An endocrine hypothesis to explain obesity-related lactation insufficiency in breastfeeding mothers.

In this Research Reflection I shall develop and validate the hypothesis that lactation insufficiency in obese breastfeeding mothers has an endocrine explanation. I shall not present data, but I shall review pertinent literature to show that obesity is associated with a partial or sometimes complete failure to initiate and maintain lactation, and critically examine the belief that this is due to psychosocial factors, a failure of prolactin secretion or both. Since progesterone is inhibitory to lactogenesis and oestrogens are inhibitory to milk secretion, I shall then explore the possibility that these steroids are linked to lactation failure, through sequestration of progesterone and aromatization of oestrogen in mammary adipose tissue. I shall conclude by describing experimental approaches in animal models that could be used to test this hypothesis.

Breast Pathology That Contributes to Dysfunction of Human Lactation: a Spotlight on Nipple Blebs.

Nipple blebs are blister-like fibrinous lesions that form on the surface of the nipple during lactation, and can result in orifice obstruction and mastitis. They likely result from superficial extension of underlying ductal plugging, and can present concurrently with hyperlactation and mammary dysbiosis. Despite their prevalence, few formal reports on nipple blebs exist. In this perspective, we review the experience of a breastfeeding medicine practice that receives referrals for patients with nipple blebs, and provide preliminary insight into etiology, management, and outcomes of these lesions.

Hypopituitarism presenting as congestive heart failure.

Sheehan's syndrome (SS) develops as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage and is characterized by various degrees of hypopituitarism. Although the occurrence of SS is now rare, it should still be considered in any woman with a history of peripartum hemorrhage who develops manifestations of pituitary hormone deficiency any time following the event. Appropriate hormone replacement therapy results in marked clinical improvement. We present an unusual case of SS in a young lady who continued to have normal menstruation after the index event, had two spontaneous pregnancies, and was diagnosed only 11 years later when she presented to us with acute heart failure.

[Complications of breastfeeding]. / Complications de l'allaitement. Son arrêt précoce est moins souvent l'effet d'un choix que de difficultés rencontrées.

Complications of breastfeeding. Complications of breastfeeding are the main causes of early termination. The identification and treatment of nipple pain is essential to ensure continued breastfeeding. Breast engorgement is a physiological event during lactation. Mastitis can be inflammatory or infectious and bacteriological culture of milk sample is needed to decide antibiotherapy and suspend breastfeeding. In case of proven infection, continuing drainage of the breast is indicated. Incision and drainage of breast abscess are the standard treatment. Past history of esthetic breast surgery or breast cancer does not contraindicate breastfeeding but are both risk factor of milk insufficiency.

Complications de l'allaitement. Les complications de l'allaitement maternel sont la principale cause de son arrêt précoce. L'identification et le traitement des pathologies du mamelon sont essentiels pour garantir le bon déroulement de l'allaitement maternel. L'engorgement mammaire est un événement physiologique au cours de la montée laiteuse. La mastite peut être inflammatoire ou infectieuse et un prélèvement bactériologique du lait est nécessaire pour décider une antibiothérapie et d'interrompre l'allaitement, en cas d'infection avérée, tout en poursuivant le drainage du sein par un tire-lait. L'incision et le drainage d'un abcès du sein sont le traitement de référence. L'allaitement des femmes ayant des antécédents de chirurgie esthétique des seins ou de cancer du sein n'est pas contre-indiqué mais peut constituer un facteur favorisant une insuffisance de lait.

A novel hook-shaped enhancement on contrast-enhanced sagittal magnetic resonance image in acute Sheehan's syndrome: a case report.

We report characteristic magnetic resonance (MR) image findings in a case of Sheehan's syndrome. A 37-year-old woman experienced complications of retained placenta and massive bleeding (3600 g) during delivery of a full-term baby. A pituitary function test demonstrated panhypopituitarism. MR image of the pituitary gland on postpartum day 10 revealed swelling of the anterior lobe. A hook-shaped enhancement was demonstrated on a sagittal image. The pituitary stalk, majority of the marginal zone of the anterior lobe, the anterior lobe just in front of the posterior lobe, and posterior lobe were well enhanced. In contrast, the central portion and the superior margin, just in front of the stalk insertion of the anterior lobe, were not enhanced. Anatomically, blood supply to these unenhanced portions of the anterior lobe was via the hypophyseal long portal vein and trabecular artery, which are tributaries of the superior hypophyseal artery that originate far from the internal carotid artery. Based on clinical history and MR image findings, the patient was diagnosed with Sheehan's syndrome and treated with hydrocortisone and levothyroxine. Follow-up MR image revealed marked atrophy of the anterior lobe. The characteristic hook-shaped enhancement in Sheehan's syndrome well reflected the vulnerability to massive bleeding based on the complex pituitary vasculature, which has not been reported previously. MR image with contrast enhancement is useful in the diagnosis of the acute phase of Sheehan's syndrome and in evaluating infarction of the anterior lobe.

