by Cynthia M. Schmidt, M.D., M.L.S.
Published December 2015
Updated September 2019
You should complete the first, second, and third episodes of this tutorial miniseries before beginning this fourth episode.
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Sarah Pilger is an obese, pregnant, 16 year-old whose LMP date and prenatal ultrasound suggest a current gestational age of 24.5 weeks. Fetal ultrasound shows asymmetric growth retardation and findings consistent with a fetal infection: placental thickening, ascites, and in the brain - mild ventriculmegaly and multiple small intraparenchymal calcifications.
Although Sarah is obese, you have learned that it is likely that she has actually lost weight during her pregnancy. She began a strict 900 - 1000 calorie/day diet and increased her physical activity level about a week after she must have become pregnant. She only returned to a more normal diet last week when she learned she was pregnant.
Sarah and Pat and Sarah's various healthcare providers are anxiously awaiting the results of Sarah's blood tests.
You decide you'd like to know which infections are most likely to cause ascites, mild ventriculmegaly and multiple small intraparenchymal, intracranial calcifications in a fetus.
1) UpToDate
2) AccessMedicine's Advanced Search (lower search box on "advanced search" page)
3) PubMed and other literature databases that index the journal literature.
As you just used UpToDate to answer questions about the implications of weight loss in obese pregnant patients, you might as well continue using UpToDate to answer this question.
Scroll to the top of the UpToDate page to find the search box at the upper left.
Search UpToDate for either --
fetal "intracranial calcifications" ventriculomegaly ascites
or
fetal AND "intracranial calcifications" AND ventriculomegaly AND ascites
As mentioned earlier, the quotes (" ... ") tell the search engine that you want the quote-enclosed words to be adjacent to each other and in the order specified.
UpToDate like most search engines, will handle a space between two search terms like an AND. In other words, it will require that both of the space-adjacent or AND-adjacent terms be present.
There are several articles in the list of results that may be of interest --- the "Congenital Cytomegalovirus" and "Congenital Toxoplasmosis" articles, for instance. However, right now just click on the article --
"Overview of TORCH infections"
You'll find that TORCH includes both toxoplasmosis ("T") and cytomegalovirus ("C") as well as other infections that might be of interest.
Hint: Use Control f (Windows users) or Command f (Mac users) to create a "find on page" box. Look for instances of the word calcification. If your "find on page" box has a "highlight all" option, use it.
According to this UpToDate article, what congenital infections might cause the intracranial calcifications seen in Sarah's baby?
Many students and faculty find UpToDate so valuable that they want to have access on their mobile devices.
The UpToDate app is available for your iPhone, iPad, and Android devices. It is free to you through the Nebraska Medicine license.
If you'd like to install the app:
If your screen is small, you will need to click on the "Menu" icon to find the "Register" link.
You will need web access to install and use the UpToDate app.
Every 1-3 months, you will receive an e-mail notice that your subscription is ending. When this happens, go to the Library's homepage-->Clinical Resources -->UpTodate--> Login with your UNMC Net ID if asked to do so. Click on the UpToDate "Login" link, if the login boxes don't appear by default, and sign in with your UpToDate username and password. This will renew your access.
On September 18th (the day after your appointment with Sarah), Pat, Sarah's mother, leaves a phone message. She says that Sarah's blood tests indicate that Sarah has a toxoplasmosis infection. Blood samples are being sent to a reference laboratory. Treatment will be started if this test indicates a recent infection.
Several days later you check Sarah's electronic medical record and see that the test results from the reference lab have been received.
Sarah has high anti-toxoplasmosis IgM levels and she has no detectable anti-toxoplasmosis IgG.
Do the lab results make sense to you? Would you be comfortable explaining the result to Sarah and her Mom? If not, we have good news! There is a great consumer-level website that explains the results of lab tests. It and many other, authoritative, consumer-level sources can be searched through the MedlinePlus search engine. Reading an article located through MedlinePlus can make reading unfamiliar, professional-level information easier. Also, MedlinPlus is a great source for information sheets that can be passed on to patients.
In the future,
Go straight to MedlinePlus.gov
Start at the Library's homepage
toxoplasmosis testing
A table explains the significance of the high levels of IgM and no detectable IgG anti-toxoplasmosis antibodies.
What do Sarah's high anti-toxoplasmosis IgM and undetectable anti-toxoplasmosis IgG indicate?
The following optional questions covers the major point of this tutorial episode:
Which of the following resources produced by the National Library of Medicine will be most helpful if you need a patient education handout?
Remember: UpToDate, AccessMedicine's advanced search, and PubMed have robust search engines that can handle searches that include multiple symptoms/signs.
http://list.unmc.edu/gots/tutorial/sb5n