By Cindy Schmidt, M.D., M.L.S.
published 06/01/2015
updated 04/29/2016
Complete episode 1, episode 2, episode 3, episode 4, episode 5, and episode 6 before beginning this episode.
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In case you want a recap:
Sarah Pilger is an obese, pregnant, 16-year-old female. Her first prenatal visit was at 24 weeks gestational age, shortly after she realized that she was pregnant. Her ultrasound at 24.5 weeks gestational age showed signs of a fetal/placental infection. Laboratory tests confirmed the presence of a recent, maternal toxoplasmosis infection. The infection has been treated with pyrimethamine, sulfadiazene, and folinic acid. Sarah is also taking prenatal vitamins.
Sarah is seeing a nutritionist and has been working with a physical therapist to treat her back pain.
Before you prescribed the toxoplasmosis treatment you spoke with an infectious disease specialist and you have been following Sarah with the specialist since that time.
Sarah has been having weekly ultrasound exams to monitor the baby's progress. These exams show no progression of the baby's brain lesions and no new lesions. The ascites is disappearing.
Sarah's routine labs have looked good thoughout her prenatal care.
Sarah's water finally breaks, a week after her due date, and her baby is delivered without complications.
The baby, Emily, has mild hydrocephalus and slight motor delays. A shunt is placed to treat the hydrocephalus.
Sarah comes in for an appointment the week after Emily's birth. She doesn't mention any problems to you. However, when your nurse, who has dealt with Sarah throughout her prenatal care, comes in to draw Sarah's blood and chat; Sarah begins to cry. Your nurse learns that Sarah has been crying frequently, is tired all the time, and has lost interest in most of her activities.
You are grateful that your nurse brought Sarah's crying and loss of interest in activities to your attention.
You ask Sarah several more questions to determine whether she meets the criteria for a major depressive disorder and/or peripartum depression. She has several additional symptoms characteristic of depression, and easily meets the criteria for a major depressive episode. Fortunately, she is not suicidal and she appears relieved when you say that medication may be helpful.
Optional: If you'd like to review the criteria for a diagnosis of depression, you can go to the Diagnostic and Statistical Manual 5 (know as the DSM 5) online.
To access the DSM 5:
To find the criteria for major depression:
You order some rush laboratory work to rule out metabolic causes for depression. You ask a pharmacist, Dr. Millicent (Milly) Graham, about drugs that might be used to treat depression in a breast-feeding mother. She suggests sertraline and paroxetine but says that there are other choices and that it would be important to check for any interactions with drugs that the patient is currently taking.
She asks if you would like to check for this info with her.
To reach Clinical Pharmacology, she mentions that one must:
1. Go to the McGoogan Library's website.
You can reach the library's homepage by going to any unmc.edu page and clicking the "Library" link at the bottom of the "Quick Links" in the lower right-hand corner of the page.
2. Click on "Drug Resources"
3. Click the "Clinical Pharmacology" link.
Click on Clinical Pharmacology's "Reports" menu and select the Drug Interaction Report" option.
Type in --
pyrimethamine
-- and select "pyrimethamine oral tablet"
Your selection will appear in the "Drug List"
One at a time, search for, and add,
sulfadiazene ("sulfadiazene oral tablet")
leucovorin ("leucovorin calcium oral tablet".
This is another name for folinic acid.
prenatal vitamin (choose the first option that includes folic acid and iron)
sertraline ("Sertraline Hydrochloride Oral tablet")
paroxetine ("Paroxetine Hydrochloride Oral tablet")
Click on the "Consumer" "Report Type" option (near the bottom of the page) to make the report a little easier to understand.
Click on the "Run Report" button.
12. According to Clinical Pharmacology, are there any drug-drug interactions between sertraline or paroxetine and the other drugs Sarah is taking?
This question is part of the Canvas test on these tutorials. Either enter your answer to this question in the Canvas test now or record your answer so you can enter it in Canvas later.
If you'd like to install the mobile version of Clinical Pharmacology on your iPhone, iPad, or Android device; click the "Regsiter" link near the upper, right-hand corner of the Clinical Pharmacology" page. Follow the instructions to create your own personal account through the Library's Clinical Pharmacology license.
Use your device to go to the device app store. If you're using an iPad, select iPhone apps. Search for the "Clinical Pharmacology" OR "Elsevier Clinical Pharmacology" app. Download and install the free app framework. When you open the app you will be asked to login with the username and password you selected when you created your Clinical Pharmacology account.
If you have a Windows device, you can e-mail the library to request a code for the web-based,mobile version of CP for Windows device. (askus@unmc.edu). Please, mention that you have a Windows device so that we don't waste your time by encouraging you to use the installable version that is only available for iOS and Android devices.
You decide to treat Sarah with Sertraline. By the end of the second week on sertraline, Sarah begins to feel better, and she feels much better after four weeks of treatment.
The following optional questions cover the major points of this tutorial episode (These questions are not included in the Canvas quiz):
The resources listed below are all available through links on the Library's "Clinical Resources" page. Which of these resources is predominantly focused on diagnostic criteria for mental disorders?
Which button on the McGoogan Library homepage would you use to reach "Clinical Pharmacology."
Clinical Pharmacology offers tools to produce a variety of custom reports. If you want to know whether one drug will interfere with the metabolism of a second drug, which type of report would you run?
During this episode, you may have looked at:
The Diagnostic and Statistical Manual 5 (DSM 5), the 'bible' of psychiatric diagnosis. You can find a link to this book by clicking the "Clinical Resources" button on the Library's homepage.
You used:
Clinical Pharmacology's "drug interaction report" tool. You can find a link to Clinical Pharmacology by using the "Drug Resources" button on the Library's homepage.
The final, and very brief, episode is next.
You will hear about Emily's one-year check-up and take the post-test. No new resources are included in Episode 8.