Hi all:

I am working with a mother who has me stumped and she's given me permission to post. This mother is 29 y.o. primip who gave birth to B/G twins at 36 1/7 weeks in mid-July. She was on bed rest for preterm labor for 6-7 weeks prior to c-section (C/S) delivery and began pumping within hours of giving birth, although she did not have a hospital-grade pump until 12-24 hours post-birth. (Was using the PumpNStyle brought from home until then.) She rented a Medela Classic pump for home and used it with a Universal double collection kit with 30mm flanges, which she'd received prior to hospital discharge after being fitted. The 30s did appear to be an appropriate fit when watching her pump. Babies had difficulty feeding at breast and by bottle initially. (Will discuss this more later.)

History: Babies were conceived with the help of clomiphene but progesterone was not needed to maintain early pregnancy and she has no apparent history of PCOS, no gestational or other diabetic condition, etc. She's not sure if she's ever had thyroid hormone level tested. (Hopefully, that and a prolactin level are being done today, as she has an appointment with her doc this AM.) She had some breast development with pregnancy, although she said her breasts are normally large and she couldn't say exactly how much more they changed in size during pregnancy, but she says they definitely are larger since delivery and with pumping. This mom has no breast surgery or trauma history; at visual inspection both breasts appear to be within normal limits (WNL) re: size, shape, structure, etc. No overall or generalized stasis/engorgement apparent via palpation. 

I first saw her at 3 weeks postpartum to check pump operation. She had been pumping regularly 8-10 times per 24 hours since the first day, but was only getting a total of <20-30ml for each pumping -- usually 12-20 from L breast; 5-8 from R. She had a reddened area at 6 o'clock on EACH breast. I asked her to take her temp and it was 101F. Needless to say, dealing with bilateral mastitis became the first order of business. In the meantime, a check of pump pressure indicated suction was WNL for low to high suction levels. I watched a pumping session and everything appeared to be in order; however, MER was slow and no spraying ever occurred -- just a more steady dripping with some expressed milk having a "thickish" appearance.

She is now 4-5 weeks post-C/S. After a first week of antibiotics and several days of recording pumping sessions more thoroughly, we discussed galactogogue options (doc would not prescribe domperidone from compounding pharmacist), she got babies from level 3 (B) and level 2 (G) to slower flow level 1/newborn of a brand we tested as having a flow rate more compatible with BF oral behaviors, started some kangarooing, put one at atime to breast a couple of times a day using 20mm nipple shield -- but time management is an issue and G does better than her brother. Both babies have s/s reflux and they have been through formula changes and just started with Zantac. (When I mentioned deleting dairy from her diet, she audibly groaned -- not because she ingests that much but because it is one more thing on top of everything else not going right with BF.)

Last Monday she had to extend her pump rental and, after discussion, decided to try the Symphony to see if there was a difference. After several days, she said she was getting about the same amount when looking at 24 hour volume outcomes but she found it more comfortable. By Thursday PM she said she felt fuller than she had, but then she had difficulty getting milk -- she got less out of both breasts than before. By Friday AM she called and said both breasts were very uncomfortable. After applying cold for 20 min, followed by RPS, she obtained 50ml from the L breast but <5ml from the R. She continued to alternate cold, RPS and pumping, but still nothing more than <5ml from the R breast and little more from the L. (More was obtained from the L than the right, but 12ml was tops; the amount of the AM was not even close to being repeated.)

I saw her Friday late afternoon. She did not appear to be engorged nor did palpation indicate engorgement. However, she had an area of edema on her R areola from 12 to 2 o'clock behind the nipple tip; she said this area was incredibly tender. Also, a pinpoint whitened area was visible on the upper aspect of nipple tip at 1 o'clock consistent with the area of edema. The LOQ had some "ropey" feel to it -- not a classic plug feel as was slightly softer than a plug but as per one or more ducts involved. (Her temp was fine and no reddened area on the breast was visible.) Plugged nipple pore appearance had not been seen on prior visits. She applied a warm compress and "scraped" over the area with a clean fingernail before applying the pump; milk drops appeared then the area seemed to "reseal"; repeat of process resulted in some sort of "opening" but it did not last. 

During the pumping session, there appeared to be another area on the R nipple tip where a plugged pore seemed just below the surface. (Hope I'm expressing this clearly enough.) A couple of areas on the L tip seem similar. Needless to say, a recurrence of mastitis is of concern.

I'm wondering if she could have (and possibly has had since the get-go) plugged ducts close to the nipple, which have blocked milk drainage for a large amount of breast tissue emptying into those ducts. Thinking of Hartmann et al's research with revision of breast anatomy, I'm also wondering if she's a woman with fewer and/or narrowing "end" ducts, making her more susceptible? (Considering where the obvious/tender plugged pore was vs. the "ropey" feeling area of that breast, I'm wondering if I felt confirmation of these newer anatomy findings?) There's also something going on with her MER -- is it delayed or do plugged areas interfere with its ability to work? (She's going to ask her doc today about having a compounding pharm make up some syntocinon nasal/mucous membrane spray...)

As you can imagine, this MOT is at the end of her rope. I am in awe of the dedication this mother has because this has been a rocky road for several months now. She cannot continue like this much longer but she is willing to try almost anything if she can fit it in with care of two babies. (Her husband is a trouper but he had to return to work this week and is getting no sleep due to babies' reflux symptoms at night; her parents are there a lot but can't be with her 24/7.)

Many thanks for any insights, ideas, etc. I think I may have "bonded" too much this time so missing some forest for the trees. 

Karen G

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