A
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To
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h e a lt h
&
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M Ag A Z I N e
advanceS in
OB/G / yn WeSTcheSTer medical cenTer
5 TeSTS you need to know about The end of
amnio? girls and the
oB/gyn: how soon is too soon?
‘i beat
ovarian cancer’
no more
Bladder WorrieS WMC_ObG_Supp_0610REV2.indd 1
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c o n t e n ts
12
4 10
welcome l e tt e r
With this special supplement to our Westchester Health & Life magazine, I am pleased to introduce
advances in
OB/Gyn
Advanced OB/GYN Associates at Westchester Medical Center, our full-service obstetrics and gynecology practice serving women from adolescence through the senior years. Led by Howard Blanchette, M.D., our specialists and sub-
2W e lco m e
specialists incorporate the latest technology into customized
3 T ota l c a r e
obstetric and gynecologic challenges. As you will read in this issue,
for women
4 S a f e g ua r d i n g
women’s health
7 T h e t r e at m e n t o f
gynecologic cancers
10 M a n ag i n g t h e
high-risk pregnancy
12
bladder woes e as i n g
treatment options in order to help women deal with a wide variety of
we provide comprehensive services for women with gynecologic cancer, urologic problems and endocrinologic disorders, and we offer minimally invasive robotic surgery. We also help women dealing with infertility and pregnancy loss, and as the region’s only Perinatal Center, we provide special care that high-risk mothers and their babies require—some even before these infants are born. We also offer the full spectrum of general OB/GYN services. Thank you for your interest in Advanced OB/GYN Associates at Westchester Medical Center. For more information, please call the practice at 914-493-2250 or visit www.worldclassmedicine.com/OBGYN.
14 T e c h n o lo gy
you should know Michael D. Israel
Advances in OB/GYN is published by Wainscot Media, Montvale, NJ. © 2010.
President and CEO
All rights reserved.
Westchester Medical Center
advances in OB/Gyn
WMC_ObG_Supp_0610REV2.indd 2
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I f yo u ’ r e a f e m a l e a n yw h e r e
Coming soon, says Dr. Blanchette, also
from the teens to the senior years, an
a professor of OB/GYN at New York Medical
obstetrician/gynecologist can be your trusted
College, is a test of the mother’s blood that will
partner in maintaining a healthy, vital life.
determine from fetal cells swirling within her
Obstetrics focuses on the care of women
own cells whether the fetus has chromosomal
during pregnancy, childbirth and the six weeks
abnormalities. “This test will just about put an
afterward that are known as the postpartum
end to the need for amniocentesis to diagnose
period. Gynecology encompasses the
a chromosomal abnormality and enable a
prevention, diagnosis and treatment of problems
woman to discontinue a pregnancy if she
of the female reproductive system. Most OB/
chooses before the first trimester,” he says.
GYNs practice in both areas. At Advanced OB/GYN Associates, Westchester Medical Center has gathered a stellar group of general OB/GYNs and subspecialists in the fields of maternalfetal medicine, reproductive endocrinology and infertility, gynecologic ultrasound, urogynecology, gynecologic oncology, and pediatric and adolescent gynecology. As a Level IV Regional Perinatal Center and the hub
Howard Blanchette, M.D.
totalforcare women
of a network of affiliated hospitals and clinics encompassing seven counties in New York, the medical center offers specialized services on site in Valhalla and Hawthorne as well as at 13
If 25 years ago gynecologists hadn’t
teaching and community hospitals. Working
pioneered the use of slender abdominal scopes
together, these partners ensure that women in
called laparoscopes to diagnose and treat
the Hudson Valley and their newborn babies
gynecologic problems, today’s surgeons and
have access to services as advanced as those
urologists might not be using specialized fiber-
available anywhere else in the United States.
optic scopes to perform many minimally invasive
All of the full-time staff members of
procedures through pinpoint incisions. “OB/
Advanced OB/GYN Associates are also
GYNs pushed the envelope, using laparoscopes
faculty members at New York Medical College,
to remove cancerous organs, perform infertility
participating in independent and collaborative
treatments, repair vaginal prolapse and treat
research designed to improve healthcare for
incontinence,” says Dr. Blanchette.
women at all stages of their lives.
Westchester Medical Center’s da Vinci®
The OB/GYNs at Westchester Medical
robotic surgical system takes laparoscopic
Center continue a proud tradition of innovation
procedures to a higher level of precision,
that over the past 50 years has brought
providing gynecologists and other surgeons
sound-wave ultrasound technology from the
with exceptional visualization of the surgical
military into hospitals and imaging centers,
field, expert suturing and the ability to translate
where it is used to provide fetal images that
their own hand movements into the smoother
are breathtaking in their clarity, and to enable
movements of the robot’s three arms.
gynecologists to plan complex cancer surgery or perform intricate procedures.
“The da Vinci has been a breakthrough in gynecologic cancer surgery,” says Dr.
“At Westchester Medical Center, our
Blanchette. “To be able to tell a patient that she
OB/GYNs use two-, three-, and even four-
can go home after only one or two nights in the
dimensional ultrasound images to determine
hospital and be back to her regular activities
fetal age, screen for genetic abnormalities,
within one week is an amazing improvement
view the fetus’ anatomy, examine the condition
over the way things were a few years ago.
of the placenta and guide amniocentesis and
The next wave for us will be the ability to
other prenatal studies,” says Howard Blanchette,
personalize a woman’s treatment with novel
M.D., Director of Obstetrics and Gynecology
chemotherapeutic agents that target cancer
at Westchester Medical Center and head of its
cells and improve cure rates for ovarian and
Advanced OB/GYN Associates practice.
other gynecologic cancers.”
For more information about Ad va n ce d Ob/gy n A ss o c i ate s or to make an appointment, call 914-493-2250 or visit www.worldclassmedicine.com/OBGYN.