Agalactorrhoea following reductive mastoplasty: a case of permanent impairment evaluation.

A woman of fertile age who had been suffering from agalactorrhoea since undergoing reductive mastoplasty was referred to us for forensic evaluation. As the impairment rating criteria listed within the main Italian assessment guidelines did not provide us with any helpful clues, we turned our attention to a selection of French, Spanish and Portuguese rating tables either legally binding or merely indicative in nature, to the barème (table) formulated by the CEREDOC (Confédération Européenne d'Experts en Evaluation et Réparation du Dommage Corporel) and to the American Medical Association guidelines, the only ones contemplating rating criteria specific for agalactorrhoea with an impairment score range of 0-5 percentage points. In light of the woman's young age and in subsequent consideration of the implications agalactorrhoea typically has both for nursing mothers and for their newborn babies, we estimated her physical impairment at five percentage points.

Septic disruption of lactiferous ducts with heterogeneous carcinoma of the breast in a lactating woman.

This report documents the diagnostic histopathological features of heterogeneous breast carcinoma following sepsis and disruption of the lactiferous ducts in a lactating woman and discusses the pathogenesis. Sections from the nipple revealed disrupted collecting lactiferous ducts presenting with intraduct precarcinoma and carcinoma of the epidermoid type, and attached reparative sprouts lined by lactiferous cells. Breast lobules showed generalised benign adenotic change with various foci of carcinoma microscopically identifiable as intraduct primitive lactiferal ectodermal carcinoma, lactating carcinoma, primitive neuroendocrine carcinoma and myoepithelioid granulomatous carcinoma. The findings led to the conclusion that the lactiferous ducts are susceptible to sepsis and disruption, which may predispose a patient to breast carcinoma. The pattern of carcinoma suggested that lactiferous epithelial cells behaved colonially, with different metaplastic changes, precarcinoma and carcinoma.

Discrepant cytologic and radiographic findings in adjacent galactocele and fibroadenoma: a case report.

BACKGROUND: Clinical, radiologic and pathologic evaluation of a breast mass during pregnancy and lactation often presents a challenge. We report a case of a longstanding benign breast mass that was negative on fine needle aspiration biopsy (FNAB) but sonographically appeared suspicious for carcinoma. CASE: A 41-year-old patient presented with a long-standing benign breast nodule that increased in size postpartum and became painful. The patient was breastfeeding when she developed mastitis in the surrounding area and was treated with antibiotics. The inflammation resolved, but the original mass persisted. FNA of the mass yielded thick, whitish material that on microscopic examination showed clusters of ductal cells with striking reactive, reparative and lactation changes admixed with amorphous material and crystals. The smear pattern was interpreted as negative. However, the sonogram revealed a solid lesion with mixed echogenicity suspicious for malignancy. The patient underwent lumpectomy, which showed concomitant fibroadenoma and galactocele. CONCLUSION: We suspect that in lactating patients preexisting breast masses may interfere with the milk flow, thus rendering the breast tissue around the mass prone to galactocele formation. This may result in erroneous clinical and radiologic impression of growth and transformation of a preexisting lesion.

Failure to lactate: a possible late effect of cranial radiation.

We conducted a retrospective review of the lactation experience of female survivors who received 24 Gy cranial radiotherapy as CNS prophylaxis for acute lymphoblastic leukemia in childhood prior to 1982 and who attend the Long-Term Follow-Up Clinic at Sydney Children's Hospital, Randwick, Australia. Median time since diagnosis is 28 years (range 25-37 years). Twelve have produced offspring. Ten report minimal or no breast changes during pregnancy and failure to lactate postpartum. All patients remain in remission. These data suggest a high risk of failure of lactation in women treated during childhood with 24 Gy cranial irradiation. Awareness of this possibility can assist in counseling.

Lactation complicated by overweight and obesity: supporting the mother and newborn.

