Timothy Deimling, M.D., Obstetrics and Gynecology, is in the final stages of obtaining institutional review board approval to launch a prospective database and tissue bank for endometriosis research. The primary purpose is to identify biomarkers for less invasive diagnosis, in addition to identifying targets for treatment of endometriosis. “Most women with pelvic pain and infertility obtain definitive diagnosis of endometriosis after a long history of problems; the delay in diagnosis is in large part due to the fact that it requires surgery,” notes Dr. Deimling. The tissue bank is being established according to guidelines set by the supporting World Endometriosis Research Foundation (WERF), and is planned to include multiple centers in the U.S. and internationally.
Routine Identification of Placental Umbilical Cord Insertion Location during Detailed Fetal Anatomic Ultrasound
Velamentous cord insertion (VCI) occurs more commonly in pregnancies involving twins, and in women who are older who have undergone in vitro fertilization (IVF) and who may be associated with a higher risk for fetal growth restriction. “With VCI, there is a higher risk for a poor birth outcome, such as pre-term delivery, low birth weight, vasa previa, thrombosis, fetal hypoxia and stillbirth [or perinatal death],” explains William Curtin, M.D., Obstetrics and Gynecology. “In addition, after a vaginal delivery, placentas with VCI are more likely to be retained, requiring manual removal of the placenta or even curettage resulting in postpartum hemorrhage. It is important for the delivering physician to have this information prior to the delivery as excessive traction on the umbilical cord to deliver the placenta may result in avulsion of the cord causing retention of the placenta in the uterus.” Continue reading
Lynch Syndrome Screening is Routine in Women with New Endometrial Cancer Diagnosis, Regardless of Age
Lynch syndrome, often called hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal dominant mutation affecting the mismatch repair system that leads to nearly 80 percent of affected individuals developing one or more types of cancer during their lifetime. In women, the most frequently observed cancers are colorectal, endometrial and ovarian. Two to 3 percent of all endometrial cancer cases are related to Lynch syndrome; Lynch syndrome-related cases of endometrial cancer emerge 10 to 15 years earlier than in sporadic cases.
According to Joshua Kesterson, M.D., Obstetrics and Gynecology, “Previously, we screened for Lynch syndrome by assessing personal and family history.” Penn State Health Milton S. Hershey Medical Center’s screening program is in line with the 2014 American College of Obstetricians and Gynecologists (ACOG) and Society of Gynecologic Oncologists (SGO) recommendations for Lynch syndrome screening.¹ Dr. Kesterson explains, “We are now transitioning to universal screening, where all women with newly diagnosed endometrial cancer are screened for Lynch syndrome.” As noted in the ACOG/SGO recommendations, this is the most sensitive approach for accurate detection of Lynch syndrome cases, with the least risk of false negatives.¹ Continue reading
At tertiary hospitals around the world, a team-centered systems approach has evolved to help physicians provide more evidence-based care to improve patient outcomes. A major challenge toward implementing systems change is the sheer size and scope of any such organization.
Using a unique alternative approach, Penn State Hershey Obstetrics and Gynecology has begun two quality initiatives. The first places the power to define and enact systematic changes to care within each of its six smaller subdivisions (see Text Box for initiatives overview), led by Matthew F. Davies, M.D., FACOG, chief of female pelvic medicine and reconstructive surgery, and vice chair of quality and patient safety. A key feature of the program focuses on small teams as drivers of change. Dr. Davies states, “I’ve been impressed by how many great ideas for change have come out of the small group approach; with a few people acting as drivers, there is very little bureaucratic inertia and teams can make changes to patient care in a relatively short period of time.” Dr. Davies and each quality team member gathers patient outcomes data to evaluate the impact of each quality initiative. The teams also define precise timelines for examining the impact of process. Continue reading
New Study Explores Pre-Treatment Lifestyle Modification for Obese Women with Unexplained Infertility
Obesity in women is associated with a negative impact on ovulation, delayed time to conception, increased pregnancy loss, and an increased risk of serious adverse maternal pregnancy and neonatal outcomes.1 A new randomized controlled trial recently began enrolling patients, aimed at evaluating the impact of two varying 16-week lifestyle modification interventions (see chart) on the frequency of healthy births (e.g., live birth at 37 or more weeks gestation with no major congenital anomaly, birth weight between 2500g to 4000g). To achieve a weight loss of approximately 7 percent of total body weight, the intensive intervention promotes increased physical activity combined with calorie restriction and a weight loss medication. The other standard intervention group promotes activity alone. Richard Legro, M.D., Penn State Hershey Obstetrics and Gynecology (lead study site), the lead investigator of this nationwide study explains, “Although the epidemiology of obesity and adverse fertility outcomes is well established, there is no evidence that losing weight or achieving fitness prior to pregnancy improves fertility. In fact, there are studies that show excessive weight loss or activity can harm the chances for pregnancy. We are doing this study to answer the question of what is safe and best for women seeking pregnancy.” Continue reading
Approximately one in 33 babies in the U.S. is born with a birth defect. Among the most common of these are atrioventricular septal defects, spina bifida, and intestinal atresia or stenosis.1 Many major defects are detected early in pregnancy during routine ultrasound imaging. “For women with a complex, high-risk pregnancy, a multidisciplinary team is usually needed to manage the needs of the mother and baby, throughout pregnancy, delivery and in the postpartum period,” explains Jaimey M. Pauli, M.D., a maternal-fetal medicine specialist, Penn State Hershey Obstetrics and Gynecology. Dr. Pauli and Thomas Chin, M.D., chief, pediatric cardiology, are co-directors of the Penn State Hershey Perinatal Program at Penn State Hershey Medical Center and the Children’s Hospital, an active outreach program for pregnant women at high risk or patients who have newborns with birth defects or abnormalities.