WMC_ObG_Supp_0610REV2.indd 3
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safeguarding women’s health
for moST young girlS, The firST physician who administers vaccinations and treats illness is a pediatrician or family practitioner. Unless there are concerns about irregular menstrual periods or medical problems affecting the reproductive system, most girls continue to see their primary care doctor past puberty. Today, pre-teen girls may
4
advances in OB/Gyn
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“tHe teenage yeaRs aRe an iDeal time FoR some giRls to Begin seeing an oB/gyn in aDDition to tHeiR peDiatRician oR Family pRactitioneR,” says moniQUe RegaRD, m.D. receive the Gardasil® vaccine at their
able to confide comfortably in your
pediatrician’s office to prevent future
OB/GYN is critical to your healthcare,
infection with human papillomavirus,
and that’s why it is best to establish that
which causes 70 percent of all cervical
relationship while you are young, before
cancers and 90 percent of all genital
you have any gynecologic problems or
warts. But in the late teen or young
become pregnant.”
adult years, most women begin to receive regular care from OB/GYNs
your yearly viSiT
who specialize in women’s healthcare.
Starting in young adulthood, an annual
Their education includes medical school
gynecologic checkup with your OB/
followed by a four-year residency, during
GYN should be a priority. This doctor
examine your breasts for lumps or other
which they are trained to diagnose and
will measure your weight, height and
abnormalities.
treat complex gynecologic problems,
blood pressure, and review your health
manage the care of healthy and at-risk
status and your family’s health history.
GYN will write you a prescription for
pregnant patients and perform surgery
He or she will perform a pelvic exam,
a mammogram, and if you are over
and other procedures that other primary
which consists of looking at and feeling
50, a prescription for a colonoscopy
care doctors don’t do. After residency,
your reproductive organs. You may also
to screen for colon cancer. Your OB/
they may choose to practice general
undergo a Pap test to screen for cervical
GYN will discuss and may prescribe
obstetrics and gynecology or specialize
cancer, an HPV test to screen for the
contraception. In your 30s or 40s, your
solely in either obstetrics or gynecology
human papillomavirus, an HIV test for
conversations may include a look ahead
independently. Other OB/GYNs continue
the human immunodeficiency virus that
toward menopause, and if you’re over
their training in two- to four-year
causes AIDS and a clinical breast exam to
monique regard, m.d.
michael Kessler, m.d.
If you are over age 40, your OB/
CONTINUED
fellowships in the subspecialties of gynecologic oncology, maternal-fetal medicine (perinatology), reproductive endocrinology and infertility, or urogynecology. eSTaBliShing a relaTionShip WiTh your oB/gyn “The teenage years are an ideal time for some girls to begin seeing an OB/GYN in addition to their pediatrician or family practitioner,” says Monique Regard, M.D., an attending pediatric OB/GYN at Maria Fareri Children’s Hospital at Westchester Medical Center and an assistant professor of clinical obstetrics and gynecology at New York Medical College. “The American College of Obstetricians and Gynecologists recommends that girls ages 13 to 15 consider coming in for an introductory visit with a gynecologist, just a meetand-greet with no pelvic exam,” she says. “By the time they are 16 to 19, we suggest they have private time with us, because they may already be sexually active. By age 19, young women should begin regular gynecologic well-care. Being
WMC_ObG_Supp_0610REV2.indd 5
gynecologic care for the y o U n g e s t g i R l s Though the typical oB/gyn treats female patients who are past puberty, a small minority see babies and children. most major children’s hospitals throughout the united States—including maria fareri children’s hospital at Westchester medical center—have a pediatric gynecologist on staff to care for girls from birth through the teen years. problems encountered by very young girls can include ovarian cysts, twisted ovaries, vaginal bleeding and labial adhesions, says monique regard, m.d., a pediatric gynecologist at the children’s hospital. many of these minor conditions usually can be treated with antibiotics or steroidal or estrogen creams. “in toddlers and children, we tend to see girls with vulvar rashes or vaginal discharge infections. vulvar rashes are often secondary to mild eczema on the outer skin, and vaginal discharge may be due to a little bacteria from the anus, especially in girls who are constipated,” says dr. regard. dr. regard’s pre-teen or young teenage patients tend to be brought in by their mothers for irregular, painful or absent menstrual periods; anatomic problems such as a vaginal blockage, or ovarian hormonal cysts or ovarian benign tumors. one of the most common reasons for irregular menstrual periods is polycystic ovary syndrome, which affects 1 in 15 girls and women in the united States. The ovaries of these patients make too much of the male hormone androgen, which impedes the development and release of eggs during ovulation. patients with polycystic ovary syndrome sometimes also make too much insulin, which can be a pre-diabetes condition. Treatment may include dietary modifications, anti-androgen medications, birth-control pills for those who do not wish to become pregnant, and insulin-lowering medication.
5/17/10 4:43:06 PM
Recommended cancer screenings for women Breast cancer: • Breast self-exam: Should be explained by OB/GYN, and each woman must decide, with her physician, whether to perform it regularly. and • Clinical breast exam: at least every three years in the 20s and 30s, every year after age 40 and • Mammogram: yearly after 40
Colorectal cancer: • Colonoscopy: every 10 years starting at 50 or • Fecal occult blood test or fecal immunochemical test: yearly after 50 or • Flexible sigmoidoscopy (to check lower end of colon): every five years starting at 50 or • Double-contrast barium enema: every five years starting at 50
Cervical cancer: • Pap test: beginning three years after vaginal intercourse but not later than age 21. Done every year with
a conventional Pap test or every two years with a liquid Pap test. After 30, if three consecutive Paps have been normal, can be done every three years. After 70, if three consecutive Paps have been normal and there have been no abnormal Paps in 10 years, can be stopped. If total hysterectomy was done for reasons other than cancer, Pap can be stopped—but if cervix is intact after surgery, follow other guidelines for continued Paps.
E ndometrial cancer: • At menopause, all women should be informed about the risks and symptoms of endometrial cancer and encouraged to report any bleeding or spotting to their OB/GYN.
