Tag Archives: obstetrics

Endometriosis Tissue Bank to Identify Key Biomarkers for the Disease

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.

Pathology slide of endometriosis and picture of an endometriosis lesion

Pathology slide of endometriosis, as well as an intra-operative picture of an endometriosis legion.

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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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Improving Quality of Care Using a Small Systems Approach

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

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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

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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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The First Baby Study: A Prospective, Longitudinal Investigation of the Relationship between Mode of First Delivery and Subsequent Fertility

First Baby Study Data

Data from retrospective study conducted 2000-2008 with reported deficits in childbearing subsequent to Cesarean delivery, prior to the First Baby Study. Cumulative percentage of women who had at least one further live birth over eight to nine years follow-up after first birth.1

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

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A Resident-Based Multi-Center Research Study of Women in Active Labor

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.

Jaimie Maines, M.D.

Jaimie Maines, M.D.

Mary Anne Carillo, M.D.

Mary Anne Carillo, M.D.

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When is Robotic Minimally Invasive Surgery the Approach of Choice?

RoboticSurgeryEquipmentA 42 year-old woman presents in the outpatient obstetrics and gynecology clinic with severe, uncontrolled pelvic pain, painful bowel movements, and constipation. The patient has a history of stage IV endometriosis and had conceived via in-vitro fertilization (IVF). The patient now desires definitive therapy; she has completed childbearing and she had unsuccessful medical management of her symptoms with oral contraceptives and a progestin IUD. Recent ultrasound revealed a large endometrioma in the right ovary. Colonoscopy results indicated deep endometriosis of the sigmoid colon.

Stephanie Estes, M.D., of Penn State Hershey Obstetrics and Gynecology says, “In complex cases like this, a minimally invasive surgical procedure using robotic technology in a single operation offers the best odds for success, both procedurally and with a good recovery. A gynecologic surgeon would begin with a hysterectomy, and then a colorectal surgeon would resect the affected portion of sigmoid colon en bloc, to complete the procedure.” Estes continues, “With the robotic surgical tools we use, there is definitely better dexterity and enhanced 3D visualization of tissue and organs, compared to an open abdominal approach. This minimally invasive approach is really key for complex cases with widespread pathology, to avoid injury to delicate surrounding tissues.” Continue reading

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Letrozole: New Oral Fertility Option for Women with Polycystic Ovary Syndrome (PCOS)

Letrozole: New Oral Fertility Option for Women with Polycystic Ovary Syndrome

Data were analyzed based on the intent-to-treat population. P values were calculated with the use of the chi-square test or Fisher’s exact test for categorical data.

In the Pregnancy in Polycystic Ovary Syndrome II (PPCOS II)¹ clinical trial, the aromatase inhibitor letrozole (Femara) demonstrated significantly greater rates of ovulation, conception, pregnancy, and live birth, compared with the selective estrogen receptor modulator clomiphene citrate (Clomid) when given for up to five menstrual cycles in women with PCOS (Figure). The main findings of PPCOS II were published in the New England Journal of Medicine last summer (2014).¹ The trial, initiated and led by Richard Legro, M.D., of Penn State Hershey Obstetrics and Gynecology, sought to identify and compare safer, more cost-effective, oral infertility treatments that could be used as first-line options for women with PCOS. Both treatments were fairly well tolerated; the most common adverse events were hot flushes (clomiphene), dizziness, and fatigue (letrozole). 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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