Obstetrics Simplified - Diaa M. EI-Mowafi

Breast Disorders in Puerperium

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Physiology of Lactation

• The sudden fall in oestrogen level after delivery is associated with reduction in the secretion of prolactin inhibiting factor from the hypothalamus and release of prolactin from the anterior pituitary.
• Prolactin is responsible for milk formation.
• Oxytocin released from the posterior pituitary due to suckling is responsible for milk ejection.

Breast Engorgement

Usually occurs in the 3rd day after delivery when secretion of milk begins.

Clinical picture

• Breasts are overdistended with visible dilated veins.
• Breasts are painful and tender.
• Pyrexia may develop.

Treatment

• Breast evacuation: in early stage baby suckling can be sufficient, but later on congestion press on the ducts preventing flow of milk so an electric breast pump is needed.
• Cold fomentations or one-two doses of bromocriptine (2.5 mg): may occasionally needed and there is no risk of suppressing lactation.
• Analgesics -antipyretics.

Deficient Lactation

Causes

• Constitutional.
• Bad general condition and malnutrition.
• Infrequent or irregular suckling.
• Sheehan’s syndrome.

Treatment

• Regular breast feeding.
• Good diet and plenty of fluids.

Cracked Nipples

Causes

• Lack of cleanness and dryness of the nipples.
• Vigorous suckling of a hungry baby in deficient lactating breasts.
• Leaving the baby too long at the breast.
• Repeated taking and leaving the nipple by the baby to breathe if its nose is obstructed by the breast.
• Monilial infection.

Treatment

• Rest: the baby should not put on the affected breast till healing occurs while it is emptied manually. Gradual going back to the breast is recommended to prevent recurrence.
• Hot fomentations.
• Panthenol ointment or flavine in liquid paraffin: applied locally.

Acute Mastitis

Causative organism

Staphylococcus aureus which may reach the breast from infected baby.

Clinical picture

• Breast is painful, tender, red, tense and hot.
• Axillary lymph nodes are enlarged.
• High fever may reach 40.5⁰C.

Treatment

• Proper treatment is indicated otherwise breast abscess will develop.
• Stop lactation: from the affected breast and breast is emptied manually or by an electric pump. When the acute phase is over breast feeding can be resumed.
• Support the breast: over a pad of cotton wall.
• Antibiotic therapy: A sample of milk is sent for culture and sensitivity then antibiotic started. Flucloxacillin 500 mg/6 hours is suitable.
• Analgesics - antipyretics.

Breast Abscess

Clinical picture

• A segment of the breast becomes painful and tender and fluctuation can be detected.
• The skin over it is oedematous.
• Fever and enlarged axillary lymph nodes.

Treatment

As soon as an abscess is formed it should be incised and drained under general anaesthesia. Do not wait for fluctuation as by that time breast disorganisation would occur.

Galactocele

• It is a retention cyst of a large mammary duct due to its obstruction.
• If it is persistent it is excised or aspirated.

Inhibition of Lactation

Indications

• Maternal:
  • Decompensated heart failure.
  • Active pulmonary tuberculosis.
  • Acquired immune deficiency syndrome (AIDS).
  • Acute illness as pneumonia.
• Foetal:
  • Cleft palate.      
  • Marked hare lip.     
  • Marked prematurity.
  • Death of the infant.

Methods

• Cold fomentations.
• Restriction of fluids and diuretics.
• Tight breast binders to prevent accumulation of milk.
• Dopamine agonists: starting as early as possible for 14 days;
  • Bromocriptine (Parlodel) 2.5mg twice daily.
  • Lysuride (Dopergin) 0.2 mg twice daily.
• Oestrogens: alone, with androgen or in contraceptive pills was used but they have the following disadvantages:
  • increase the risk of thrombo-embolic complications,
  • withdrawal bleeding usually occurs,
  • lactation may return again and
  • not effective if not started immediately after delivery.

Links

• Breastfeeding complications : Guidelines, reviews