Other cancers: • During a periodic checkup, all women should be examined for cancers of the thyroid, ovaries, lymph nodes, oral cavity and skin, and should be counseled about sun exposure, tobacco, diet and nutrition, sexual practices, and environmental and occupational exposures. Source: American Cancer Society
continued
safeguarding women’s health
preconception counseling,” adds Dr. Kessler. “The ideal time to discuss pregnancy is before it happens, so that a
50, menopause and osteoporosis risk are
sexually transmitted diseases, depression
woman can lose or gain weight if she is
important topics to discuss.
and cancer prevention,” says Michael
over- or underweight, control any chronic
Your yearly OB/GYN checkup is
Kessler, M.D., chief of the Division of
diseases she may have and treat any
also the time to discuss any gynecologic
General Obstetrics and Gynecology
gynecologic problems that can cause
problems you may be experiencing,
at Westchester Medical Center and an
infertility, such as endometriosis, uterine
such as irregular menstrual periods and
assistant professor of obstetrics and
fibroids or blocked fallopian tubes. When
abnormal vaginal bleeding, discharge
gynecology at New York Medical College.
a woman is ready to conceive or has
or irritation.
Dr. Kessler and four other Westchester
become pregnant, we begin prenatal
Medical Center OB/GYN generalists see
care in the first trimester and follow her
women’s healthcare, we also address
patients at the offices of Advanced OB/
through delivery, postpartum care at the
primary care issues such as tobacco use,
GYN Associates in Hawthorne, N.Y.
hospital, and at her six-week checkup
high blood pressure, diabetes, nutrition,
“We also spend time on
“In providing the full spectrum of
after the baby is born.”
To learn more about adult OB/GYN care at Westchester Medical Center, please call 914-493-2250, or call 1-877-WMC-DOCS stchester Medical Center to learn more about n ee co lo gy. You can also visit our website at www.worldclassmedicine.com. advances in p e d i atr i c gyW
OB/Gyn
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the treatment of
gynecologic cancers Each year, the five main cancers
available to patients in the Hudson Valley, thanks
that originate in women’s reproductive organs—
to the establishment of Westchester Medical
ovarian, cervical, uterine, vaginal and vulvar—are
Center’s Division of Gynecologic Oncology and
diagnosed in almost 82,000 American women and
Center for Robotic Gynecologic Surgery.
claim more than 28,000 lives. But many of these
The division and center are headed by Sean
cancers are highly treatable and even curable
S. Tedjarati, M.D., M.P.H., who devotes his clinical
given a comprehensive, expert, multidisciplinary
time exclusively to the medical center’s patients
preventive and treatment approach.
and is also an associate professor of obstetrics
Gynecologic oncology is the branch of
and gynecology at New York Medical College.
obstetrics/gynecology that treats these illnesses,
As he explains, most gynecologic cancers are
which together account for about 12 percent of
treated with a combination of surgery, radiation
all cancers in women. Fortunately, top-quality
therapy and chemotherapy.
comprehensive care in this key specialty is now
continued
advances in OB/Gyn
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A young woman’s c a n c e r t r e at m e n t Twenty-five-year-old Danielle Osorio of Suffern wanted to concentrate on what to do during her winter break from Rockland Community College. Instead, on December 28, 2009, the aspiring scientist underwent complex cancer surgery for stage I ovarian cancer at Westchester Medical Center. Sean S. Tedjarati, M.D., M.P.H., Chief of Gynecologic Oncology, removed her right ovary and a watermelon-sized tumor that was engulfing the ovary. To determine the extent (stage) of the cancer, he also took out her appendix, several lymph nodes and nodules and her omentum, a layer of fatty tissue that covers the abdominal organs like an apron. During the four-hour surgical procedure, an exploratory laparotomy, Dr. Tedjarati also removed tissue samples and abdominal fluid to be sent for pathological examination so that he could properly stage the cancer. Because of her age and desire to have children someday, he did not remove her left ovary, uterus or fallopian tubes, which did not show evidence of cancer.
A s n e a ky i l l n ess The tumor was discovered by Osorio’s gynecologist during a routine gynecologic checkup. As is often the case with ovarian cancer, Osorio did not experience any of the disease’s known symptoms, which include bloating, abdominal pain, a bloated feeling after eating, urinary urgency and/or frequency, back pain, constipation, fatigue and menstrual changes. The common nature of these symptoms is one reason ovarian cancer is rarely found early and causes about half of all deaths from gynecologic cancers each year in the United States. Though most women treated for stage I ovarian cancer are alive five years later, overall survival for women with all stages of the disease remains difficult because of the way it grows and spreads without warning. The challenge is that the majority are at risk of recurrence. “After recovering from the shock of hearing about the
continued
the treatment of
gynecologic cancers
In some cases of complex and advanced cancers, the surgery must
tumor, I went home, did my research, and called Dr. Tedjarati the next day,” says Osorio. “I felt comfortable with him right from the start.” Pathological samples revealed that Osorio’s tumor was an immature teratoma, an aggressive, malignant type of tumor made up of germ cells—cells found inside the ovary that normally develop into eggs. Less than 2 percent of all ovarian cancers are germ-cell cancers, which tend to occur in girls and young women. Dr. Tedjarati recommended three courses of combination intensive chemotherapy following surgery to reduce the risk of recurrence. Because she is young and may wish to have children someday, before her chemotherapy Osorio chose to undergo fertility preservation treatment by Kutluk Oktay, M.D., Westchester Medical Center’s Director of Reproductive Medicine, Infertility and Fertility Preservation, who works closely with Dr. Tedjarati. Dr. Oktay harvested five eggs from Osorio’s healthy ovary, inseminated them with donor sperm and then froze the resulting embryos in liquid nitrogen. With embryos preserved in this way, Osorio has an “insurance policy” against the possibility of becoming infertile from the effects of the chemotherapy on her remaining ovary and its eggs. In the future, she may choose to use one or more of the frozen embryos to become pregnant.