“Expectant parents are often overwhelmed when they learn about these types of serious fetal abnormalities. Aside from help coping with the obvious emotional impact, they need help obtaining the complex care their baby requires. With our program, a team of specialists handles everything and provides highly coordinated care at a single center, which reduces a lot of stress and supports the parents,” adds Dr. Pauli. Through the perinatal program, Drs. Pauli and Chin assemble a team of maternal-fetal medicine specialists and pediatric specialists. This team can include pediatric cardiologists, cardiothoracic surgeons, neonatologists, neurosurgeons, pediatric surgeons, nephrologists, urologists, orthopaedic surgeons, radiologists and social workers, based on the needs of each individual infant and aimed at achieving the best possible outcomes. Continue reading
Fertility preservation is now within reach for nearly all post-pubertal, premenopausal female cancer patients. In 2013, the American Society for Reproductive Medicine published a clear opinion, stating “Clinicians should inform patients…about options for fertility preservation and future reproduction prior to the initiation of [gonadotoxic therapies].”¹ Oocyte and embryo cryopreservation are considered non-experimental procedures, thanks to significant technological advances achieved in the past ten years. With this, insurance payer coverage for the procedures is available in many states. In others, like Pennsylvania, private charitable organizations are stepping forward. According to Stephanie Estes, M.D., of Penn State Hershey Obstetrics and Gynecology, “At Penn State Hershey Medical Center, Four Diamonds covers fertility costs for Penn State Hershey pediatric cancer patients younger than 22 years-old who qualify to benefit from Four Diamonds. This coverage includes harvesting of eggs or semen for future fertility use and the annual storage fees for cryopreserved eggs or semen until the childhood cancer patient reaches five years off treatment.” Continue reading
The First Baby Study: A Prospective, Longitudinal Investigation of the Relationship between Mode of First Delivery and Subsequent Fertility
While retrospective studies conducted in countries throughout the world have reported deficits in childbearing subsequent to Cesarean delivery (including a study conducted from 2000 to 2008,* see figure), the First Baby Study (FBS), conducted by researchers at Penn State Hershey Medical Center, is the first prospective interview study designed specifically to investigate the effect of Cesarean delivery on subsequent childbearing and understand why the post-Cesarean fertility deficit occurs. More than 3,000 women were interviewed during their third trimester, and again at one, six, twelve, eighteen, twenty-four, thirty and thirty-six months postpartum. These women delivered between 2009 and 2011 at seventy-six hospitals in Pennsylvania, and approximately one-third had a Cesarean delivery. The primary goal of the interviews was to measure factors related to subsequent childbearing – including marital and relationship issues, use of birth control, subsequent pregnancy intentions, unprotected intercourse over the three years of follow-up, and difficulty conceiving or carrying subsequent pregnancies. Continue reading
Dr. MILK® Supports Physician Moms, Recognizes Unique Challenges to Breastfeeding in the Health Care Work Place
The transition back to work can spell trouble for continued breastfeeding among physician moms.¹ In October 2014, Penn State Hershey Medical Center started one of only four United States’ chapters of Dr. MILK (Mothers Interested in Lactation Knowledge), a monthly support group for breastfeeding moms who are also physicians, mid-level providers, residents, or medical students.
Jointly led by two Penn State Hershey Obstetrics and Gynecology physicians, Nicole Hackman, M.D., and Sarah Louise Juza, M.D., the goal is to make breastfeeding a positive experience for these moms so they can promote it whole-heartedly with their own patients. Kerri Brackney, M.D., FACOG, who started and formerly led the program, points out, “There is very little formal medical education around breastfeeding. Most physicians know that breastfeeding is good for babies and moms. What they don’t realize is how physically and emotionally challenging breastfeeding can be. When physician moms choose to breastfeed, they have a unique opportunity to more effectively help their patients be successful too.” Continue reading
A group of investigators at Penn State Hershey Medical Center, including OB/GYN resident physicians as site investigators, have recently completed a multi-center clinical trial and published the results in the Journal of Maternal Fetal and Neonatal Medicine (March 2015). The objective of the study was to determine if the intrapartum use of a 5 percent glucose-containing intravenous solution decreases the chance of a Cesarean delivery for women presenting in active labor, under the theory that the glucose would provide adequate energy for the contracting uterus and prevent Cesarean delivery. Another objective was to bring together other Pennsylvania medical centers with obstetric residency training programs (Lehigh Valley Hospital, Reading Hospital, and St. Luke’s Hospital in Bethlehem) in this prospective and randomized study that analyzed 309 women. There was no significant difference in the Cesarean delivery rate for the glucose group (23/153 or 15 percent) versus the non-glucose group (18/156 or 11.5 percent). The authors concluded that the use of intravenous fluid containing 5 percent glucose does not lower the chance of Cesarean delivery for women admitted in active labor.
Jaimie Maines, M.D., former resident physician and soon-to-be faculty member in Penn State Hershey Women’s Health at the Medical Center, performed a key role in launching the study and co-authored the paper with Mary Anne Carrillo, M.D., a fourth-year resident in the department.