maternal conditions and breastfeeding
TRANSCRIPT
Maternal Conditions and Breastfeeding
dr. Muhammad Ilham Aldika Akbar SpOGMaternal Fetal Medicine Division
Dept Obgyn RSUA-RSUD Dr. SoetomoFaculty of Medicine Universitas Airlangga
Surabaya
dr. M. Ilham Aldika A, SpOG - FK UNAIR
LactogenesisThe changes that occur between pregnancy and
lactationTwo stages:
Lactogenesis I: during pregnancy, initiation of the synthetic capacity of the mammary glands
Lactogenesis II: after delivery, initiation of plentiful milk secretion
Lactation• Physical and
mental health• Past
experiences• Intention
related to breastfeeding
• Body image
• Socioeconomic factors
• General physical environment
• Family support• Hospital and
clinician support
• Maternal conditions
Internal Environment External Environment
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Lactogenesis IIChanges in milk
constituentsFeeling of breast fullness 30-40 hours following birthInfluenced by complex hormonal milieu• Reproductive hormones (E, P,
HPL, Prolactin, Oxytocin)• Metabolic hormones
(glucocorticoid, growth, insulin, thyroid)
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Problems in Lactogenesis II
DELAYED FAILEDLonger than usual interval between the colostrum phase and copious milk production
The mothers able to achieve full lactation but an extrinsic factor has interfered with the process
One or more factors result in failure to attain adequate milk production
Primary Secondary
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Delayed or failed achievement of
Lactogenesis 2 is a result of various
maternal and infant factors
Early recognition of these factors is critical for
clinician
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Risk Factor for Delayed or Failed Lactogenesis II
Primiparity Psychosocial stress/pain
Maternal Obesity Diabetes
Hypertension Stressful labor and delivery
Unscheduled Cesarean Section
Delayed first breastfeed episode
Low perinatal breastfeeding
frequencyBreast
surgery/injuryRetained placental fragments
Cigarette Smoking
Hypothyroidism,
hypopituitarismPCOS Post partum
hemorrhageInsufficient mammary
gland tissue
Hormonal and metabolic problems
Diabetes, Hypothyroidism, Obesity, PCOS, SLE
Delay breastfeeding initiation
Preterm labor, CS Complication pregnancy
Gestational DM, preeclampsia
Problem related to labor and delivery
Post partum haemorrhage, Hysterectomy, Sheehan
Anatomic breast abnormalities
Post breast surgery, breast implants, reduction mammoplasty
Maternal medication
Pseudoephedrine, birth control
Maternal Condition causing Delay/Failed Lactogenesis II
dr. M. Ilham Aldika A, SpOG - FK UNAIR
BREASTFEEDING AFTER A CESAREAN DELIVERY
dr. M. Ilham Aldika A, SpOG - FK UNAIR
CS rate is dramatically increasing in recent years
CS is strongly associated with delayed lactogenesis, delayed in early breastfeeding, decrease in success of
breastfeeding, poorer infant suck, more suplementation, and shorter duration breastfeeding
(Dewey et al, 2002; Smith, 2010)
Different breastfeeding experience with vaginal delivery
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Caesarean Section
Delay/FailureLactogenesis
Post operative
pain
Pain Relief drugs
Supress Breastfeedin
g
Stress/Fatique
Decreased milk
supply
Blood loss
Anemia
StressHormone
Infant Problem
s
RDS NICU
Admission
Separation from mother
IMD
BF difficulties
Inhibit oxytocin
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Benefits of Breastfeeding after Caesarean
Faster uterine involution
Endogenous oxytocin release by breast stimulation Less postpartum bleeding Weight loss more quickly
Risk of immobility after caesarean Decreases incidence of infant infection
Risk of infection from longer hospitalisation Prevent hypoglycemia, jaundice Bonding
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Breastfeeding After CSEpidural or spinal anesthesia is ideal (pain free