Forecast: b righ t “Danielle’s prognosis for cancer-free survival is very good,” says Dr. Tedjarati. “I expect that with continued diligent surveillance, she will continue to do well and lead a normal and productive life.” Osorio is looking forward to going back to college in the fall of 2010. She says selecting Dr. Tedjarati for her care was like choosing a wedding dress. “You know right away when you’ve found the perfect one. I trust him with my life.”
treatment that employs a minimally
endometrial (uterus), cervical and ovarian
invasive laparoscopic approach. In these
cancers. He sits at the da Vinci console
procedures, the surgeon uses small
near the patient in the operating room.
abdominal incisions and introduces
Using special instruments at a control
a thin scope with a tiny camera and
center, he manipulates the robotic arms
light attached and special instruments.
to complete complex operations with a
Laparoscopic surgery results in less pain,
precision and accuracy afforded by the
quicker recovery and a decreased risk of
unique feature of the robotic system
infection or other complications.
that mimics the full range of motion of
These days, Dr. Tedjarati is taking
human hands. The robotic system offers
be a traditional “open” procedure
laparoscopic surgery a step further by
superb three-dimensional visualization
requiring a large incision. But for a
using the da Vinci® Robotic Surgical
of the surgical site, precise suturing,
growing number of patients, Dr. Tedjarati
System to treat benign and malignant
fluid movements and exceptional
and his colleagues can offer surgical
gynecologic conditions—including early
maneuverability of the surgical
advances in OB/Gyn
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instruments. It allows for all the benefits of
can safely get through most treatments
reducing surgery.
minimally invasive surgery with the same
with adjustments and a comprehensive,
Counseling can
surgical outcomes.
compassionate, supportive team.
also help patients
The division has the mission of
cope with life
Radiation and chemotherapy
advancing clinical research to afford
issues that arise
“One of the things that drew me here
patients the benefit of the latest clinical
after their cancer
was the opportunity to develop a
trials and research to optimize their chances
treatment,
comprehensive, state-of-the-art multi-
of survival and improve quality of life.
including hair loss,
disciplinary center with experts such as
Dr. Tedjarati’s team also treats
Sean S. Tedjarati, M.D., M.P.H.
sexual and dietary
Chitti Moorthy, M.D., Chief of Radiation
gestational trophoblastic disease, a
Oncology, who has more than 30 years of
condition that arises out of an early
experience in treating gynecologic tumors
abnormal pregnancy in which a tumor
from patients and referring doctors has
with all types of radiation therapy,” says
develops in the cells and tissue that form
been outstanding,” says Dr. Tedjarati.
Dr. Tedjarati. Dr. Moorthy has helped make
the placenta, preventing the embryo from
“In the division’s first six months, we
Westchester Medical Center a regional
developing normally. If benign, the tumor
treated almost 170 women, performed
leader in the use of brachytherapy to treat
is generally called a molar pregnancy.
nearly 100 operations and opened a
advanced cervical and uterine cancers.
In rare cases, the tumor develops into a
state-of-the-art outpatient center. Our
malignancy that can invade the walls of
patients enjoy beautiful private rooms
“brachy” meaning “short-distance”) refers
the uterus or other organs. Trophoblastic
in the hospital. We are in the process of
to a therapy in which the radiation source
disease is usually treated with a dilatation
expanding our chemotherapy infusion
is placed inside or next to the tissue to be
and curettage, a scraping of the uterine
center. We have established our robotic
treated. At the medical center, templates
walls. In some cases of persistent disease,
gynecology surgery program and begun a
containing tiny rods are temporarily
chemotherapy or additional surgery may
da Vinci robot training program for other
placed directly within the tumor. Using
be required.
gynecologists at the medical center.
more cancer cells while minimizing
Caring counselors
comprehensive, state-of-the-art,
unnecessary radiation to surrounding
Some women may be at risk of
multidisciplinary center between New York
healthy organs. The choice to employ high-
developing related breast, ovarian or
City and Albany for treatment of all forms
or low-dose brachytherapy depends on
endometrial cancers because of genetic
of gynecologic cancers,” says Dr. Tedjarati.
the stage of the cancer and other clinical
susceptibility— they carry mutations
“We will offer counseling, prevention and
parameters.
in the BRCA1, BRCA2 or HNPCC genes.
treatment for women at risk for developing
For them, the Division of Gynecologic
gynecologic precancerous and cancerous
malignancies, Dr. Tedjarati uses
Oncology offers clinical counseling to
conditions, state-of-the-art surgical care
combinations of chemotherapy
help implement healthy lifestyle changes
including da Vinci robotic surgery, and a
medications and other agents that
or make decisions about undergoing
research program as well as programs of
“starve” tumors of their blood supply.
blood tests, genetic counseling or risk-
support for our patients and their families.”
“Brachytherapy” (from the Greek root
higher doses makes it possible to destroy
To treat advanced gynecologic
concerns and staying cancer-free. “The response to our program
“We aim to be the only
He is also treating patients with stages III and IV ovarian cancer who have
The 5 main g y n e c o l o g i c c a n c e r s
undergone surgery with intraperitoneal (IP) chemotherapy, which bathes the
Figures are for 2009, according to the National Cancer Insititute.
pelvic cavity with aggressive cancerfighting medications after malignant
Type
Number of new cases
Number of deaths
Uterine*
42,160
7,780
Ovarian
21,550
14,600
has been shown to significantly
Cervical
11,270
4,070
improve survival in those patients. IP
Vulvar
3,580
900
Vaginal
2,160
770
Other female genital cancers
1,095
373
TOTAL
81,815
28,493
tumors or organs have been removed. The combination of this treatment with standard intravenous chemotherapy
chemotherapy can have difficult side effects (including abdominal pain, nerve irritation and fatigue) that prompt many women to stop treatment before the full course is delivered. But it is an important tool in the armamentarium of
*includes endometrial cancer and other cancers of the uterus. Source: WWW.cancer.gov
ovarian cancer treatment and patients
To find out more about gynecologic oncology care at Westchester Medical Center, please call 914-493-2250 or visit www.worldclassmedicine.com/OBGYN.
