all inpatients aged ≤19 years who received inpatient services between January 2003 and December 2017. Males, newborns, and infants younger than 11 months were excluded from the study. A total of 4,628 eligible inpatients, with available medical records, were identified. The data from the hospital medical records included age, principal diagnosis for hospital admission, and treatment plan. Based on the International Statistical Classification of Diseases and Related Health Problems 10th Revision, all eligible inpatients were classified into the following eight disease groups: gynecological tumors (including benign and malignant); pregnancy and childbirth (including the puerperium); congenital malformations of the genital organs; inflammatory diseases of the female genital and pelvic organs; gestational trophoblastic disease; dysfunctional uterine bleeding; disorders of the breast; and injury as well as other consequences of external causes. We classified both chromosomal abnormalities and endocrine diseases under the same category because of their relevance to primary amenorrhea. There were 22 cases of infertility, wherein inpatients mainly had hydrosalpinx, which was categorized under inflammatory diseases of female genital and pelvic organs. We investigated the spectrum of diseases in the hospitalized female children and adolescents. In addition, the possible relationship between the diseases and the years was analyzed. The study was approved by the Ethics Committee of Obstetrics and Gynecology Hospital of Fudan University.
Student's t-test and one-way analysis of variance were used to determine statistical significance between inpatient groups. P < 0.05 indicated statistical significance. All continuous data were expressed as mean ± standard deviation.
| Results|| |
Summary of inpatients
A total of 4,628 inpatients (aged ≤19 years) were admitted to Obstetrics and Gynecology Hospital in Shanghai during the last 15 years. Their mean age was 16.33 ± 2.42 years (range: 2–19 years; 95% confidence level: 16.26–16.40 years). With each passing year, both the total number of inpatients and the number of inpatients within each group showed an increasing trend, especially in the groups of gynecologic tumors, pregnancy-related conditions, and disorders of the breast [Figure 1]. In comparison with the first half of the period, the total number of cases increased by about 39.0% in the second half of the period. Moreover, the mean ages of the inpatients varied across the different classifications. The mean ages of the pregnancy and childbirth group, the gynecologic tumor group, and the disorders of the breast group were 17.57 ± 1.37, 15.79 ± 2.43, and 16.99 ± 2.06 years, respectively [Table 1].
|Figure 1: Both the graph of point and connecting line (a) and separated bar (b) designed the distribution of eight disease groups in successive years. AUB: Abnormal uterine bleeding; GTD: Gestational trophoblastic disease. Inflammation: Inflammatory diseases of the female genital and pelvic organs; Malformation: Congenital malformations of the genital organs; Injury and else: Injury and other consequences of external causes; Tumors: Gynecological tumors (including benign and malignant); Pregnancy: Pregnancy and childbirth (including the puerperium).|
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|Table 1: Characteristics and classifications of female children and adolescents admitted to the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China, in January 2003–December 2017|
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Summary of inpatients within the eight disease classifications
We analyzed the relationship between age and each disease category. Of the total inpatients, 41.9% (n = 1,939) had gynecologic tumors, 85.5% (n = 1,657) of which were benign. The mean age of this group was 15.79 ± 2.42 years, and the most common tumors were ovarian cysts (68.3%, n = 1,325) and Gartner's duct cyst (15.4%, n = 299). These patients were hospitalized for a laparoscopic mass extraction operation. The remaining 14.5% (n = 282) of the inpatients had malignant tumors, with 87.6% having ovarian cancer (n = 247), 7.1% (n = 20) having endometrial cancer, and 5.4% (n = 15) having cervical cancer [Figure 2].
