Denise wrote

>Cathy, Lisa and anyone else with an interest in breast physiology I'd
>appreciate your opinions on this.  A colleague of mine is currently
>assisting a mother with an initially poor milk supply to breastfeed her
>intrauterine growth retarded  2nd baby who was delivered early at around 37
>weeks due to failing growth.  This same scenario happened with her first
>baby and she was never able to achieve a full milk supply - though lots of
>mismanagement happened along the way with that one.  This time the mother
>reported that, unlike last time, she did notice some breast growth, but her
>milk 'came in' very slowly - no abundant oversupply at all.  She has very
>small breasts.  She received optimal breastfeeding management from the
>beginning this time and commenced taking domperidone at about 2 weeks and
>has plenty of milk now.
>We were discussing the possibility of placental insufficiency having an
>effect on breast development during pregnancy.  I know human placental
>lactogen is responsible for proliferation of the ducts and alveoli, and
>that in most women it happens early - first trimester;  but not all ...
>some it happens quite late.  What we were wondering was could a woman who
>is predestined to be a 'late' breast developer find she misses out
>altogether (pre-birth anyway) if she develops placental insufficiency.  Are
>human placental lactogen levels affected by placental insufficiency?  When
>doing blood tests on a woman who has a diagnosed IUGR do they check HPL
>levels?  Can anyone enlighten me more on this subject?

This is a really interesting observation, that I have to say has never
occurred to me, thankyou for asking such an interesting question

Serum concentration of human placental lactogen (HPL) parallels placental
weight; its levels rise in maternal serum until 37 weeks' gestation, then
remains constant or declines.

However the literature cites only 18% of intra uterine growth retarded
(IUGR) foetuses were detected by low HPL maternal serum levels so it does
not have a high predictive value for diagnosis of IUGR (there are obviously
many other factors that may be involved in causation of IUGR). There are I
think about ten predictors that can be used as diagnostic tests for IUGR but
HPL is not included due to its low predictive value.

However, HPL is highly associated with breast growth in pregnancy so if HPL
is low (as it is in some IUGR pregnancies) then we can expect breast growth
to be either minimal or in the lower range of normal. But we also know were
there is no significant breast growth in pregnancy, women (given the
appropriate stimulation) will have increased proliferation of breast tissue
in the post partum period and can achieve established lactation (if perhaps
a little later than the norm)

So for an IUGR infant whose pregnancy was associated with a low HPL there is
risk for delayed or failed initiation of lactation. Failure is likely to
occur if the IUGR infant is weak and doesn't suckle strongly enough, and
frequently enough, in the early post partum period to stimulate further
glandular tissue proliferation.

So Denise this is important that you have noted this because if this occurs
and we do not support early lactation (with expressing and encouraged
frequent feeds and perhaps galactogogues) then the mother may not establish
an adequate supply. The case histories you cite reflect this, as this mother
wasn't able to establish her supply with the first baby but with appropriate
management with the second baby she experienced greater success.

So we should be vigilant with small for gestational age infants and be
particularly careful to support these mothers in the establishment of their
lactation.

Warm regards
Cathy Fetherston CM MSc IBCLC
Perth, Western Australia

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