Research shows that mothers who are obese (with a BMI >30) are less likely to initiate lactation, have delayed lactogenesis II, and are prone to early cessation of breastfeeding. Black women, with the highest rates of American obesity, have the lowest rates and shortest duration of breastfeeding compared to Hispanic and white women. Women who are overweight and obese have lowered prolactin responses to suckling. Women who are obese are at risk for prolonged labors, excessive labor stress, and cesarean birth, all of which delay lactogenesis II. Lactation has a small but significant role in preventing future obesity in the mother and child. Midwifery management of obesity-related lactation problems begins with education about optimal prenatal weight gain and regular weight assessment to avoid excessive gain. Support of physiologic birth processes to avoid stress, prolonged labor, and surgical birth and limit maternal-newborn separation enhances the onset of lactogenesis II. Massage or pumping may soften and extend the obese nipple for easier latch. Infants of lactating women with prior bariatric surgery are at risk for B12 deficiency and require regular nutrition and growth assessment. Five hundred calorie per day restriction paired with aerobic exercise for intentional postpartum weight loss does not affect milk quality or infant growth.

Impact of birthing practices on the breastfeeding dyad.

For breastfeeding to start and continue, the newborn must be able to suck, swallow, and breathe; the mother must be able and willing to let her infant breastfeed; and surroundings must support the biological unit: the mother-baby dyad. This article reviews how birth practices, including epidural anesthesia, cesarean surgery, forceps, and vacuum extraction, can affect the newborn's ability to feed, the mother's motivation and lactation capacity, and the mother-baby relationship.

The effects of breast augmentation surgery on future ability to lactate.

The majority of women receiving breast augmentation surgery do so at a time in their lives when both reproduction and lactation are common. It does not occur to most women to consider the possible effects breast augmentation surgery may have on their future ability to exclusively breast-feed their baby. Most women raise concerns about their inability to exclusively breast-feed years after surgery when they have a child. It is therefore important that women considering breast augmentation surgery be fully informed of the possible effects surgery may have on their future ability to lactate. The possible direct effects of surgery on the breast tissue and the complications of breast surgery on future ability to lactate are discussed. Surgical technique, i.e., implant type and placement, are also discussed. The types of incisions made into the breast tissue and the positioning of the implants once inside the breast parenchyma are analyzed and their possible effects on future ability to lactate are explored. Women who undergo breast augmentation surgery have a greater incidence of lactation insufficiency. Factors directly related to the surgical procedure as well as short- and long-term complications of surgery compromise future ability to exclusively breast-feed a baby. Factors directly related to surgery include severing of the lateral and medial branches of the fourth intercostal nerve or the nerve endings of the nipple-areolar complex, which, lead to reduced sensation and loss of the suckling reflex resulting in decreased milk production. Hematoma formation increases the risk of developing capsular contracture therefore necessitating the need for further surgical intervention. Infection also requires further intervention and as a result, further risk to the breast tissue. Long-term breast pain, capsular contracture, and pressure effects on the breast from the implant are all possible long-term complications that compromise a woman's future ability to lactate and exclusively breast-feed her baby. With good surgical technique and proper postoperative management, most of the complications associated with surgery that may result in insufficient milk production can be minimized but not always avoided. Compared with nonaugmented women, women who have had augmentation surgery have a higher incidence of lactation insufficiency.

A case of prolactin deficiency with familial puerperal alactogenesis accompanying impaired ACTH secretion.

We report here the case of a 34-year-old female with puerperal alactogenesis. Her menstrual cycle was regular and breast development normal. She had delivered a healthy boy but could not breast-feed after parturition. Endocrinological studies disclosed that the cause was a prolactin (PRL) deficiency. In addition, she showed accompanying impaired ACTH secretion that was believed to be triggered by encephalitis, although her plasma levels of GH, TSH, LH and FSH remained intact. Pituitary MRI showed no specific findings and anti-pituitary antibody tests were negative. Interestingly, both her mother and grandmother also reported puerperal alactogenesis. The sequences of all five exons of the PRL gene, including promoter region and transcription initiation point, were surveyed in order to examine for certain genetic disorders, but no mutations were identified. Although it cannot be definitively concluded that this PRL deficiency was not a genomic DNA disorder, in our case at least, her PRL gene was normal and, therefore, was not directly responsible for the patient's impaired PRL secretion. This evidence suggests that familial puerperal alactogenesis and PRL deficiency can be induced by other causes such as via disorders of unknown transcription factors or molecules that contribute to translation of PRL gene.