|Figure 2: Distribution of the eight disease classifications. (a) Disease classifications of the inpatients in this study. (b) The proportion of the inpatients in each classification. AUB: Abnormal uterine bleeding; Breast: Disorders of the breast; GTD: Gestational trophoblastic disease. Tumors: Gynecological tumors (including benign and malignant); Pregnancy: Pregnancy and childbirth (including the puerperium); Malformation: Congenital malformations of the genital organs; Inflammation: Inflammatory diseases of the female genital and pelvic organs; Injury: Injury and other consequences of external causes.|
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In total, 32.9% (1,524) of the inpatients were in the group for pregnancy, childbirth, and puerperium, with a mean age of 17.57 ± 1.37 years. Within this group, 18.6% (n = 284) had hospital deliveries, with a mean age of 17.76 ± 1.78 years. Another 66.5% (n = 1,014) had abortions (induced abortion or missed abortion), with a mean age of 17.51 ± 1.35 years, and 13.7% (n = 209) had ectopic pregnancy, with a mean age of 17.54 ± 1.70 years.
The group with congenital malformations of the genital organs comprised 8.8% (n = 405) of the total inpatients, with a mean age of 14.03 ± 2.38 years. These inpatients required certain plastic surgeries, such as female gonadectomy, hymenotomy, artificial vaginoplasty, and vaginal diaphragm incisions. Furthermore, the group with disorders of the breast and that with inflammatory diseases of the female genital and pelvic organs and infertility comprised 7.2% (n = 332) and 2.9% (n = 135) of the total inpatients, respectively. The remaining three groups had fewer cases of gestational trophoblastic disease (2.2%, n = 102), dysfunctional uterine bleeding (2.0%, n = 93), and injury as well as other consequences of external causes (2.1%, n = 98) [Table 1].
Most common pathologies found within each disease classification
The ten most common pathologies observed in all the inpatients were ovarian cysts (28.6%, mean age: 15.81 ± 2.45 years), abortion (21.9%, mean age: 17.51 ± 1.35 years), disorders of the breast (7.2%, mean age: 16.73 ± 2.27 years), labor (6.1%, mean age: 17.76 ± 1.18 years), malformations of the cervix/uterus (5.9%, mean age: 14.04 ± 2.33 years), ovarian cancer (5.3%, mean age: 15.93 ± 2.21 years), Gartner's duct cyst (4.9%, mean age: 15.54 ± 2.16 years), ectopic pregnancy (4.5%, mean age: 17.54 ± 1.70 years), inflammatory diseases of the female genital and pelvic organs (2.4%, mean age: 15.57 ± 3.22 years), and abnormal uterine bleeding (2.0%, mean age: 15.46 ± 2.28 years). Ovarian cysts, Gartner's duct cyst, and ovarian cancer were the three most prevalent pathologies within the group of inpatients treated for gynecologic tumors. Labor, abortion, and ectopic pregnancy were the three most common conditions found among inpatients treated for pregnancy and childbirth. Among inpatients treated for congenital malformations of the genital organs, the three most prevalent pathologies were imperforate hymen, malformations of the vagina, and malformations of the cervix/uterus [Figure 3].
|Figure 3: Proportion of all inpatients participating within this study. (a) Frequency of all pathologies. (b) Distribution of the age within each pathology. 100: Abnormal uterine bleeding; 201: Labor; 211: Abortion; 212: Ectopic pregnancy; 213: Hyperemesis gravidarum; 214: Fatal death; 215: Pregnancy complications (upper respiratory tract and ovarian cyst); 220: Puerperal disease; 310: Disorders of sexual development; 320: Imperforate hymen; 330: Malformations of the vagina; 340: Malformations of the cervix/uterus; 350: Malformations of the Fallopian tube More Details (only one case); 410: Inflammatory diseases of the female genital and pelvic organs; 420: Infertility (tubal adhesion or dropsy); 511: Gartner's duct cyst; 512: Ovarian cyst; 513: Neoplasm of the vulva/vagina/cervix; 514: Endometrial polyp; 521: Ovarian cancer; 522: Endometrial cancer; 523: Cervical cancer; 610: Hydatidiform mole; 620: Gestational trophoblastic neoplasia; 700: Disorders of the breast; 810: Injury; 820: Other consequences of external causes.*: Significant outliers.|
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| Discussion|| |
We found that the total number of children and adolescent inpatients gradually increased from January 2013 to December 2017. The number of inpatients also increased in each disease classification in the time spans. Therefore, the increase in the number of children and adolescent inpatients each year may be attributed to the increase in the general population of Shanghai (Shanghai Statistical Yearbook, 2003–2017). The population of Shanghai consists of the local resident population and the foreign resident population, with the latter including people from other provinces and regions, as well as foreign nationals. No official data were available on the foreign resident population in 2003 and 2004. The household resident population was 13,417,600 in 2003, 13,710,400 in 2008, and increased to 14,201,900 in 2012. The foreign resident population was 4,180,000 in 2005, 5,174,200 in 2008, and increased to 9,602,400 in 2012. While the foreign resident population more than doubled from 2005 to 2012, the household resident population only increased by 5.8%. This is largely due to the increased level of urbanization in the entire country; an increasing number of young people are moving to larger cities for better employment opportunities, with Shanghai seen as a viable option. While it appears that the population of this age range (≤19 years) also increased, we did not find accurate data to support this point.