WMC_ObG_Supp_0610REV2.indd 9
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managing the
high-risk pregnancy Most pregnant women continue
disease or kidney disease—or health
program, our maternal-fetal specialists do
to see their general OB/GYN for prenatal
problems that result from pregnancy, such
consultations for their regional colleagues
care throughout the entire nine months
as gestational diabetes or preeclampsia
in obstetrics and care for the highest-risk
and delivery. But a woman who has an
(toxemia), a potentially life-threatening
mothers and babies in a seven-county
underlying medical condition, or develops
type of high blood pressure.
region that includes 13 affiliate hospitals
a pregnancy complication affecting her
They also manage healthy mothers carrying multiple fetuses or those who
Smith, M.D., Chief of Perinatal Medicine
expert subspecialist treatment by a board-
have experienced prior preterm labor
and a professor of clinical obstetrics and
certified maternal-fetal medicine specialist.
or delivery, recurrent miscarriages or
gynecology at New York Medical College.
This physician, also called a perinatologist,
premature rupture of the membranes, in
has completed a three-year fellowship
which the amniotic sac has broken before
high-risk pregnancies at the medical center
in maternal-fetal medicine after medical
onset of labor. If the fetus is diagnosed
in 2009—most women with relatively
school and a four-year OB/GYN residency.
with a genetic or anatomic abnormality,
uncomplicated pregnancies don’t deliver
maternal-fetal medicine specialists can
there. “We believe that a birth close to
maternal-fetal medicine specialists care
oversee her care through to delivery or, in
home is best, so our doctors go on site to
for expectant mothers with prior medical
some cases, help the expectant mother
our partner hospitals to provide prenatal
conditions—for example, diabetes, heart
decide whether to continue the pregnancy,
care to mothers,” says Dr. Smith. “Most
At Westchester Medical Center, four
The physician can also coordinate
Edmund F. La Gamma, M.D.
10
within a two-hour radius,” says James
body or the fetus, may benefit from
James Smith, M.D.
About 1,000 babies were born from
of our mothers can have their babies
any specialized neonatal services, such
delivered by their local obstetricians at
as heart surgery, that the infant may
their community hospitals, where they are
require before or after birth. Maternal-
close to their homes, families and support
fetal medicine specialists also perform
systems. The others, who need higher-level
diagnostic sonograms and chorionic villus
care, come to Westchester Medical Center
sampling and amniocentesis to diagnose
when it’s time to deliver. The decision is
genetic abnormalities in the fetus. (See
based on the baby’s gestational age and
“Technology You Should Know,” page 14.)
the capabilities of the local hospital and
“As part of our regional perinatal
the medical staff.”
advances in OB/Gyn
WMC_ObG_Supp_0610REV2.indd 10
5/17/10 4:43:18 PM
and molecular biology at New York
Follow-Up Program, to monitor and provide
determined that her fetus will need
If a woman’s doctor has already
Medical College. “We pride ourselves on
medical and rehabilitative care for 80
advanced medical care at the center’s
a seamless integration of services. This
percent of all Regional NICU “graduates” at
40-bed Regional Neonatal Intensive Care
makes it easy to transfer babies back to
six clinics throughout the region.
Unit (RNICU), the mother usually comes
their community hospitals when they are
to Westchester when labor begins or the
ready and fully able to transition to step-
services, outreach education and public
time for a scheduled induction or Cesarean
down care in preparation for going home.
health initiatives, we have improved access
section nears. For newborns who need to
It’s better for the whole family if their baby
to high-level neonatal and perinatal
get to the Regional NICU promptly from
is closer to where the family lives during
services, improved survival rates for tiny
other hospitals, Westchester Medical Center
convalescence and growth, because some
preterm babies to 80 percent for those
has the only full-service, 24/7 helicopter
extremely premature neonates may require
weighing 750 grams [1.65 pounds], and
and ground high-risk neonatal transport
hospitalization for more than a month.”
lowered the occurrence of chronic lung
program between New York City and
Dr. La Gamma and his team work
“Through our regional healthcare
disease in our patients to 20 percent, while
Albany. It brings critically ill, very early
closely with neonatologist Jordan Kase,
the national average is 60 percent for the
preterm babies (some as early as 23 weeks’
M.D., Director of the High-Risk Neonatal
tiniest patients,” says Dr. La Gamma.
gestation) or low-birth weight babies (under 1,000 grams, about 2.2 pounds) to the medical center after they’re born. Specialized care at the RNICU The Regional NICU at Maria Fareri Children’s Hospital at Westchester Medical Center has board-certified neonatologists —pediatricians who have completed an additional three-year fellowship in intensive-care treatment of newborns—on site around the clock to care for these vulnerable babies. They and neonatologists who staff the NICUs and special care nurseries at nine affiliated hospitals provide coordinated clinical services based at the Regional NICU. The facility itself has 21 staff neonatologists plus 14 advanced training neonatal fellows, 12 nurse practitioners and more than 140 nurses. (See “The Highest Level of Perinatal Care,” at right.) Neonatologists from throughout the region rotate through the Regional NICU to ensure the highest level of coordination of the complex medical care provided to the most critically ill newborns. The Regional NICU treats about 720 babies each year—roughly 500 who are born at the medical center and 220 others who are transported there from other hospitals. “We see each affiliate hospital as a different room of our home Regional NICU,” says Edmund F. La Gamma, M.D., Director of the Division of Newborn Medicine, Director of the Regional NICU at Maria Fareri Children’s Hospital and
The highest level of p e r i n ata l c a r e To earn its Level IV designation, the Regional Neonatal Intensive Care Unit at Maria Fareri Children’s Hospital at Westchester Medical Center must provide comprehensive services that go beyond what is offered at community hospitals that provide obstetrical and newborn care, including: • a Neonatal Intensive Care Unit in a teaching hospital or academic medical center • consultations from maternal-fetal medicine specialists plus in utero procedures • maternal and neonatal technology that is the highest level available • maternal and neonatal transport services • methods to ensure top-notch quality of newborn care in its affiliated hospitals • a full range of pediatric subspecialty care, including cardiac and other pediatric surgical subspecialties, extracorporeal membrane oxygenation (ECMO) for babies whose hearts and lungs are not functioning, and “Cool Caps” to induce hypothermia in infants’ brains to inhibit or decrease permanent brain damage, with every form of ventilation support available • data collection and assessment, individual case presentations, educational training for physicians at affiliated hospitals and data collaboration with public health agencies • ongoing research into the mechanisms of perinatal diseases to develop ever-improved methods of rendering healthcare, including regional services and outreach programs
a professor of pediatrics, biochemistry
For more information about the care for high-risk pregnancies at Westchester Medical Center, please call 914-493-2250 or visit www.worldclassmedicine.com/OBGYN. To learn more about our Regional NICU and Perinatal Center, visit www.worldclassmedicine.com/RPC.
