Star wrote:
< 31-
year- old, gravida 1, para 1, lacta 1. Just underwent a modified radical
mastectomy. She is 35 weeks pregnant. She wants to breastfeed! The
surgeon
is talking about waiting on the radiation therapy for about 6 weeks
postpartum and no Chem at this point. The surgeon is open to the mom
breastfeeding on the unaffected breast but is concerned about the
pressure
of the milk coming in against the post surgical breast tissue and also
concerns about a milk fistula forming on the affected side.>
The first thought that comes to my mind is to discuss with the doc the
possibility of ice bags after delivery for 20-30 minutes q. 2 hours (or
at different intervals of his discretion if that would effect the healing
incision) round the clock for at least the first 96 hours, on the
surgical breast, to minimize the effect of circulatory expansion in that
breast as the uterine circulation involutes after delivery. Some sort of
mild binding of that breast might be considered too, especially if enough
lymph nodes were removed to precipitate any possible lymphedema.
Secondly, part of the swelling of engorgement comes from edema in the
connective tissue spaces, which I can see would strain the scar tissue.
Here are some references about the effect of crystalloid IV solutions
(such as Ringer's Lactate and others) on colloid osmotic pressure, which
is one of the main factors controlling the formation of edema.
Park GE, Hauch MA, Curlin F, Datta S, and Bader, AM, The effects of
Varying Volumes of Crystalloid Administration Before Cesarean Delivery on
Maternal Hemodynamics and Colloid Osmotic Pressure, Anesth Analg
1996;83:299-303.
Gonik BG, Cotton D, Spillman T, Abouleish E, and Zavisca F. Peripartum
colloid osmotic pressure changes: Effects of controled fluid management,
Am J Obstet Gynecol 1985;151:812-5.
Cotton D, Gonik B, Spillman T, and DormanKF, Intrapartum to postpartum
changes in colloid osmotic pressure, Am J. Obstet Gynecol 149:174, 1984.
So the way that the labor, anesthetic, and/or the C.section is managed as
far as IV fluids will have a great bearing on the edema component of
engorgement. Here's hoping that the amount of crystalloid IV fluids can
be kept to a minimum.
I do not understand physiology and biochemistry well enough to know other
effects of colloid IV solutions (such as albumen) on the kidneys, etc.
but they do help maintain the colloid osmotic pressure better than
crystalloid solutions. (That particular reference is not at hand at the
moment, but I will try to find it if the doctor thinks it helpful.)
Thirdly, considering the questions that have arisen about the existence
and nature of lactiferous sinuses due to the work of Donna Ramsey and
Peter Hartmann, could the pathologist be enlisted in thoroughly
investigating the lactiferous sinuses on the surgical specimen.
By 35 weeks, these are well expanded, IME. No doubt the necessary
incisions have allowed leakage of any colostrum already in them and the
ducts, but the shape and expansion of the sinuses at this stage might be
discerned with something like paraffin or dye, and give valuable
information.
Lactiferous sinuses are clearly demonstrable at the microscopic level,
but most other histological descriptions of lactiferous sinuses in the
literature I have read have been obtained from inactive (non-lactating)
breasts from autopsy specimens or surgical specimens for breast reduction
or breast disease. Such unfortunate situations as this provide the only
way to study directly the nature of lactiferous sinuses in the active
(lactogenesis I stage) reproductive stages.
Here's hoping that the good rapport you seem to have developed with the
surgeon will gain his cooperation in medical discussions with her
obstetrician and anesthesiologist before the onset of labor. Thus far,
this seems to be a shining example of collegiality at its finest.
Congratulations on your part, and I know you will continue to advocate
for good lactation management for the mother to make her experience with
the other breast a positive and fulfilling one.
Jean
*********
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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