Sarah's Baby 1n: Meet Sarah and Pat

Using UNMC's Online Resources to Address Clinical Questions

by Cindy Schmidt, M.D., M.L.S.

Published December 2015, Revised July 2019

 

Warning:

If you are using Internet Explorer, please STOP now! Open another internet browser (we recommend Firefox), go to --

http://library1.unmc.edu/gots/tutorial/sb1n

-- and continue working on the tutorial in the new browser.

 

Instructions:

1.  Use the Arrow icons below this instruction panel to go forwards and backwards in the tutorial.

Avoid working ahead of the instructions. Deal only with the information on one panel before clicking the "forward" arrow to move to the next.

2. You do NOT have to complete this tutorial miniseries in one sitting.

• When you leave the tutorial temporarily, note the tutorial episode number and "chapter" that you are completing.
• When you later return to the tutorial, you can skip forward to the needed "chapter" of the tutorial by clicking the tutorial's menu icon-

-- and selecting the needed 'chapter.'

3.  If the page or chapter menu jitters, right-click on the instruction panel header and select the refresh/reload option.  This will correct the problem.

4. To see or save the contents of this tutorial in a single document, click the "single-page view" link at the top of this panel.

 

Overall Aim

This tutorial uses a clinical case, the case of Sarah Pilger, a pregnant adolescent with a somewhat complicated pregnancy, to introduce you to the information resources that are available at UNMC.

We hope that this tutorial will help you learn to find needed resources, and the relevant information within those resources, quickly. Only read all of the information retrieved if you find it fascinating and have lots of free time!

Specific Objectives

The specific objectives of the tutorial series are listed below:

1. After being presented with a learning issue, students will identify an information resource likely to be useful from among 8 frequently used resources -- ProceduresConsult, Online journals/Ebooks finder, AccessMedicine,  UpToDate, MedlinePlus, PubMed with GetIt!@UNMC buttons, Clinical Pharmacology, and LexiComp.

2. After identifying a resource appropriate for their learning issue, students will use the library’s website to navigate to the needed resource, conduct a search in the resource, and identify needed information.

3. Students will conduct keyword and MeSH-based searches of PubMed. The constructed searches will make appropriate use of operators (AND, OR, NOT), asterisks*, parentheses (), quotation marks "", and article type filters.

4. Students will be aware of the methods that can be used to contact librarians when they are faced with resource or access questions, need search training, or want a librarian to conduct a literature search for them.

Sarah: Referral Note

1 of 3For the purpose of this tutorial, you'll need to pretend it's Tuesday, September 17, 2019 and that you are a clinical nutritionist seeing a new patient.

Sarah: Referral Note

2 of 3

The referral note tells you that Sarah Pilger, is a 16 year-old, obese female, who didn't realize she was pregnant until one week ago. The date of Sarah's last menstrual period (LMP) suggests that Sarah is in the middle of her second trimester.

Before Sarah learned that she was pregnant she had been on a low calorie diet. She hasn't gained any weight during the pregnancy. Dr. Pham Li, Sarah's family practitioner, wants you to recommend the best diet and ideal pregnancy weight gain for Sarah. Dr. Li asks that you continue seeing and counseling Sarah throughout her pregnancy.

Sarah: Referral Note

3 of 3With the referral, Dr. Li sent the following data gathered on September 13th:

height: 5’6”

weight: 210 lb.

last menstrual period: approximately March 30, 2019, suggesting a gestational age of 24.5 weeks, but menstrual periods have always been irregular.

Fundal height: 27 cm.

Ultrasound scheduled for September 16, 2019

Meds: prenatal vitamins prescribed September 13, 2019.

Sarah: You meet Sarah and Pat

When you call Sarah out of the waiting room you see that, as expected, she is an obese, white teenager. She is accompanied by her mother, who introduces herself as Pat Pilger. Sarah and Pat look worried.

They tell you that they are having a hard time concentrating and are worried they will forget everything you tell them. They ask you to write down anything that they will need to remember. They tell you that Sarah had an ultrasound exam on Monday. It showed signs that Sarah's baby has an infection that could be very dangerous for the baby. Sarah has had a blood test, but the results aren't back yet.

