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Because of its focus on the female reproductive system and pregnancy, the Department of Obstetrics and Gynecology plays the largest single role in women’s health.
We are stewards of the normal pregnancy. The attending physicians, faculty and staff of NewYork-Presbyterian/Queens deliver approximately 4,000 infants a year. Mothers are seen for routine exams, consultation, and support in their physicians’ offices, referred to the hospital for tests, and deliver in comfortable, modern surroundings. “Patient education should start at the very beginning of the pregnancy,” says Wesner Thenor-Louis, M.D., director of OB/GYN medical student education, “from the first moment our patient comes into the office. Her physician is with her every step of the way to help her understand what to expect and to make choices, such as type of delivery and type of pain medication. “We do regular checks of the patient’s health and that of her fetus. Is it growing properly? Are there any signs of fetal anomalies? We offer childbirth classes, breastfeeding classes and sibling classes that teach older children what it means to have a new baby in the family. We also offer a tour of the facilities so the patient will feel comfortable when it comes time to deliver.”
Dr. Thenor-Louis says that his is a happy field. On occasion, however, there may be an emergency, such as massive bleeding, that requires quick thinking and many helping hands. Postpartum hemorrhage is an obstetrical emergency that can be fatal. In 2001, the hospital appointed a patient safety team to address the care of women with major obstetric hemorrhage. It included representatives from Anesthesiology, Maternal Fetal Medicine, Hematology and the Blood Bank, as well as the departments of Nursing, Communication, and Administration.
The group created “Team Blue,” a rapid response team using the cardiac arrest team as a model. It also developed rigorous protocols for the diagnosis, assessment, and management of patients at high risk for hemorrhage, involving members of the trauma team, as well as Anesthesiology, and OB/GYN clinical and ancillary personnel.
Infertility is defined as the inability to conceive despite having frequent unprotected intercourse for at least a year. As many as 10 to 15% of couples in the United States have experienced infertility. “I feel privileged to be working in this area,” says Tony Tsai, M.D., a reproductive endocrinologist and a specialist in assisted reproductive technologies. He helps to determine the cause of infertility and to suggest appropriate treatments to increase chances of conceiving.
Dr. Tsai cautions against assuming that in vitro fertilization will be the answer, pointing out that there are other options available. The reproductive process is a complex one, and the causes of infertility are many and varied, involving one or both partners. In about 20% of cases, the causes involve only the male; in 30 to 40% of cases, both partners; and in 40 to 50% of cases, only the female. In many instances, a specific cause will not be found.
A variety of tests can be performed to evaluate structural, hormonal and other issues that can affect a couple’s fertility. For men, the tests can include: a general physical exam, semen and sperm analysis, a blood test to determine the level of testosterone and other male hormones, and transrectal and scrotal ultrasound.
For women, they can include: a regular GYN exam; blood test to determine hormone levels; structural analysis of the uterus, fallopian tubes, and ovaries; an exam to check for endometriosis and scarring; ovarian reserve testing; genetic testing; and a pelvic ultrasound to look for uterine or fallopian tube disease.
Treatment includes a variety of surgeries, either through the abdomen or the vagina, to correct structural problems such as blockage of the fallopian tubes or other uterine anomalies. “We do it all,” says Dr. Tsai. He notes that NewYork-Presbyterian/Queens is one of the few hospitals in the metropolitan area to have a Yag laser and the da Vinci® Surgical System, which permit extremely precise minimally invasive surgery. Treatment also includes fertility drugs, for women who are infertile due to ovulation disorders, and in vitro fertilization. Before implantation, Dr. Tsai performs a single-cell genetic diagnosis of an embryo to screen for cystic fibrosis, Tay-Sachs, and sickle cell disease or other genetic defects.
“Genetic diagnosis is a topic of great current interest,” says Gary S. Eglinton, M.D., the chairman of Obstetrics & Gynecology. “Obstetricians have used ultrasound for many years, but the ability to diagnose in utero is difficult, and there are more than 4,000 known birth defects. If we can identify the genetic root of each of these, we can catalog them, study them, identify their causes, and ultimately improve the outcomes for newborns affected with those problems.” And if one is undergoing in vitro fertilization, how many embryos should be implanted? “The guidelines vary by age,” Dr. Tsai says. “They are aimed at limiting embryo transfer during IVF procedures in order to reduce the occurrence of multiple births. The guidelines recommend that no more than two embryos be transferred to women under 35 during a single cycle of IVF treatment. For women between 35 and 37, the number is up to three embryos, with up to four for women between 37 and 40, and no more than five for women over 40.” “If your age is a concern, or if you are facing chemotherapy, which can make you infertile, you can freeze your eggs to preserve their quality,” he advises.
“I think that being a mother and raising a child is the most difficult job in the world,” says Daniel W. Skupski, M.D., “and that’s why I’ve devoted my life to supporting mothers.” Dr. Skupski is associate chairman of Obstetrics and Gynecology and director of Maternal and Fetal Medicine at NewYork-Presbyterian/Queens. The woman facing a high-risk pregnancy is in very good hands with the maternal-fetal specialists at NewYork-Presbyterian/Queens.
A pregnancy can be deemed high risk when the woman or baby is more likely than usual to become ill or die. It is also high risk when complications before or after delivery are considered more likely to occur than usual. The maternal-fetal specialist assesses the risk factors and creates a treatment plan to manage the pregnancy for a successful outcome.
The causes of a high-risk pregnancy can be conditions the mother already has before becoming pregnant, such as high blood pressure, obesity, being younger than 20 or older than 40, or having diabetes or kidney disease. These risk factors can cause preeclampsia, a sudden increase in the mother’s blood pressure after the 20th week of pregnancy. Preeclampsia can affect the mother’s kidneys, liver and brain, and if left untreated, can be fatal for the mother and/or the baby.
Among other conditions that can develop during pregnancy are gestational diabetes and low blood pressure. If the mother has high blood sugar, the fetus can grow too big, leading to possible injury to either the mother or the fetus during birth. If the mother has low blood pressure, the fetus will not be getting enough nutrients or oxygen, which can lead to a stillbirth.
In some cases, women will be helped to modify existing risks before becoming pregnant. As the pregnancy progresses, the fetus is checked through blood tests and ultrasound. If these noninvasive methods suggest a problem, fluid may be withdrawn from the amniotic sac and chromosomes can be analyzed. The health of the fetus can also be checked by monitoring the fetal heart rate in the department’s antenatal testing unit.
Some problems can be prevented or corrected before birth, Dr. Skupski explains, in a program called fetal therapy. The most common, he says, is to give the mother steroid injections to speed up the development of fetal lungs and other organs for a fetus with threatened or impending premature delivery. One high-risk condition sometimes seen in mothers of twins or other multiples is TTTS, twin-to-twin transfusion syndrome. TTTS is a disease that strikes about 10% of identical twin pregnancies. It occurs when the fetuses share a single placenta containing randomly connected blood vessels. The result can be an uneven blood flow that threatens the survival of both fetuses, because blood is transferred disproportionately from one to the other. The donor twin will experience decreased blood volume, retarded growth and development, and a lower than normal level of amniotic fluid. The recipient twin will experience an increased blood volume, which can strain its heart and lead to heart failure, as well as an excess of amniotic fluid.
Treatment involves amniocentesis to drain the excess fluid in the recipient twin or laser surgery to disconnect the blood vessels. The laser surgery was developed by Julian E. De Lia, M.D., who was recognized by NewYork-Presbyterian/Queens as the 2010 recipient of its highest honor, the Pacesetter Award.