post operative)Need extra support by hospital staff and familyCommon position: cradle hold, football hold
and side-lying position IMDRooming in
dr. M. Ilham Aldika A, SpOG - FK UNAIR
BREASTFEEDING IN WOMEN AFTER POST
PARTUM HAEMORRHAGE
Many Factors Contributed to Breastfeeding Failure in Women with PPH
Maternal condition(unconsious,
fatique, severe anemia)
ICU Admission (mother baby separation)
Traumatic maternal
stress
Severe blood loss/hypotension
Ischemia/infarct pituitary glands
Altered prolactin level
Sheehan Syndrome
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Management of Breastfeeding in Women After PPH
Collaboration care by lactation consultant, obgyn, pediatrician, nurse, patient and family
Maternal condition stabilisationEducate mothers about potential problemsStimulate maternal lactation potentialCarefull infant feeding plan, supplementation
needed Partial BF complete BF
dr. M. Ilham Aldika A, SpOG - FK UNAIR
BREASTFEEDING IN WOMEN WITH
PREECLAMPSIA
dr. M. Ilham Aldika A, SpOG - FK UNAIR
dr. M. Ilham Aldika A, SpOG - FK UNAIR
PREECLAMPSIA2nd leading cause
direct maternal mortality
70-80.000 maternal and 500.000 perinatal death annually
> 99% South Asia & Sub Saharan Africa
Incidence 29.7% (RSUD DR. Soetomo)
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Breastfeeding in Women with Severe
Preeclampsia
Maternal Condition
Magnesium Sulphate
administrassion
Prematurity
ICU admission
NICU admission
Early Separation
Obesity
Delay initiation of Breastfeeding
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Study of Breastfeeding in women with PE, Cordero L et al, Breastfeeding Medicine vol 7, number 6, 2012
2007-2010, USA281 women with Severe Preeclampsia81 term and 200 late preterm infants
• All mothers and infants survive
• 54% infants were admitted to NICU
• 51% sucessfully initiated breastfeeding
• Factors associated with Breastfeeding initiation failure:• African american race• Young age• Lower education• Multiparity• Smoking• Obesity
Magnesium Sulphate
Prevent EclampsiaFetal neuroprotectantNo effect on Apgar Score
Transfer trans placentallyRisk neonatal
hypermagnesemia?Decrease in sucking rate?Decrease breast stimulation?
Benefit Risk
Breastfeeding
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Is not expected to affect breastfeed (not increasing magnesium level significantly in milk)Decrease in sucking rates decrease in breast stimulation Need to feed more frequently, need more stimulation to suckling
Manual expression or breast pumping
Magnesium Sulphate on Breastfeeding
Retained Placental
Fragments
dr. M. Ilham Aldika A, SpOG - FK UNAIR
dr. M. Ilham Aldika A, SpOG - FK UNAIR
RETAINED PLACENTAL FRAGMENTS DELAY/FAILED LACTOGENESIS II
Causing haemorrhagic post partum Sheehan Syndrome
Inhibit decrease of progesterone level inhibit action of prolactin to stimulate milk production
Management: removing placental fragments
DELAYED LACTOGENESIS RELATED TO GESTATIONAL
DIABETES
dr. M. Ilham Aldika A, SpOG - FK UNAIR
dr. M. Ilham Aldika A, SpOG - FK UNAIR
GESTATIONAL DIABETESHigh blood glucose level in pregnant women who
have never had diabetes9.2% (CDC) 7x more likely to develop permanent Diabetes type
2
dr. M. Ilham Aldika A, SpOG - FK UNAIR
BREASTFEEDING IN GESTATIONAL DIABETES WOMENDelay onset of lactation by 15-28 hDecrease milk volume over 3 first daysHypoglycemia may reduce glucose availability to
lactocytes reduce lactose synthesis & ability to initiate lactation
Women with GDM are less likely to breastfeed (cross sectional study, 2038 women, 2005-2007)
Longer duration of breastfeeding showed a correlation with reduction in risk of developing type
2 diabetes
Kaiser prospective cohort study, 1010 women who breastfeed 2 month vs several month.
RESULT:• After 2 years, 11.8% women developed DM• 35% to 57% reduction in two years diabetes incidence
associated with longer duration of breastfeeding (< 2 vs > 10 month)
Why Mothers with GDM should Breastfeed?