The ultrasound also showed that the baby's legs are short compared to it's head. The doctor told them that this is a sign of borderline growth retardation and might be due to the infection. However, they are wondering whether Sarah's recent diet might have affected the baby.

Sarah: Weight/Diet/Nutrition history

1 of 4

You ask Sarah about her weight and diet history. She tells you that she was never thin, but she gained 50 pounds in 2018, the year of her parents' divorce. She stopped weighing herself in January 2019 (nine months ago), when she weighed 210 pounds. She continued to eat a lot of junk food after the January 'weigh-in' and may have gained more weight before she started dieting in late April.

In late April, her Mom was offered a new job in Omaha. Pat says that the job opportunity was excellent and also had two other advantages. 1) It brought Pat back to Omaha, where her mother, Sarah's grandmother, still lives, and 2) it removed Sarah from the influence of her boyfriend. Pat disliked the boyfriend and had discovered that Sarah and the boyfriend had been sexually active.

Sarah: Weight/Diet/Nutrition history

2 of 4Sarah admits that the boyfriend, while a smart guy, hadn't always been kind to her. It was a relief to move to Omaha, and be able to start over. She had been excited about turning over a new leaf, and had really gone at dieting with a fury. She reduced her calories to between 900 and 1000 calories a day. She ate several fruit servings daily, a little protein every day, and avoided extreme hunger by eating large quantities vegetables. She would put a small amount of butter or olive oil on the vegetables. She also found that drinking a glass of metamucil each day helped keep hunger at bay.

Sarah: Weight/Diet/Nutrition history

3 of 4

Sarah also began exercising and working hard in the community garden.

Sarah didn't weigh herself during the course of her low calorie diet.  Her 210 pound weight in January had been depressing enough.  She hadn't wanted to know how much weight she gained after January.

Sarah thought her legs and arms had slimmed down a bit during the diet, but her torso hadn't followed suite. The reason for the lack of torso slimming is obvious now, but she really hadn't considered the possibility she might be pregnant. Dieting had always made her menstrual cycles irregular.

Sarah: Weight/Diet/Nutrition history

4 of 4Sarah has been trying to eat a more normal diet since learning she was pregnant, but would really value exact recommendations.

Sarah: You ask for ultrasound data

You want to know more about Sarah's ultrasound examination findings before making dietary recommendations. The ultrasound was just performed yesterday.  The final report isn't available, but you are able to obtain the following information:

1) fetal brain shows

a) mild ventriculomegaly

b) several, tiny areas in the brain parenchyma are consistent with intraparenchymal calcifications.

2) abdomen shows some ascites.

3) The thickness of fetal subcutaneous fat is reduced.

4) Placental thickness is increased.

5) Some of the fetal measurements are:

Biparietal diameter: 62 mm

Abdominal circumference: 175 mm

Femur length: 37 mm

Learning Issues

What do you need to learn to be a clinical nutritionist who can provide excellent care to Sarah?

Perhaps some of the following are among the learning issues that occurred to you:

1. How were the fetal measurements obtained?

2.  How severe is the 'borderline' growth retardation?

3. What gestational age is suggested by a fundal height of 27 cm?

4. What are the recommendations for pregnancy-related weight gain in obese pregnant women? Do these recommendations vary for pregnant adolescents?

5. Could Sarah's poor nutrition prior to her pregnancy and her severe diet (and probable weight loss) during the first trimester of her pregnancy have contributed to the growth retardation or other ultrasound findings?

6. What fetal infections can cause intracranial calcifications and ascites?

It's Time to Complete the Pre-Tutorial Survey

Before moving to episode 2 in this tutorial series, please complete the pre-test at http://unmc.libwizard.com/sarahsbabymne

When working on the pre-test questions, please, do not labor over the questions or consult any resource for help. Just give us your best response based on your current knowledge.

We expect most students to spend less than 7 minutes answering the pre-tutorial survey questions.

The data we obtain from the pre- and post-tutorial tests will allow us to better focus our educational efforts for your class and for future classes.

When you submit your answers to the pre-test you will be provided a link to episode 2 of the tutorial series.  The format of tutorial 2 is a bit different, you will need to click a "Start Tutorial" button.  Two windows will appear.  Please, resize the narrow instruction panel/window so that it is as long as possible and can sit adjacent to the resource window.