USMLE Obstetrics II Breast

  1. Breastfeeding
    • is the ideal nutrition for infants and is recommended as the exclusive form of nutrition for those age <6 months.
    • Breastfeeding confers protection for the infant against infections such as necrotizing enterocolitis, diarrheal illnesses, otitis media, respiratory tract infections, and urinary tract infections.
    • Mothers who breastfeed also benefit by having decreased postpartum bleeding, more rapid uterine involution, decreased menstrual blood loss, increased child spacing, earlier return to prepregnancy weight, and decreased risk of breast and ovarian cancer.
  2. Contraindications to breastfeeding
    • • Active untreated tuberculosis (mothers may start breastfeeding 2 weeks after anti-tuberculin therapy)
    • • Maternal HIV infection (in developed countries where formula is readily available)
    • • Herpetic breast lesions
    • • Varicella infection
    • • Chemotherapy or ongoing radiation therapy
    • • Active abuse of alcohol or drugs
    • Infant
    • • Galactosemia (Only condition in infant which is absolute contraindication of breast feeding)
    • It Is strongly recommended that mothers with both hepatitis B and C breastfeed whenever possible. However, they should be strongly counseled to abstain if their nipples are cracked or bleeding.
  3. Common problems related to lactation
    • Engorgement :Bilateral, symmetric fullness, tenderness & warmth
    • Nipple injury : Abrasion, bruising, cracking &/or blistering from poor latch
    • Plugged duct : Focal tenderness & firmness &/or erythema; no fever
    • Galactocele : Subareolar, mobile, well-circumscribed, nontender mass; no fever
    • Mastitis : Tenderness/erythema +fever
    • Abscess : Symptoms of mastitis + fluctuant mass
  4. Breast engorgement
    • can occur 3-5 days after delivery, when colostrum is replaced by milk.
    • Although it may occur at any point during breastfeeding due to milk accumulation with inadequate drainage, breast engorgement is especially common early in the postpartum period, when milk production is particularly robust.
    • Symptoms of engorgement include bilateral, symmetric breast fullness, tenderness, and warmth, without fever.
    • Intrapartum intravenous fluid administration can also cause breast edema and exacerbate pain. Cool compresses, acetaminophen, and nonsteroidal anti inflammatory drugs may be used for symptom control.
    • Patients should experience improvement as breastfeeding or regular pumping is established.
  5. Mastitis
    • is a breast infection that causes unilateral breast pain with an isolated firm, tender, erythematous area accompanied by fever >38.3 C.
    • Plugged ducts can cause a firm, tender, and sometimes erythematous area of one breast. This condition can be distinguished from mastitis by the absence of fever or systemic symptoms.
    • Breast abscess is a potential complication of mastitis and has its features plus fluctuance.
  6. Benefits and CI of breast feeding
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    • Breastfed infants have lower rates of otitis media (as well as gastrointestinal, urinary tract, and respiratory infections).
    • other infant benefits include improved overall immunity and reduced risk of chronic diseases such as type I diabetes mellitus and cancer.
    • For these reasons. mothers should be encouraged to exclusively breastfeed their infants until age 6 months.
    • This mother should be counseled on this information and techniques to make breastfeedlng more comfortable.
    • A visit with a lactation consultant may be helpful for her.
  7. Composition of Human Milk
    • The composition of human milk varies based on the mother's diet, the duration of lactation, and the needs of the infant.
    • The protein in human milk is 70% whey and 30% casein, and the protein content is highest at birth and decreases over the first month of life.
    • Whey is more easily digested than casein and helps to improve gastric emptying.
    • Human milk also contains lactoferrin, lysozyme, and secretory immunoglobulin A proteins that confer improved immunity to the Infant.
    • The main carbohydrate in both human milk and standard infant formulas is lactose.
    • Although calcium and phosphorus content is significantly lower in human milk when compared to formula, these minerals are better absorbed from human milk.
    • Breast milk has an inadequate supply of vitamin D and exclusively breast-fed infants must receive supplemented vitamin D
  8. Iron Deficiency Anemia in infant
    • Iron deficiency anemia is the single most common nutritional deficiency in infants and children and is often asymptomatic.
    • Fullterm, healthy infants are born with robust iron stores that generally prevent them from developing iron deficiency anemia until age 4-6 months, regardless of dietary intake.