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Another Benefit of Breastfeeding in Gestational Diabetes
MothersBetter overall health Less insulin need during
lactation
InfantHelp adjust glucose levelProtection against
malnutrition during early childhood
Lower risk of developing obesity, diabetes, hypertension and cardiovascular disease later in life
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Study of womens experience with early breastfeeding after gestational diabetes
Barriers to breastfeeding:BF challenges and supportMilk supply challengesConcern for infant health
A need for consistent breastfeeding education as well as strategies for
addressing BF challenges and milk supply issues
dr. M. Ilham Aldika A, SpOG - FK UNAIR
MATERNAL OBESITY
dr. M. Ilham Aldika A, SpOG - FK UNAIR
MATERNAL OBESITY Delay increase prolactin
after breastfeeding > 2 days
Low milk transfer at 60 hours post birth
High Leptin inhibit milk ejection
1 unit increase in BMI ~ 0.5 hour delay in lactogenesis
Maternal BMI ~ shorten BF duration
Developmental Origins of Health and Disease
Warner MJ, Ozzane SE, 2010
Fetal Programming
dr. M. Ilham Aldika A, SpOG - FK UNAIR
DELAY LACTOGENESIS RELATED TO POLYCYSTIC
OVARIAN SYNDROME
High Androgen down regulate prolactin receptor Insulin resistance Low progresterone poor breast tissue development
dr. M. Ilham Aldika A, SpOG - FK UNAIR
dr. M. Ilham Aldika A, SpOG - FK UNAIR
MANAGEMENT OF DELAY/FAILURE OF
LACTOGENESIS II
dr. M. Ilham Aldika A, SpOG - FK UNAIR
MANAGEMENT PLAN for DELAY-FAILURE LACTOGENESIS II
Provide adequate infant nutrition
Maximizing breast stimulation, and complete breast
emptying
Strategies to measure milk intake during BF
Writen record of progression on feeding
plan
Recognition when maternal lactation
potential is reached
dr. M. Ilham Aldika A, SpOG - FK UNAIR
PROVIDE ADEQUATE INFANT NUTRITION
An infant who is malnourished will not have energy to BF effectively
Recommending the mother simply increase frequency BF will not improve this situation when failed lactogenesis II is suspected
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Determining the need for supplementation is essential in provide adequate infant nutrition
Expressed breast milk/formula should be given as a complement (immediately following BF session) rather than full suplement (replace BF)
To maximize maternal breast stimulation and maintain infant BF ability
Determining suplementation feeding methods need carefull consideration
Bottle, cup, syringe, or feeding tube device
dr. M. Ilham Aldika A, SpOG - FK UNAIR
dr. M. Ilham Aldika A, SpOG - FK UNAIR
MAXIMIZE BREAST STIMULATION AND COMPLETE BREAST EMPTYINGAny potential infant sucking problems should be
correctedBreast problem should be correctedBreast pumping following each BF should be initiatedGalactagogues
dr. M. Ilham Aldika A, SpOG - FK UNAIR
OBJECTIVE MEASUREMENT OF MILK INTAKE DURING BREASTFEEDINGSubjective estimation is inaccurateTest weighing procedure are important
diagnostic tool for delayed/failed lactogenesis II 1 g ~ 1ml milk intake
Weekly provider visit to asses BF paterns, vol of supplement, and post feeding pumping vol
MAINTAINING FEEDING or PUMPING RECORDHaving mothers maintain a
simple record of daily feeding, pumping and infant stooling and urinary patterns is useful to monitor progress
Guide plan of care for modification as BF improves or not
dr. M. Ilham Aldika A, SpOG - FK UNAIR
dr. M. Ilham Aldika A, SpOG - FK UNAIR
RECOGNIZING When MATERNAL LACTATION POTENTIAL Has Been Reached
This is a challenge!
Asses proportion of daily BF, supplements, and expressed breast milk volume information to determine lactation potential has been reached
Refference Anderson AM, 2001. Case Report: Disruption of Lactogenesis by Retained Placental Fragments. J Hum Lact.
17(2), 2001.
Chapman DJ, 2014. Risk Factors for Delayed Lactogenesis among Women with Gestational Diabetes Mellitus. Journal of Human Lactation 2014, Vol. 30(2) 134-135.
Cordero L, Valentine CJ, Samuels P, Giannone PJ, Nankervis CA, 2012. Breastfeeding in Women with Severe Preeclampsia. Breastfeeding Medicine Vol 7, Number 6, 2012.
Hurst NM, 2007. Recognizing and Treating Delayed or Failed Lactogenesis II. Journal of Midwifery & Women's Health.
Kair LR, Colaizy TT, 2015. When Breast Milk Alone is Not Enough: Barriers to Breastfeeding Continuation among Overweight and Obese Mothers. Journal of Human Lactation 1-8, 2015.
Sema Kuguoglu, Hatice Yildiz, Meltem Kurtuncu Tanir and Birsel Canan Demirbag (2012). Breastfeeding After a Cesarean Delivery, Cesarean Delivery, Dr. Raed Salim (Ed.), ISBN: 978-953-51-0638-8, InTech, Available from: http://www.intechopen.com/books/cesarean-delivery/breastfeeding-after-a-cesarean-delivery
Marasco L, Marmet C, Shell E, 2000. Polycystic Ovary Syndrome: A Connection to Insuficient Milk Supply? J Hum Lct 2000;16(2):143-148.
Neville MC, Morton J, 2001. Physiology and Endocrine Changes Underlying Human Lactogenesis II. J Nutr. 131: 3005S-3008S, 2001.
Riordan J, Hoople KG, Angeron J, 2005. Indicators of Effective Breastfeeding and Estimates of Breast Milk Intake. J Hum Lact. 21(4):406-412, 2005.
dr. M. Ilham Aldika A, SpOG - FK UNAIR
Thank You!