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high-risk pregnancy easing bladder woes Women with bladder-control
Center and an assistant professor of
Finding the cause
difficulties sometimes feel as if they’re
obstetrics and gynecology at New York
of the leakage
alone—but they’re not. Nearly 13 million
Medical College. “But almost all bladder
All patients who come to Dr. Zhou undergo
American women deal with incontinence
problems can be improved with lifestyle
a thorough evaluation, physical examination
(involuntary urine leakage from the
changes or the state-of-the-art treatment
and diagnostic testing, which may include
bladder) or other disorders of the pelvic
methods we offer here.”
a urinalysis and urine culture test to rule out
floor, which supports the bladder and
infection, a “urodynamic” test to monitor
reproductive organs. Their ranks include
focuses on the diagnosis and treatment
urination and a cystoscopy, an examination
twenty-somethings and even teens,
of problems that affect women’s urinary
of the bladder via a small scope and camera
as well as almost
and reproductive systems. Dr. Zhou is
inserted through the urethra, to check
50 percent of post-
one of only a few urogynecologists in the
for obstructions, tumors, polyps or other
menopausal women.
Hudson Valley. In the summer of 2010, a
irregularities. It’s critical to identify the type
second urogynecologist will join her at
of incontinence the woman experiences.
“Many women
Huan-Sue Zhou, M.D.
12
The subspecialty of urogynecology
Women who suffer from stress
believe they must simply
the medical center’s Advanced OB/GYN
accept incontinence
Associates. Besides an OB/GYN residency,
incontinence leak urine when they cough,
as a fact of life,” says
urogynecologists complete a two- or
laugh or sneeze or when pressure is
Huan-Sue Zhou, M.D.,
three-year fellowship in urogynecology
placed upon the bladder. That problem
a urogynecologist at
and pelvic reconstructive surgery (three,
results from tissue damage, and it can be
Westchester Medical
in Dr. Zhou’s case).
triggered by pregnancy and childbirth,
advances in OB/Gyn
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which may injure the tissues and muscles
are another option, but they need to be
that support the pelvic organs.
repeated periodically. Many patients choose
In urge incontinence, or “overactive
a minimally invasive procedure called sling
bladder,” a woman just can’t get to the
surgery, which can be performed vaginally
bathroom quickly enough—often despite
through one small incision under the urethra
frequent visits. It is caused by nerve difficulties.
and two tiny skin incisions at the ”bikini line”
Some medical conditions, including diabetes
or in the groin. A small band of mesh is placed
and neurological disease, may cause urge
under the urethra to support the urethra and
incontinence by weakening pelvic floor
prevent stress-related urine leakage.
muscles and damaging the surrounding nerves that control bladder function.
“This is essentially pain-free, because the minimally invasive techniques we use do not disrupt tissue,” says Dr. Zhou. “Most patients
Treating urge incontinence How incontinence is treated depends on its
go home the same day.” Sling surgery is effective in 90 percent
type. For urge incontinence, medications can
of patients, says Dr. Zhou. For others,
sometimes be effective. Tolterodine (brand
she recommends an “adjustable sling”
name Detrol) acts on bladder receptors, as
procedure (see “Relief From the Worries of
does solifenacin (Vesicare) and darifenacin
Incontinence” at right). In it, the mesh is held
(Enablex). The latter two are newer
by small arms that are connected to a dial,
medications that are bladder-specific and
buried under the skin on the patient’s lower
give relief to roughly 60 percent of patients.
abdomen. A day after surgery, the doctor
But it’s important to note that all medications
rotates this dial to adjust the tension of the
have side effects, some more than others.
sling as the patient stands up and coughs.
Tolterodine can cause cognitive problems,
“The bladder is a dynamic organ,” says
drowsiness and blurry vision, while solifenacin
Dr. Zhou. “We can’t simply make the sling as
and darifenacin may result in blurred vision,
tight as possible, because then the patient
constipation, dizziness and coughs.
cannot empty her bladder. The adjustable
Botox injections can also be used for treating urge incontinence. Injections are made into the bladder through the urethra;
sling procedure lets us adjust the tension of the sling to the patient’s individual needs.”
they work to paralyze tissue. (These treatments
Prolapse repairs—by robot
must be repeated every few months.) And
Dr. Zhou uses the da Vinci® robotic system
an implantable sacral neuromodulator
to repair uterine prolapse, in which the
device called InterStim® delivers electrical
uterus sags or drops into the vagina. The
impulses to the sacral nerve, which controls
robot’s fiber optics provide magnified three-
the bladder and muscles related to urinary
dimensional visualization of the surgical area,
function; an InterStim acts as a pacemaker to
and the robotic arm makes incisions, places
calm an overactive bladder.
sutures and reconstructs the supporting uterosacral ligaments. The prolapsed area
Treating stress incontinence
is pulled back into place and secured with
By the time they reach Dr. Zhou, many
tension-free mesh tapes, and mesh straps
women—working with their OB/GYNs or
reinforce the vaginal walls.