As the number of inpatients in the pregnancy, childbirth, and puerperium groups increased each year, the group generally increased by about 18.0% in the second-half period, which might be related mainly to the expansion of the hospital in 2010. However, a similarity in mean age was observed from the first-half period (17.15 years) to the second-half period (17.87 years). A study in the United States showed that the teen birth rate dropped between 2007 and 2010, and this was attributed to the rigorous education on pregnancy prevention targeted at teenagers. Similarly, the results of this study can be attributed to the sexual and reproductive programs conducted by the Chinese government. In 1978, China promulgated the “Physical health outline (draft)” in high schools. In 1988, the National Education Committee and the Ministry of Health and National Family Planning Board jointly issued the program “On the conduct of adolescent education in secondary schools,” which officially launched puberty education in secondary schools. The subsequent decade included the initial stages of development of adolescent sexual health education policies in China. In September 1992, the Ministry of Health, the National Education Committee, and the National Patriotic Health Campaign Committee jointly issued “Basic requirements of health education in primary and secondary schools (Trial)” and “Basic requirements of health education in the universities (Trial).” Adolescent sexual health education was clearly defined as physiological, psychological, and moral. The “Population and Family Planning Law of People's Republic of China” was officially implemented in 2002, making it clear that schools should carry out physical health education, adolescent education, and sexual health education in an appropriate manner. The Ministry of Education issued the “AIDS prevention program in primary and middle school students” and “Drug prevention program in primary and middle school students” in 2003 and required schools to enlighten students on AIDS prevention, such as by using monographs to educate students on how to develop a healthy lifestyle, toward enhancing their self-protection awareness and limiting the spread of AIDS.
We believe that the most important policy contributing toward this difference was issued in 2006. In this year, the State Council promulgated the “China Containment and AIDS Action Plan (2006–2010)” which propagated awareness on the prevention of AIDS and information on voluntary blood donation. It reached more than 85% of the youth in schools and more than 65% of the youth outside of schools by the end of 2007; by the end of 2010, it reached more than 95% of the youth in schools and more than 75% of the youth outside of schools. This policy highlighted and paid special attention to the foreign resident population. As mentioned previously, the foreign resident population more than doubled from 2005 to 2012, whereas the household resident population only increased by 5.8%. The policy has substantially promoted the development of sexual and reproductive programs in Shanghai. Many measures were significantly developed during this period to promote adolescent sexual reproductive health, including creating an open college students' marriage program, peer education, and reproductive health programs with participatory learning methods in schools. Providing open access to relevant books and video materials through libraries also proved to be a good approach. These measures can prevent risky sexual behaviors and accidental pregnancies. The annual growth rate of gross domestic product was 11.4% in Shanghai during this decade. The economic growth combined with these policies and measures caused a reduction in the proportion of inpatients in the pregnancy, childbirth, and puerperium groups from 2008 to 2017 in this hospital.
