Breast problems after delivery and its management

Sunil Kumar Daha

Breast complications in puerperium

1. Breast engorgement

2. Cracked and retracted nipple

3. Mastitis

4. Breast abscess

5. Lactation failure

Breast EngorgementCommon in primiparous and patient with inelastic breasts

Onset: 3 to 5 days after delivery (if do not breast feed) exaggerated normal venous and lymphatic engorgement of breast which precede lactation

Prevents the escape of milk from lacteal system

SymptomsConsiderable pain and feeling of heaviness in both the breasts

Generalized malaise or even transient rise of temperature and

Painful breast feeding.

Prevention Avoid prelacteal feeds

Initiate breast feeding early and unrestricted

Exclusive breast feeding on demand,

Feeding in correct position

Treatment Support the breasts with a binder or brassiere

Manual expression of any remaining milk after each feed

To administer analgesics for pain

The baby should be put to the breast regularly at frequent intervals

In a severe case gentle use of a breast pump may be helpful.

Cracked nippleThe nipple may be painful due to:

Loss of surface epithelium Due to a fissure situated at tip or base of nipple or at both area

Causes:Poor hygiene formation of crust over the nippleRetracted nippleTrauma from baby’s mouth due to incorrect attachment to mother’s breastInfection with candida albicans and S. aureus

*Condition may be asymptomatic but becomes painful when the infant sucks the breast

Prophylaxis

Local cleanliness during pregnancy and puerperium, before and after each

breastfeeding to prevent crust formation in the nipple

Treatment

Latch on will provide immediate relief from pain and rapid healing

Purified lanonin with mother’s milk applied 3-4 times a day to hasten healing

*Fresh human milk and saliva have got healing properties

Treatment cotd…Miconazole lotion applied over nipple as well as in the baby’s mouth (if there

is oral thrush).

If fails to heal, rest is given to affected nipple using breast pump while the nipple heals.

*Biopsy is needed to exclude malignancy, if nipple ulcer persists in spite of above therapy

Retracted and flat nippleCommon in primigravidae

Babies can attach and are able to suck adequately

If unable to suck, manual expression of milk and fed

Acute Mastitisincidence:

2-5% in Lactating mothers

<1% in non-lactating mothers

Organisms involved:Staphylococcus aureus

Staphylococcus epidermidis

Viridans streptococci

Risk factorsPoor nursing

Maternal fatigue and cracked nipple

Types of mastitis (based upon site of infection)Infection in breast parenchymal tissue cellulitis

Infection in lactiferous ducts primary mammilary adenitis

Non-infective mastitis due to milk stasis

Clinical featuresSymptoms:Generalized malaise and headache, nausea, vomiting Fever (102°F or more) with chills Severe pain and tender swelling in one quadrant of the breast

Signs includetoxic featuresswelling on the breast The overlying skin- red, hot and flushed and feels tense and tender.

ManagementBreast support

Plenty of oral fluids

Continued breastfeeding in the unaffected side

Infected side manually emptied

Dicloxacillin is drug of choice 500 mg 6 hourly for 7 days

Erythromycin is alternative to the people allergic to penicillin

Analgesics for pain *Breast feeding maintains flow- prevents proliferation of staphylococcus in the stagnant milk

ProphylaxisHand wash before each feed

Clean nipple before and after each feed with mild soap

Keep nipple dry

Complicationsbreast abscess due to variable destruction of breast tissues

Breast AbscessClinical features

Flushed breast not responding to antibiotics promptly

Edema of overlying skin

Marked tenderness with fluctuation

Swinging temperature

Breast pain : due to engorgement, infection (Candida albicans)

nipple trauma, mastitis or occasionally with let down reflex

Management:

Surgical draining of abscess (Incision and drainage under general anesthesia)

Breast feeding is continued from uninvolved side

Infected breast is mechanically pumped every 2 hours and with every let down

Lactation failureInadequate milk production

Causes:

Infrequent suckling

Depression or anxiety state in puerperium

Reluctant or apprehension to nursing

Ill development of nipples

Painful breast lesions

Endogenous suppression of prolactin(retained placental bits)

Prolactin inhibition(pyridoxine, ergot preparation, diuretics)

Treatment guidelinesAntenatal

Counsel mother

Take care of breast abnormalities (retracted nipples)

Puerperium

Encourage adequate fluid intake

Nurse baby regularly

Treat painful local lesions

Selective dopamine antagonist (Metoclopramide 10mg TDS Po)

References

• Konar.H, DC Dutta’s Textbook of obstetrics 8th edition, Jaypee

publication

• Cunningham ,Bloom, Spong,Dashe,Hoffan,Casey,Sheffield,

Williams obstetrics,24th edition ,Mc Graw Hill education

Thank You