Looking to the wise ones for some input on two cases. Mom's in both have
given permission to post.
 Mom 1: First baby. Mom developed a mass in the lower left breast about a
year before she became pregnant. It was ultrasounded and biopsied and the
diagnosis was "enlarged milk duct". During this pregnancy- lump became
larger and mom was reassured that the DX was unchanged.  2 days after
delivery, I saw mom and noted lump- 3-4cm x2-3cm, firm with fairly well
rounded boarders, starting at base of left nipple and extending under
areola to base of breast- slightly tender. Mom said lump was a little
firmer after delivery than prior but otherwise no change. As milk came in
lump became more tender and firmer. While babe was able to soften the rest
of the breast during nursing, this area only slightly softened and remained
too tender so I tried having mom gently massage and pump briefly after babe
nursed to see if it would soften further, which it did but slightly and no
reduction in size. Because this affects part of the areola and nipple, I
figured that babe may not be able to fully stimulate area to reduce this
but hand and mechanical pumping also did not make much improvement. While
mom's other caregivers at this time don't seem greatly concerned, I'm
hesitant to just drop this. The lump/mass distorts the shape of the breast
and if it is a enlarged milk duct that doesn't seem to fully drain, I worry
about abcess or mastitis formation......any ideas?
Mom 2:  First time mom,normal pregnancy. C-section for failure to progress.
Extreme engorgement during early postpartum lasting 3 days despite all
interventions and infant nursed well despite this. Followed weekly in
support group and noted slowing of weight gain by second week. Followed up
in office and noted despite good latch and easily expressed milk, babe only
recieved 15cc in 20 minutes nursing first breast and 5 cc nursing 10
minutes second. Normal infant oral anatomy. Had mom pump and with pumping
volumns remained same. Mom's breasts normal in size and appearence with
good tissue and nipples- no surgery,thyroid normal, etc.  Tried mom on a
course of fenugreek, noted sweet odor at 2 caps QID but no change in milk
production. Mom also mentioned she was still soaking 3-4 pads QD of per her
description" fresh blood". Got her an appointment with OB to evaluate. OB
NOT probreastfeeding, told mom that at (now) three weeks post c-section
soaking 3-4 pads was normal and in no way would influence lactogensis, told
mmom to stop taking fenugreek, placed her on mini pill and said her milk
supply was down because she was under stress from moving to new house.
When I called OB to discuss, was given same answer. When I asked about
starting minipill on mom with problems in lactation was told what we all
are told- it wouldn't cause any problems and that it didn't take much
clinical skill to see that mom was not lactating because of stress from
moving. When I asked OB if this was true and he felt she was under so much
stress that would compromise a healthy moms ability to normally lactate,
did he prescribe antianxiety meds or refer her for mental health support he
told me that was clinically not indicated and I needed to quit wasting his
time. (GROAN- don't you love days like this)  MOm does not feel like she
was under any exteme stress, except why she was having trouble making
enough milk for her baby. So- since I'm unable to countermand a physicians
order, I just gave mom the info on the minipill, started her on
reglan,cont. pumping, nursing,and unfortunately ABM supplements. Babe is
gaining weight but mom is unchanged in production. Was able to get thyroid
and HCT- all normal. Any ideas? Would appreciate the input.
Lisa Jones RN CLE IBCLC
Washington

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