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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

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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

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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.

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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.

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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

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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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Advances in OB/GYN  

A supplement to Westchester Health & Life magazine

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