Mastitis

/

Here’s the RoshReview Question of the Week:

A 30-year-old woman presents to the office with right-sided breast swelling and pain. She is 8 weeks postpartum from a spontaneous vaginal delivery of a term infant and is currently breastfeeding. She states her right breast is very painful, swollen, and red, and she has had a fever for the last 2 days. Which one of the following is the most appropriate next step for this patient?

Check your answer and get a special discount at the link above!

For more on breastfeeding, see our prior breastfeeding episodes (Part I and Part II) with Dr. Erin Cleary 

Before we get into mastitis… Breastfeeding is challenging!

  • There are many benefits to breastfeeding

    • Decrease in breast cancer, ovarian cancer, diabetes, HTN, heart disease 

    • Recommendation for breastfeeding for first 6 months of life or longer 

    • Benefits to the infant as well 

  • However in the US, as high as 45% of women report early, undesired weaning

    • Can be because of many things; nipple pain, perception of low milk supply, difficulty with latch

    • Other social factors, ie. limited access to maternity leave, barriers to breastfeeding in the workplace  

    • Depression, previous negative breastfeeding experiences 

  • Also, many things can occur in breastfeeding that can be a challenge 

What can look like mastitis? 

  • Engorgement

  • Physiologic breast fullness that often occurs between day 3-5 postpartum 

  • Typically reassuring sign that mature milk is being secreted 

  • However, can cause symptoms of distention, pain, tenderness, firmness and even fever (usually lower fever) - which can make it easy to confuse with mastitis 

  • Slightly swollen and tender lymph nodes 

  • Can sometimes be very pronounced and there should be anticipatory guidance 

  • Treatment:

    • Overall, data on prevention is limited

    • Can try acupuncture, hot and cold packs, cabbage leaves - but all from systematic reviews have found insufficient evidence to recommend a particular treatment regimen 

    • Can use milk expression to relieve some symptoms 

  • Persistent breast pain with feeding

    • Can be caused by many things  

      • Nipple damage from baby or with overuse/misuse of pump

        • Infant with tight lingual frenulum “tongue tie” - can get frenotomy or frenectomy 

        • Can help observe pumping session and adjust level of suction or fit of flange with lactation consultants  

      • Psoriasis, eczematous conditions - need to apply emollient and reduce identifiable triggers 

      • Candida infections - topical azole and antifungal ointment or cream are ok, or even oral fluconazole 

      • Herpes simplex or zoster - can be seen a small, clustered tender vesicles

        • Treatment with oral antiviral therapy 

        • Stop breastfeeding on that side temporarily 

  • Galactocele - milk retention cyst 

    • Usually just a collection of fluid that is caused by obstructed milk duct - usually soft cystic masses 

https://creogsovercoffee.com/notes/2019/6/16/breastfeeding-part-ii-facts-and-myth-busting

  • Infant’s chest rests against maternal body

  • Infant’s chin touches the breast, tongue is down 

  • Lips flanged outward

  • Little or no areola is visualized 

  • Rhythmic sucking present 

  • Audible swallowing present

  • Latch is not uncomfortable or painful and nipple is not injured or misshapen after breastfeeding  

What is mastitis? 

  • Defined as inflammation of the breast 

    • Can occur spontaneously, but today we’re talking just about mastitis in the context of breastfeeding 

  • Can occur in about 10% of patients who are breastfeeding 

    • Is especially problematic because it can lead to discontinuation of breastfeeding 

  • Risk factors:

    • Infant attachment issues - ie. short frenulum, cleft lip/palate

    • Cracked nipples, local milk stasis 

    • Missed feedings 

    • Poor maternal nutrition 

    • Previous mastitis 

    • Primiparity

    • Use of breast pump 

    • Yeast infection 

  • Diagnosis

    • Usually is made clinically 

    • Presentation usually is:

      • Localized, unilateral breast tenderness + erythema 

      • Fever - usually high! >101.0F (38.5C)

      • Can also have malaise, fatigue, body aches, headache 

      • Rarely will need to have culture to identify organism 

    •  On exam: will find redness, tenderness on one aspect of a breast (can be in different quadrants)

      • Be sure to examine for fluctuance - is there an abscess?  

    • When to get imaging:

      • If you suspect abscess on physical exam 

      • If symptoms are not improving despite medical management 

      • Usually can diagnose via ultrasonography  

  • Treatment

    • Breastfeeding technique

      • Lactation consultation to improve technique 

      • Counsel that patient should not stop breastfeeding or pumping on that side, as stopping can lead to milk stasis and more likely to develop abscess 

      • Can continue breastfeeding!  

      • Usually, the baby is already colonized by the same organism 

    •  Medical management

      • Antibiotics are usually needed for 10-14 days

      • Possible treatments include:

        • Augmentin 875 mg BID 

        • Keflex 500 mg 4x/day (hard to do 4x/day meds) 

        • Clindamycin 300 mg 4x/day - can be used against MRSA 

        • Dicloxacillin 500 mg 4x/day 

        • Bactrim DS (160mg/800 mg) BID - can be used against MRSA, but usually may want to avoid in patients with preterm infants 

  • When to refer

    • Abscess

      • Usually needs to be drained 

      • Can often be done at the bedside, and usually will not need to refer to breast surgery if you feel comfortable 

      • However, can depend on individual provider’s level of comfort  

    •  Abnormal presentation/lack of response to treatment

      • Most mastitis should resolve after initial treatment, and recurrence is not common, but can result from inappropriate or incomplete antibiotic therapy 

      • Most abscesses do not recur 

      • Inflammatory breast cancer can resemble mastitis at times, but may be differentiated by skin thickening as well as axillary lymphadenopathy 

Postpartum Care

/

Here’s the RoshReview Question of the Week:

A 23-year-old G1P1001 woman presents to the office for her routine postpartum visit. She is 6 weeks postpartum status post vaginal delivery of a healthy infant. Her pregnancy was complicated by diet-controlled gestational diabetes mellitus and obesity. She completes a 2-hour glucose tolerance test using a 75 g glucose load. Her fasting plasma glucose level is 85 mg/dL, and her 2-hour plasma glucose level is 130 mg/dL. Which of the following is the most likely diagnosis?

More Reading: ACOG Committee Opinion 736 from May 2018: Optimizing Postpartum Care 

Why Do We Care About PP Care? 

  • The days/weeks following birth are critical for patient and infant well-being 

    • Multiple physical, social, and psychological changes 

    • Recovery from delivery (either vaginal or cesarean) 

    • Challenges of breastfeeding

    • Lack of sleep, fatigue, pain, stress

    • New or exacerbation to mental health disorders 

    • Urinary or even anal incontinence 

  • Challenges 

    • Fragmented care between pediatric and obstetric care providers: 

      • As an example of what babies get: day 1-2 of life, day 3-5 of life, 1 month check up, 2 month, 4 month, 6 month, 9 month, and 12 month 

      • Just for well babies! 

      • If other complications, maybe more visits! 

    • Long time before we see our patients 

      • Usually, will see them at 4-6 weeks postpartum 

      • Initial lack of attention to maternal health needs - more than half of pregnancy related deaths occur after the birth of the infant! 

      • Instead of ongoing care, we have fragmented, one or two time visits 

A Call to Action 

  • Because of these issues, ACOG has wanted to increase awareness for the fourth trimester 

  • What we currently have - (FYI, this is me ranting about our current system because I’m a raging socialist. Feel free to chop as much as needed) 

    • 4-6 week visit x1 

    • Edinburgh postpartum depression screens to try and catch postpartum blues, but administered in the hospital and again at 4-6 weeks - can miss depression in the first month after birth

    • With COVID, often not letting family members or infants come to postpartum visits 

    • All pregnant patients receive health insurance through Medicaid, but this insurance stops at 6 weeks postpartum 

    • The US is also one of 7 countries in the entire world without paid maternity leave (WTF) 

    • On average, countries that provide paid maternity leave pay 77% of previous pay 

    • The UK has paid maternity leave minimum of 39 weeks. Most places have a minimum paid maternity leave of 12 weeks to a full year, and on average, globally, the paid maternity leave is 29 weeks. Average paternity leave is 16 weeks 

NY Times

  • What this results in

    • Less attendance of postpartum visits

      • Not wanting to use accrued family leave/sick days for appointments 

      • Unable to find someone to care for themselves/their infants to go to appointments 

      • Results in as many as 40% of patients don’t go to postpartum visits 

      • 23% of employed women return to work within 10 days postpartum, and an additional 22% return to work between 10-40 days pp!!!!! 

    • Less anticipatory guidance

      • With decreased time during pregnancy (due to covid) and also with not going to postpartum visits and not having PP visits soon enough → on a national survey, less than ½ of patients attending a PPV reported the received enough info about depression, birth spacing, healthy eating, importance of exercise, changes to their sexual response and emotions 

      • In randomized controlled trial, 15 minutes of anticipatory guidance before discharge, followed by phone call at 2 weeks reduced symptoms of depression and increased breastfeeding duration through 6 months among black and hispanic women  

    • More maternal morbidity and mortality 

  • What we want (and ACOG wants) 

    • Timing of postpartum visit be individualized and woman centered 

    • Initial assessment within 3 weeks postpartum to address acute issues 

    • Follow this up with ongoing care as needed - ie. well woman visit no later than 12 weeks after birth 

    • Insurance should allow for this care (don’t take it away after 6 weeks!)

      • American Rescue Plan Act - allows states to extend Medicaid coverage for pregnant people from 60 days to 1 year postpartum 

      • As of 4/2022: currently in effect for 13 states 

      • 14 states and DC planning to implement a 12 month extension 

      • 4 states with limited overage extension approved or proposed 

      • 4 states pending legislation to seek federal approval 

What should we be doing then for PP Care? 

  • Start early - begin anticipatory guidance even in prenatal care! 

    • Develop a postpartum care plan (Table 1 - can go through some of these things) 

    • Reproductive life planning 

      • Review desire for future pregnancies 

      • Counsel pregnancy spacing (avoid short interval pregnancy, within 6 months, and risks and benefits of pregnancy sooner than 18 months) 

      • Review contraception options if desired 

    • Build a support system 

      • Review: who will provide social and material support? Ie. family, friends

        • Can get social work involved if needed  

      • Identify providers that patient can call with questions

        • Primary care provider, Ob provider, psychiatry provider 

        • Pediatric provider 

        • Lactation support 

        • Care coordinator/case manager 

        • Home visitation 

        • Provide phone numbers or other contact information  

  • Intrapartum to Postpartum Care

    1. Early postpartum period contains substantial morbidity 

    2. Blood pressure evaluation no later than 7-10 days postpartum for those with hypertension

      1. Great studies regarding postpartum blood pressure checks via text message - easy for both patients and clinicians

      2. Decreases usage of emergency rooms 

      3. Those with severe hypertension should be seen within 72 hours!  

    3.  In person follow up earlier for patients with complications such as: 

      1. Cesarean section or perineal wound infection 

      2. Lactation difficulties 

      3. Chronic conditions like seizures that may require postpartum medication titration 

    4. WHO recommends follow up of all women and infant dyads at 3 days, 1-2 weeks, and 6 weeks - we don’t do this in the US! 

    5. Based off of this ACOG recommends first contact within 3 weeks (does not have to be in person, can be by phone) 

    6. Can set up postpartum care either in the prenatal period (we will usually make pp appointments for patients in the hospital or right before delivery) 

  • The components of postpartum care - these were really good from ACOG, so thought I would include 

    1. Mood and emotional well-being 

    2. Infant care

    3. Sexuality, contraception, birth spacing 

    4. Sleep/fatigue 

    5. Physical recovery 

    6. Chronic disease management 

    7. Health maintenance 

What about birth trauma? 

  • Remember that trauma is in the eye of the beholder

    • Many healthcare providers may not even be aware that their patient experienced trauma 

    • Allow patients to ask questions about their labor, childbirth course and review any complications 

    • Complications should be reviewed and how they can best be avoided in next pregnancy if possible (ie. reduce risk of preterm birth, preeclampsia)  

    • Referral to support group, mental health care specialist 

  • Pregnancy loss 

    • Remember to always review someone’s labor course and delivery!

      • May sound basic, but there are times when people miss a cesarean scar or even that someone had a pregnancy loss and congratulate the patient (omg)  

    • Emotional support and bereavement counseling with referrals if appropriate 

    • Review labs and path from loss 

    • Order other labs if needed (look at our stillbirth episode) 

Transition to ongoing care 

  • Refer to ongoing well woman care within 12 weeks 

  • Make sure that there is a good transition for birth control/continued prescriptions

    • Write this out in your notes/recommendations 

    • Many patients all of a sudden don’t have access to get their birth control because their obstetrician or midwife isn’t seeing them anymore 

    • Or, if their OB started them on an antidepressant, all of a sudden, they don’t get scripts anymore because they are not longer postpartum - make sure to help patients get appointments to their PCP or mental health care and transition them!  

Postpartum IUD Placement, with Dr. Sarah Prager

/

This week we are joined by Dr. Sarah Prager, a professor at the University of Washington in OB/GYN and Complex Family Planning. She shares with us some particular expertise in an ever-more common procedure - the postpartum IUD placement. There’s definitely a few pearls in the podcast that are worth listening for!

Definitions: 

  • Immediate postplacental insertion: within 10 minutes of placental extraction

  • Immediate postpartum insertion: 10 minutes to 48 hours after delivery

  • Delayed postpartum insertion: 48 hours to 6-8 weeks after delivery

  • Interval placement: IUD placement not related to recent delivery

  • Trans-cesarean insertion: IUD placed through the hysterotomy at the time of cesarean delivery

Exclusion criteria:

  • Chorioamnionitis/uterine infection

  • Prolonged rupture of membranes (18-24 hours)

  • Excessive postpartum bleeding that is unresolved

  • Extensive genital trauma that would be negatively impacted by IUD placement

Expulsion rates: 

  • 10% if placed in the first 10 minutes

  • Up to 25-30% if placed after 48 hours

  • Limited data on 10 minutes to 48 hours

    • Pilot study in Zambia showed 4% expulsion with “morning after delivery” IUD placement

  • Provider experience matters!

    • Study from 1985 showed providers cut their expulsion rates almost in half comparing the beginning to the end of the study

  • Take home message: don’t get discouraged! Your expulsion rate will decrease with experience!

Copper vs. LNG-IUD

  • Most older data is with various copper IUDs (primarily the Copper T 380A – ParaGard)

  • Some limited data with specifically Mirena brand LNG-IUD.

  • Recent data often pooled LNG-IUD, without separating different IUDs

  • Limited comparative data

    • Possibly higher expulsion rates with LNG-IUD than Copper IUD

    • Could be due to method used for insertion – inserter vs. no inserter

    • LNG-IUD inserters are long enough to reach the fundus of a PP uterus, ParaGard IUD inserters are not

    • There is a dedicated PP inserter for Copper IUD (longer, stiffer, but not available in USA at this time); unclear if it changes outcomes

  • Recent study out of Kaiser showed slightly lower expulsion rates for breastfeeding vs. non-breastfeeding people.

    • Largest study to date with mostly LNG-IUD

    • Expulsion rates:

      • 10.7% expulsion by 5 years with placement 0-3 days

      • 3.9% for 3 days to 6 weeks

      • 3.2%for 6-14 weeks postpartum

      • 4.9% for interval placement

Medical Eligibility Criteria:

  • CDC: category 1 or 2 at any time, regardless of type of IUD or breastfeeding status.

    • Of course, category 4 if uterus is infected

  • WHO: category more nuanced depending on type of IUD and timing of placement

Method of placement:

  • With the inserter

    • Need a long enough inserter

    • Often can use the LNG-IUD inserters

    • Also need the inserter to be stiff enough – sometimes doesn’t work with LNG-IUD inserters

    • Dedicated copper IUD inserter both longer and stiffer

  • With an instrument

    • Can use a ring forceps

    • Can use a Kelly placenta forceps (longer)

  • With your hand

    • No difference in expulsion seen compared with instrument

    • Personal bias – WAY more painful! No-one likes a hand in their uterus

      • Not reported in the early studies that compared this to using a ring

Clinical tips and tricks for successful insertion with an instrument:

  • Place a ring on the anterior lip of the cervix

  • Hold the IUD gently in a ring forceps (don’t click down if LNG-IUD – don’t want to disrupt the LNG delivery system!)

  • Know the orientation of the IUD with respect to the orientation of the ring handles to make sure you place IUD with the proper orientation in the uterus!!!

  • Once the IUD is in the lower uterine segment, gently let go of the ring on the cervix and place the non-dominant hand on the uterine fundus

  • Drop your wrist! Drop your shoulder! Aim for the fundal hand

    • Angle different from interval insertions – basically aim for the umiblicus

    • Will not go wrong if you aim for the fundus! Feel it with your fundal hand!