According to a survey carried out in 2008 in 49 universities across China, 54% of the 10,700 college students who had active premarital sexual behaviors reported a history of condom use. This is far below what is observed in developed countries worldwide., China has a serious policy against inequity in offering health resources to its citizens. However, in some undeveloped areas, it is quite concerning that teen birth rates remain higher. Dropping out of school and early marriages are more serious and common in the less developed inland cities of China. As China's economic and financial center, Shanghai is usually the pilot city for a variety of policies. What was observed in Shanghai does not reflect the rest of the country. Therefore, the accurate rate of adolescent pregnancy, childbirth, and puerperium is most likely higher countrywide than that reported in this study. There is still a great challenge in promoting sexual and reproductive education in China.
Adolescent mothers face many problems, such as dropping out of school, poverty, subsequent adolescent pregnancy, parental stress, and postpartum depression. It has been reported that adolescent mothers are at a high risk of rapid subsequent pregnancies. Parental stress was reported to be a significant risk factor for developing postpartum depression and subthreshold depression among adolescent mothers. It is vital to improve the health and the achievements of female adolescents and ensure their maturation into becoming productive members of the society. However, there are few effective measures on providing social support for them in China. Most parents feel ashamed of their own children, and babies are mostly given away for adoption or abandoned in hospitals, with the welfare institutions only able to accommodate a few abandoned infants. It should be noted that several adolescent pregnancies in China are only discovered in the middle or later stages of pregnancy as observed in this study. This may be due to the fact that girls in China are more traditional compared to their Western counterparts and are less likely to share this information with other people. Thus, Chinese parents should play their guardian role and pay close attention to their daughters so as to be able to discover pregnancy early enough. This is also a complex endeavor that requires collaborative efforts of the schools, health-care systems, public health-care systems, and the youths themselves. It is very necessary to provide sexual and reproductive knowledge to teenagers to improve their quality of life.
In this study, the number of inpatients in the benign and malignant tumor groups increased over the past decade. This finding suggests that the prevalence of neoplasms in the female genital organs might have increased over the past 15 years. It is worth noting that the proportion of benign tumors in the last 5 years of the study period was significantly higher than that of the former 10 years (2003–2012). The incidence of ovarian masses has been estimated at 2.6 cases/100,000 girls/year, with malignant ovarian tumors comprising approximately 1% of all childhood cancers. In the benign and malignant tumor groups, ovarian germ cell tumors were the most common tumors in the pediatric and adolescent populations. This finding is consistent with those of other studies.,, The population of this study is for children and adolescents, all of which need to consider fertility requirements. With the new therapeutic modality, it is now possible to perform fertility-sparing treatment for these inpatients with gynecologic malignancy.
In the group with breast disorders, the number of inpatients dramatically increased each year (increasing by about 74.6% in the second-half period), which may be related mainly to the large expansion of hospital in 2010. However, the average age of these inpatients in the first-half period (16.24 years) was lower than that in the second-half period (17.10 years), with most of them presenting with benign neoplasms. These might also be related directly to an increasing pressure to live, study, and work in Shanghai. Congenital malformation of the genital organs was the third most common reason for children and adolescents to be hospitalized in this study, attributable to the improvements in the overall strength of the gynecological teams in disease diagnosis and treatment within this particular hospital.
However, our study has some limitations. As it was a retrospective study, some data were unavailable. For example, the socioeconomic status of the inpatients involved was missing. This is an important factor when considering social policies as socioeconomic class can dictate who has the means to seek health care, as well as how to respond to health-care education promoted by the government. Owing to the expansion of the hospital in 2010, the distribution of all inpatients was also affected to a certain extent.
In conclusion, the policies of government toward the promotion of the sexual and reproductive health of children and adolescents have been effective in China. However, education on parental roles requires further improvement.
Financial support and sponsorship
This work was supported by the National Natural Science Foundation of China (Grant No. 81873124).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]