Category Archives: Clinical

TRUCLEAR 5C System Expands Office Hysteroscopy Treatment Options

Over the last several decades, significant progress in both technique and instrumentation has turned hysteroscopy into a common outpatient procedure for treatment, as well as diagnosis.1 Penn State Health Milton S. Hershey Medical Center has offered outpatient hysteroscopy for seven years, and recently acquired a more advanced type of instrumentation, the TRUCLEAR 5C System. The new system allows specialists to perform procedures in the office that would have previously required surgery, along with its associated risks. “This is a ‘see and treat’ model,” says Stephanie Estes, MD, director of robotic surgical services and associate professor, reproductive endocrinology and infertility. “With it, I can do full operative procedures in the office, not just small polypectomies and the removal of malpositioned IUDs, but also larger polypectomies and adhesion resections, as well as myomectomies.” Continue reading

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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

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Lynch Syndrome Screening is Routine in Women with New Endometrial Cancer Diagnosis, Regardless of Age

Kesterson-article

A representative picture of endometrial adenocarcinoma typically associated with HNPCC.

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

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Perinatal Program for Infants with Congenital Abnormalities

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

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Overcoming the Challenges to Preserving Fertility in Women with Cancer

Preserving Fertility in Women with CancerFertility 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

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Group Prenatal Care: Centering Pregnancy

Most pregnant women receive one-on-one prenatal care from their OB provider, but a group-care model has shown increasing promise and is becoming more widely available. Danielle Hazard, M.D., of Penn State Hershey Obstetrics and Gynecology, explains: “We offer a group prenatal care program called Centering Pregnancy. This model integrates three important components of care: health assessment, education, and support. During the group sessions, ten to twelve pregnant patients, all due around the same time, participate in a facilitated discussion focused on health-promoting behaviors, complete their standard physical health assessments, and develop a support network with other group members. The group discussions provide a dynamic environment for learning and sharing that is impossible to create in a one-on-one encounter.”

The group-centered care approach, developed by midwife and nurse, Sharon Schindler Rising in the 1990s, is currently supported by the nonprofit Centering Healthcare Institute (CHI), which trains physicians to implement standardized group-based prenatal care programs throughout the United States (centeringhealthcare.org).

Initiated at Penn State Hershey in 2009, the Centering Pregnancy program gained CHI site approval in 2011, and is among only six sites in Pennsylvania. Continue reading

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Fertility-Sparing Options for Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy in the United States. The incidence is increasing, including in premenopausal women.

According to Joshua Kesterson, M.D., a gynecologic oncologist with Penn State Hershey Obstetrics and Gynecology, “Such women may wish to consider fertility-sparing treatment options and avoid standard treatment, which consists of hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection.”

When considering fertility-sparing treatments, multiple factors must be considered, including the risk of an unstaged cancer, a coexisting cancer, an inherited genetic predisposition to cancer, and the lack of uniformity in medical management of endometrial cancer. When patients move forward with treatment, Kesterson stresses the importance of a thorough pre-treatment assessment, to decrease the chances of an undetected cancer.1

Endometrial Hyperplasia

Excess estrogen can lead to hyperplasia of the endometrium, a precursor to endometrial cancer, as seen here with back-to-back crowding of glands.

“I begin each case with dilation and curettage, as both a diagnostic step to confirm the low-grade nature of the tumor and a potential therapeutic benefit from removing the abnormal cells. I follow with an MRI to identify potential myometrial or cervical invasion or lymph node involvement. If there is evidence of grade 2 cancer or higher or metastatic spread, the patient is not an appropriate candidate for uterine preservation.”

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Pelvic Organ Prolapse (POP) Treatment is Not “One-Size-Fits-All

There are multiple surgical and nonsurgical approaches for treating pelvic organ prolapse (POP), and deciding which one best fits a given patient is often based on care provider preference and experience with certain techniques. With POP stages >2, marked by the vaginal wall protruding to varying degrees through the vaginal opening, many urogynecologists intervene surgically.

“In addition to conventional colporrhaphy, transvaginal mesh-based repairs had gained acceptance as a treatment option for POP over the last ten years, only to see the pendulum swing the other way secondary to fanfare surrounding postoperative complications,” explains Matthew Davies, M.D., of Penn State Hershey Obstetrics and Gynecology.

The Food and Drug Administration (FDA) issued a safety warning for mesh repair of POP, noting that mesh erosion is the most common complication, potentially requiring hospitalization and secondary re-operation.

“In addition to the risk for erosion, another complication seen with mesh-based repair is dyspareunia; unlike erosion or infection, dyspareunia may not resolve when the mesh is explanted and may be permanent. Because of these reported risks, many patients with POP are fearful and refuse to undergo a mesh-based repair,” says Davies. Continue reading

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Laparoscopic Cytoreduction for Primary Advanced Ovarian Cancer: A Strategy to Limit Morbidity and Maintain Patient Quality-of-Life

Ovarian cancer, occurring in approximately 25,000 women each year in the United States, frequently presents as advanced disease, with most cases at stages 3/4 at initial detection. Improvements in chemotherapy regimens and cytoreductive surgery have boosted five-year survival rate to about 40 percent. “On average, most of these patients will require two or three additional cytoreductive surgeries over five years, and right now most are managed with conventional open laparotomies,” explained James Fanning, D.O. of Penn State Hershey Gynecologic Oncology.

Minimally invasive laparoscopic surgery is one strategy Fanning and his colleagues are actively employing to reduce the complications and morbidity associated with repeated cytoreduction in their patients with advanced ovarian cancer. “Because a minimally invasive laparoscopic approach is well-proven to lead to less blood loss, postoperative pain, gastrointestinal complications, and adhesions, this type of procedure was evaluated for cytoreduction in patients with ovarian cancer.” In one report of outcomes among twenty-five patients with advanced stage 3/4 ovarian cancer, all of whom had evidence of omental metastasis and ascites, and in whom Fanning performed laparoscopic cytoreduction, disease outcomes were similar to those typically seen with open laparotomy.1 Continue reading

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