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

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome