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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Journal Clubs That Go Beyond Discussing the “Key Take-Aways,” Have Global Impact

If you’ve ever sat through a journal club meeting where the article headlines were just re-hashed, you’re not alone. Over time, journal clubs tend to get stale. Pitfalls, like choosing from a limited range of topics, and having only two or three people who are consistently willing to rotate leading discussions, are common.

Yet the need for clinicians to stay abreast of research, technical advancements, and controversial professional issues is a constant which can’t be fulfilled by attending annual meetings.

William C. Dodson, M.D., of Penn State Hershey Obstetrics and Gynecology, has taken on the challenge of making journal clubs a key part of ongoing, meaningful medical education worldwide. In 2009, as part of Dodson’s longtime leadership role with Obstetrics and Gynecology (i.e. the Green Journal), he and Cathy Spong, M.D., from the National Institutes of Health (NIH), began to create a monthly journal club feature aimed at enhancing the journal club experience (journals.lww.com/greenjournal). “Each month, for two articles from the current issue, we develop facilitator questions intended to lead club members to critically weigh the most salient points of each manuscript. It’s like providing a study guide for club facilitators, so even if they aren’t experts on a given topic or technique, they can lead discussion.” 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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Welcome to the OB/GYN Report

John T. Repke, M.D., F.A.C.O.G.

John T. Repke, M.D., F.A.C.O.G.

Greetings from Penn State Hershey! I am pleased to share with you the first issue of the OB/GYN Medical Report from the Department of Obstetrics and Gynecology of the Penn State College of Medicine and Penn State Milton S. Hershey Medical Center.

We recognize the importance of collaboration among our peer physicians, and regularly work with other academic medical schools to propel our field forward through new research discoveries, better patient care, and educating new physicians. Our hope is that this publication helps inform physicians like yourself of some of this important work, and that you find it to be a valuable resource.

In the coming year, this publication will feature Penn State Hershey clinicians and researchers who are helping to raise current standards of patient care and shape the future of OB/GYN practice. Our department features five divisions – General OB/GYN, Maternal-Fetal Medicine (MFM), Reproductive Endocrinology and Infertility (REI), Gynecologic Oncology, and Urogynecology/ Minimally Invasive Gynecologic Surgery. Continue reading

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Resident Training Program Emphasizes Minimally Invasive Hysterectomies: Achieving a New Standard of Patient Care

A residency training program that stresses minimally invasive hysterectomies is proving to be not only feasible, but a highly effective strategy for providing valuable surgeon training and improving patient outcomes. As leaders of Penn State Milton S. Hershey Medical Center’s Division of Urogynecology and Minimally Invasive Gynecologic Surgery, Gerald Harkins, M.D., and his colleague Matthew Davies, M.D., have closely tracked resident performance and patient outcomes. At the September 2013 Minimally Invasive Surgery Week and Endo Expo in Reston, VA, Harkins and his colleagues presented the first full twelve months of outcomes data from the training program. Among 537 patients who underwent hysterectomies for benign indications including abnormal bleeding, pelvic pain, fibroids, endometriosis, and prolapse/incontinence in a single year, 96 percent underwent minimally invasive surgery, either with vaginal or laparoscopic approach with a resident as the lead surgeon or the first assist, explained Harkins in an interview. Training new physicians and surgeons to provide up-to-date standards of care, including the use of minimally invasive techniques and robotic surgery, is a major challenge facing the health care field today. “Most physicians with established practices don’t have the necessary training in minimally invasive techniques, and so despite evidence that such techniques are safer and more cost-effective,1 60 percent of hysterectomies are still open procedures,” says Harkins. Recent nationwide OB/GYN residency training data suggest most U.S. trainees continue to lack needed minimally invasive surgical experience, with the average surgical resident completing sixty-four abdominal, eighteen vaginal, and twenty-three laparoscopic hysterectomies during training.2

Two physicians perfom minimally invasive surgery in a Penn State Hershey operating room.

Kristin Riley, M.D., fellow, assists Gerald Harkins, M.D. during minimally invasive gynecologic surgery. As part of its residency training program, residents act as lead surgeon or as first assist in 96 percent of the minimally invasive hysterectomy procedures at Penn State Milton S. Hershey Medical Center.

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Advancing Safer, More Cost-effective Fertility Treatment Options for Women with Polycystic Ovary Syndrome (PCOS) and Couples with Unexplained Infertility

For infertile women with polycystic ovary syndrome (PCOS) or couples with unexplained infertility who wish to become pregnant, fertility treatment is often expensive and invasive, and holds greater risks. Increasingly, couples are being advised to consider in vitro fertilization (IVF) as a front line treatment. “Even though we have effective strategies for inducing ovulation and achieving pregnancy in women with PCOS or unexplained infertility, going straight to IVF for infertility treatment results in high cost and in risky multiple gestation pregnancies,“ explains Richard Legro, M.D., Penn State Hershey Obstetrics and Gynecology. Multiple gestation pregnancies are associated with risks to the mother, as well as the infant, including preterm labor and delivery, infant morbidity, and ensuing financial and personal burden to the parents. Worldwide, rates of twin pregnancies have increased nearly 60 percent, and rates of higher-order multiple pregnancies have increased a staggering 400 percent since 1980, largely ascribed to infertility therapy, including injectable gonadotropins and IVF. Gonadotropin regimens are also associated with increased risk of ovarian hyperstimulation syndrome which can be life-threatening. 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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