urologists—have tried lifestyle changes
Prolapses of the uterus and other
and nonmedical treatments to relieve
pelvic organs can cause urinary retention,
stress incontinence. These include limiting
constipation, abdominal and pelvic pressure
liquids, doing Kegel exercises to strengthen
and pain. Dr. Zhou repairs bladder, rectal and
the pelvic floor and using biofeedback
small-intestinal prolapses using minimally
techniques (which employ computer graphs
invasive laparoscopic techniques. Although
or lights to train the patient to alter muscle
most patients get general anesthesia, the use
responses) or bladder relaxation techniques
of local and epidural anesthesia is growing.
to control the urge to urinate. But these
Patients generally go home the same day.
methods take time and require discipline. Injections of collagen to bulk up the urethra and stop it from leaking urine
Relief from the worries of i n c o n t i n e n c e
Croton-on-Hudson resident Evelyn Reiter, 60, is even more excited than usual about her upcoming trip to visit her foster son in graduate school in Rochester, a six-hour car ride away. That’s because it’s the first time she will make that trip without having to worry about too-frequent bathroom stops along the way. For more than two decades, Reiter struggled with incontinence. She tried not to let it stop her from enjoying life, but disposable underwear was expensive and carrying a change of clothes at all times was a hassle—especially because Reiter is also blind. Collagen injections in the bladder and two “sling” surgeries failed to bring her bladder under control. But Reiter found relief after Westchester Medical Center urogynecologist HuanSue Zhou, M.D., performed a minimally invasive “adjustable sling” procedure. (Reiter learned about Dr. Zhou at a seminar about incontinence, hosted by Westchester Medical Center.) Through a small incision under Reiter’s urethra, the doctor placed a mesh sling beneath her pelvic bone to support her urethra. She also implanted a quarter-sized adjustment dial under her skin. Using this dial, Dr. Zhou adjusted the tension of the sling. For the first time in years, she was able to sleep through the night without wetting her clothing. The adjustment dial was removed in the morning, before Reiter left the hospital. Adjustable slings are often the answer when other methods fail, says Dr. Zhou.
“Soon we will be expanding our use of the robot to other urogynecologic procedures,” says Dr. Zhou.
For more information about u r o gy n e co lo gy at Westchester Medical Center, call 914-493-2250 or visit www.worldclassmedicine.com/OBGYN.
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tests your oB/gyn may order ct (comPUted tomoGraPhY) or caT (computed axial tomography) scan: a diagnostic test that combines a computer and X-rays passed through the body at different angles to produce cross-sectional images, or “slices,” of tissue. cT scans are used by oB/gyns to diagnose and plan cancer treatment and to evaluate pelvic pain.
cYstoscoPY: a diagnostic procedure in which a thin scope with a tiny camera and light is directed into the urethra and bladder to examine them, often used in patients with incontinence
hYsteroscoPY: a diagnostic procedure in which a thin scope with a tiny camera and light is used to view inside the uterus and then diagnose and/ or treat abnormal bleeding, tumors, cysts, fibroids, polyps or other problems within the uterine walls that may cause infertility
mri (maGnetic r e s o n a n c e imaGinG): a diagnostic procedure that employs a magnetic field and bursts of radio signals to produce cross-sectional images of the body. mris are used by oB/ gyns to diagnose infertility, fetal organ abnormalities, pelvic floor prolapses and gynecologic cancers.
technology you should know T h e r e Wa S a T i m e W h e n a n
expertise not available at other area
obstetrician assessed fetal development
hospitals, including radiologists who
relying on his hands, a special stethoscope
specialize in gynecologic imaging,” he adds.
sonoGram (or U lt r as o U n d) :
called a fetoscope and reports of whether
an imaging test that uses high-frequency sound waves bounced off internal structures to create two- or threedimensional views. Sonograms are employed by oB/gyns to evaluate fetal development, screen for fetal genetic abnormalities and guide these doctors during procedures such as amniocentesis and cancer surgery.
the baby was kicking. Today’s OB/GYN
ulTraSound STudi eS
can easily view the world inside the womb
ShoWcaSe feTal developmenT
using sonogram images created by high-
Two-dimensional sonograms in the first
frequency sound waves bounced off the
and second trimesters to evaluate the
fetus, placenta and uterine walls.
growth and development of a fetus are
At Westchester Medical Center,
now a “standard of care” for all pregnant
state-of-the-art ultrasound sonograms to
women, says Monica Brito, M.D., Director
evaluate fetal well-being are just one of
of Westchester Medical Center’s OB/GYN
several types of high-tech diagnostic and
Ultrasound Department and an associate
s o n o h Ys t e r o G r a m : a trans-
therapeutic equipment used in obstetrics
professor of obstetrics and gynecology at
vaginal ultrasound during which sterile saline water is used to dilate the uterine cavity so that the uterus and fallopian tubes can be examined for tumors, fibroids or polyps, or for injuries, blockages or abnormal structures that may be contributing to difficulty in conceiving
and gynecology. Magnetic resonance
New York Medical College. “There may be
imaging (MRI) and computed tomography
additional scans if the condition of the fetus
(CT) scans are also invaluable, says Zvi
or the mother’s health requires them.”
