I have been absent from this listserve for quite a while, but now have a very
complicated case that I want to make sure we are doing everything to
optimize breastfeeding, and I am hoping some of you wise ones will have some
ideas!
Mother is a 28 year old G3 now P1021, baby boy was born 6/4/09 by cesarean
section after a failed pitocin induction. Baby was born at 36 1/7 weeks.
Mother's history includes longstanding infertility due to classic PCOS with
impaired glucose tolerance prior to pregnancy (but not meeting criteria for
diagnosis of diabetes during pregnancy.) She had 2 previous spontaneous
miscarriages in the first trimester as well. This pregnancy was spontaneously
conceived, and mother received progesterone supplementation in the first
trimester due to history of previous miscarriages and family history of
progesterone insufficiency.
Pregnancy was complicated by gestational diabetes requiring insulin - on 120
units total of insulin a day at delivery, with relatively poor control. Mother
was extremely compliant with blood sugar testing, diet and insulin
administration, but had very high insulin requirement and sugars were resistant
to frequent increases in insulin dose. Pregnancy was also complicated by mild
pre-eclampsia, with induction of labor finally for worsening blood pressure and
pre-eclampsia symptoms (headache, visual changes and generalized swelling.)
Since delivery, mom's blood sugars have been much lower and she has not
required any insulin coverage, although she still appears to have impaired
fasting glucose.
Labor induction was started with cervical ripening with cervidil, which was
unsuccessful due to uterine hyperstimulation and fetal tachycardia. Then a
foley bulb catheter was used for mechanical cervical ripening, followed by
pitocin. Mother had received 24 hours of pitocin by the time of cesarean
section, and an epidural had been started approximately 2 1/2 hours prior to
delivery. She also received magnesium sulfate in labor, and a large amount of
IV fluids.
Infant was 3572 gms at birth (large for gestational age for 36 1/7 weeks) and
initially had some transient tachypnea of the newborn, but never required
oxygen or any other medical treatment. He was initially treated with constant
skin to skin with mother and close monitoring. He started breastfeeding within
the first hour of life, but initial would latch only briefly. Over the first 24 hours
of life he latched and sucked only briefly at the breast, but did go to breast
frequently and stayed with mom in between feedings as well except for brief
periods when care for mom was needed.
During the second day of life, the infant had several assymptomatic low blood
sugars (high 20s and low 30s) and was cup fed small amounts of formula.
Infant continued to be very sleepy at breast and would latch readily but fall
asleep almost immediately. Because of this and the low blood sugars, mother
was started with a supplemental nursing system around 48 hours of life. Once
the SNS was started, the infant was noted to be much more awake at the
breast and to suck vigorously for 10-20 minutes per feeding. He takes usually
10-15 ml from the supplementer per feeding.
Today (day 3 of life now) the baby's weight is 3257 gms (a 9% loss.) Also
today, he was noted to be jaundiced and had a bilirubin of 16.3, so
phototherapy was started. He is wetting adequate diapers (5 today) and
stooling (still passing meconium, with 2 small stools today) He is going to
breast every 2-3 hours (sometimes more frequently) and latching well and
sucking vigorously in the last 20 hours or so.
Mom's history is further complicated by a unilateral breast reduction in her late
teens. Her surgeon assured her she would have no trouble breastfeeding later
in life, but I don't know any other surgical details. Her sister had a bilateral
breast reduction with the same surgeon and fully breastfed her last infant (her
4th, but the only child she attempted breastfeeding with.) She did notice
some breast growth in during the pregnancy and can express drops of
colostrum from both sides. At present, she has no signs of mature milk
production. (Approximately 84 hours after delivery by cesarean.)
So. A lot of issues, obviously! I am wondering specifically with the history of
PCOS, gestational diabetes, and continued impaired glucose tolerance if
metformin would help her milk supply at all. Also, given the multiple potentially
confounding factors of premature infant, jaundice requiring phototherapy,
mother with complicated medical history and delivery by cesarean after a long
induction, delayed onset of mature milk production, and a unilateral breast
reduction if there is any more or anything different I can be doing to optimize
this dyad's breastfeeding relationship.
If you made it this far - thanks! I look forward to any suggestions any of you
have.
Jennifer Tieman
Parkview Family Practice
Streator, Illinois
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