  • Let go of the IUD and gently remove the ring without pulling on the IUD or strings

  • If strings are visible, cut at the os

    • Can also pre-cut the strings of LNG-IUDs so they are about 10 cm

    • Cutting strings can sometimes pull the IUD lower or out

  • Can use ultrasound if you want!

If using an inserter: 

  • Pre-deploy the IUD – you do not need the narrow profile with an open cervix!

  • Personal bias – don’t use the inserter

If using your hand:

  • Change your gloves

  • Precut the strings

  • Hold between the index and middle fingers with the strings laying across your palm

  • Make sure you don’t pull it out when you remove your hand!

If trans-cesarean placement:

  • Close 1/3 – ½ the hysterotomy then place

  • Precut the strings shorter before directing down into the cervix

  • Personal bias again toward instrument placement, but usually hand and inserter also work fine

Follow-up care:

  • See patients at 1-2 weeks postpartum and trim strings as needed.

    • May need to do this again at 6-week visit

  • If strings not visible at follow-up, do an ultrasound to verify presence of IUD in the uterus

    • If IUD there, NO NEED FOR ROUTINE ULTRASOUND TO CHECK CONTINUED PRESENCE OF THE IUD

    • Counsel patient that efficacy unchanged, but removal may be more complicated if strings don’t emerge from the cervix

      • This should have been a counseling point during consent!

Perinatal Depression

/

Depression is a major health disorder affecting around 10% of women, particularly in the perinatal and postpartum periods. Depression is twice as common in women as in men, and OB/GYNs should be familiar with its diagnosis and management, particularly in the perinatal period. You can read more with ACOG CO 757.

There are many different types of depression diagnoses, including: major depressive disorder, persistent depressive disorder, seasonal affective disorder, perinatal (postpartum) depression, premenstrual dysphoric disorder (PMDD), etc. According to the DSM-V, a major depressive episode is diagnosed when one has: 

  • Five (or more) of the following symptoms have been present for a 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest/pleasure. 

  • Symptoms cannot be explained by medications or another medical illness (i.e., hypothyroidism).

  • The remaining (need 4+ from this list):

    • Depressed most of the day, nearly every day as indicated by subjective report or observation made by others;

    • Diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day;

    • Significant weight loss when not dieting or weight gain, or increase/decrease in appetite nearly every day;

    • Insomnia or hypersomnia;

    • Psychomotor agitation or retardation; 

    • Fatigue or loss of energy;

    • Feelings of worthlessness or inappropriate guilt;

    • Decreased ability to think/concentrate;

    • Recurrent thoughts of death/suicidal ideation.

Perinatal depression is defined separately as major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery. This is one of the most common medical complications during pregnancy and the postpartum period, affecting 1/7 women. 

Depression and other mood disorders can have devastating effects on women and their families: maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality 

SO how do we screen for perinatal depression? ACOG recommends that obstetric care providers screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized tool, and again in the postpartum period during a comprehensive postpartum visit. There is evidence that screening alone can have clinical benefits for patients suffering with depression.

One of the most commonly used is the Edinburgh Postnatal Depression Screen, which is a 10 item survey that takes less than 5 minutes to complete. The sensitivity is estimated between: 59-100%, and specificity: 49-100%. A Spanish version is available.

The Patient Health Questionnaire 9 (PHQ-9) is another acceptable tool. Other items like the Postpartum Depression Screening Scale (PDSS) is more sensitive (91-94%) and specific (72-98%), but it is a 35 item survey and thus more time intensive.

Management of perinatal depression is a team sport, requiring multiple additional support members and medical team members. Medication prescription will vary for OB/GYNs and their comfort with this. In brief:

  • Women with current depression/anxiety or a history of perinatal mood disorder should have close monitoring, evaluation, and assessment.

  • Some OB/GYNs are comfortable starting antidepressant medication and following their patients, most commonly an SSRI. Psychiatry referral is also acceptable.

  • Referral to social work and behavioral health - possibly for psychotherapy, which alone is a reasonable alternative to antidepressants if needed.

  • For those with severe postpartum depression, another possibility is brexanolone.

    • Limited clinical experience and restricted availability 

    • Usually restricted to patients who do not improve with antidepressants