Lefkovitz, M.D., Director of Advanced
be screened by ultrasound for genetic
and professor of clinical radiology at New
abnormalities between eight and 11
York Medical College.
weeks’ gestation using two-dimensional
“We offer patients levels of radiologic
14
A fetus as small as a grain of rice can
Imaging and the Department of Radiology
sonograms and blood tests of the mother.
advances in OB/Gyn
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Dr. Brito, who completed a fellowship in
can drain pelvic abscesses
female pelvic ultrasound, uses three- and
and remove simple uterine
four-dimensional targeted transvaginal
cysts, fibroids and polyps. A
sonograms to perform complete head-
sonohysterogram, using an
to-bottom anatomic surveys of fetuses as
ultrasound probe inserted
early as 14 weeks’ gestation. Combined
into the vagina and sterile
with the mother’s age and blood tests,
water to dilate the uterine
an anatomic survey can determine if a
cavity, helps physicians
fetus is at high risk for Down syndrome,
evaluate the uterus and
Turner syndrome or other chromosomal
fallopian tubes. Ultrasound
abnormalities based on several
guides infertility specialists in performing
diScovering and TreaTing
“sonographic markers,” including:
ovarian tissue transplants, obtaining
gynecologic condiTionS
eggs from a woman’s ovaries and later
Three-dimensional CT scans, MRI studies
implanting them into the uterus following
and sonohysterograms can often take
in vitro fertilization.
the place of an exploratory laparotomy,
• extra fluid under the skin along the back of the neck (nuchal translucency) • the lack of a nasal bone
Stuart Bentley-hibbert, m.d., ph.d.
• a bright spot in the heart
monica Brito, m.d.
zvi lefkovitz, m.d.
a surgical procedure gynecologic deTecTing aBnormaliTieS
oncologists use to diagnose gynecologic
CT scans are almost never used to evaluate
cancers. Dr. Brito, Dr. Bentley-Hibbert
• short femur and humerus bones
a fetus because of potential damage from
and their colleagues work closely with
Dr. Brito’s expertise, found at very few
radiation, says Stuart Bentley-Hibbert, M.D.,
Westchester Medical Center’s Chief of
medical centers, helps pregnant patients
Ph.D., Director of Body MR Imaging at
Gynecologic Oncology and Director
and their OB/GYNs make early decisions
Westchester Medical Center.
of Robotic Gynecologic Surgery, Sean
• a “sandal gap” foot with a large space between the big toe and others
about treating a problem before or after birth or discontinuing a pregnancy.
“But fetal MRIs, which do not use
S. Tedjarati, M.D., in diagnosing and
radiation and have not been shown to
treating women with malignancies of
harm the fetus, produce very clear pictures
the uterus, endometrium, cervix, ovaries
right into an OR for heart surgery minutes
that show developmental brain defects,
and vagina.
after it is born,” says Dr. Brito.
kidney blockages and other anatomic
“At Westchester, we can whisk a baby
Dr. Brito and maternal-fetal medicine
“The detailed images produced by
abnormalities of the fetus as well as the
CT scans, MRIs and sonohysterograms
specialists also use ultrasound to guide
placement of the placenta,” he says. “Fetal
differentiate between benign and
them in obtaining genetic material for
MRI is an exciting, growing specialty, and
malignant tumors, describe the
chorionic villus sampling in the first
very few other facilities in the Hudson
extent of a malignancy and enable Dr.
trimester and for gathering amniotic fluid
Valley offer this capability. We are also the
Tedjarati to plan the surgery,” says Dr.
for amniocentesis in the second trimester.
only location in Westchester County to
Bentley-Hibbert. “And our 256-slice CT
offer dynamic pelvic floor imaging using
scanner is often the first line of defense
help doctors make sure that the fetus is
MRI technology to see in real time if a
in evaluating pelvic abscesses and
breathing, that its heart is not stressed,
woman’s pelvic organs are prolapsing.”
inflammatory diseases of the pelvis.”
In the third trimester, ultrasound can
that there is adequate amniotic fluid and that the placenta is still providing nutrients. Technology in inferTiliTy Infertility specialists and reproductive endocrinologists diagnose and treat infertility with a number of tests, including sonograms, MRI studies, hysteroscopies and sonohysterograms. MRIs can show in detail tumors or other masses in the uterus or ovaries. A hysteroscope, a slender instrument containing a tiny camera and light, can help OB/GYNs see inside the uterus to check for abnormal bleeding, structural problems of the uterine walls, blockages of the fallopian tubes, or fibroids and polyps. Special
the new W o m e n ’ s i m a g i n g c e n t e R Westchester medical center’s new 5,000-square-foot Women’s imaging center consolidates all diagnostic breast-care services and bone-density scanning technology into one convenient location. it features the most advanced screening and diagnostic technology available today; the expertise of radiologist Julian Sanchez, m.d., director of Breast imaging; and a highly trained team of registered mammography and ultrasound technologists. The Women’s imaging center’s services include: • low-dose digital mammograms • ultrasound-guided and stereotactic-guided breast biopsies • bone density scanning • breast sonograms (ultrasounds) • breast mris The Women’s imaging center is located at 19 Bradhurst avenue in hawthorne. for more information or to make an appointment, call 914-493-2500, ext. 310 or visit www.worldclassmedicine.com/imaging.”
instruments inserted into the hysteroscope
for more information about o B /gy n - r e l aT e d T e STS , call 914-493-2250 or visit www.worldclassmedicine.com/oBgyn.
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Our changes will change your life.
Sean S. Tedjarati, M.D., Chief, Gynecologic Oncology, Huan-Sue Zhou, M.D., Urogynecology, James F. Smith, M.D., Chief, Maternal-Fetal Medicine Sub-Specialists at Advanced OB/GYN Associates
When it comes to finding answers to gynecologic and obstetric issues, there is one place where women can turn for help for even the most complex, high-risk cases — the specialists and sub-specialists at Advanced OB/GYN Associates at Westchester Medical Center. Whether diagnosed with gynecologic cancer, experiencing urological disorders or facing other gynecologic illnesses, women find new hope in the compassionate care of our highly trained and specialized doctors, nurses and staff. We incorporate the latest technology into customized treatment options in order to help women overcome a wide variety of issues. And as the region’s only Perinatal Center, we can provide the special care that high-risk mothers and their babies require — some even before they are born. At Westchester Medical Center, we’ve created a place where women can count on exceptional specialty care when they need it most. Westchester Medical Center. One hospital, changing countless lives.
s7-#s$/#3 worldclassmedicine.com ADVANCED OB/GYN ASSOCIATES
Perinatology • gynecologic endocrinology and infertility Urogynecology • gynecologic oncology • general ob/gyn
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