    • However, the presence of maternal iron deficiency, prematurity, and early introduction of cow's milk before age 12 months increases the risk of iron deficiency anemia in infants.
    • Human breast milk contains only small amounts of vitamin D that are inadequate for meeting the infant's dally requirement.
    • All exclusively breastfed infants should be started on 400 International Units of vitamin D daily within the first month of life.
    • Given that this infant was born prematurely and is excluively breastfed, she is at significantly increased risk for iron deficiency anemia, and both iron and vitamin D supplementation should be initiated.
    • Iron supplementation should be continued until age 1 year in preterm Infants.
  9. Prognostic indicators in Breast Cancer
    • Tumor burden is the single most important prognostic consideration in the treatment of patients with breast cancer. It Is based on TNM staging.
    • The following are other important prognostic factors of breast cancer, in the order of decreasing significance.
    • 1. ER+ and PR+ are good prognostic features.
    • 2. Overexpression of the Her-2/neu oncogene is related to a worse prognosis.
    • 3. The histological grade also tends to reflect the outcome. Poorly differentiated tumors have the worst prognosis.
    • 4. There is currently inconclusive data regarding the prognostic significance of mammogram findings.
  10. Trastuzumab
    • It is also known as Herceptin
    • It is a monoclonal antibody used in the treatment of breast cancer that is positive for HER2 gene amplification.
    • It can be used In patients with early stage disease for an adjuvant effect or in patients with later stage metastatic disease.
    • The combination of trastuzumab with chemotherapy can lead to cardiac toxicity.
    • An echocardiogram is recommended before beginning treatment, due to concern for cardiotoxicity in the future as well as to consider other treatments in patients with poor baseline heart function.
    • Patients with borderline or low ejection fractions (less than 55%) are thought to be at higher risk for cardiotoxicity secondary to trastuzumab.
  11. Fibrocystic breast changes
    • They are benign and common in women of reproductive age.
    • The changes may develop from fluctuations in estrogen and progesterone during the menstrual cycle.
    • Symptoms typically improve during or after menstruation.
    • Patients can be offered nonsteroidal anti inflammatory drugs ancl/or oral contraceptives (OCs) for symptomatic relief.
  12. Benign Breast Disease
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  13. Risk Factors for breast cancer
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  14. Alcohol Consumption and Breast Cancer
    • In women, moderate alcohol consumption can be defined as less than 2 drinks/day or less than 7 drinks/week.
    • Although moderate alcohol consumption is linked with decreased mortality and possible cardiovascular benefits, even low alcohol intake (less than 1 drink/day) in women confers an increased risk of breast cancer.
    • Alcohol consumption has a known dose-dependent causal effect on breast cancer.
    • The patient should also be counseled that excess alcohol intake increases the risk of cirrhosis, pancreatitis, and head and neck cancers.
  15. Indications of testing for BRCA gene mutation in Females
    • Testing for genetic mutations (eg, BRCA, HER2) can first be performed in an affected individual with characteristics of a carrier (eg, breast cancer diagnosis at age less than 50, ovarian cancer at any age).
    • Bilateral mastectomy can be offered to BRCA carriers.
  16. Screening for breast cancer
    • It involves clinical breast examination and mammography.
    • Most current guidelines suggest routine screening mammography at age more than or equal to 50 due to increased risk of cancer with increased age.
  17. Breast Engorgement
    • It results when milk production exceeds release.
    • Examination shows bilateral swollen, firm, painful breasts with no erythema; patients with engorgement are also afebrile.
    • Engorgement itself creates a chain of events that lead to cessation of the lactation process due to negative inhibition of prolactin release.
    • Current evidence does not support the use of medications for lactation suppression.
  18. Lactation suppression
    • It is accomplished by wearing a comfortable, supportive bra, avoidance of nipple stimulation and manipulation, application of ice packs to the breasts, and nonsteroidal anti-inflammatory drugs to reduce inflammation and pain.
    • Breast binding is not recommended for lactation suppression due to the risk of mastitis, plugged ducts, and increased pain.
    • In addition, a tight bra or binder may lead to inadvertent nipple stimulation.
  19. Evaluation of a palpable breast mass
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  20. Evaluation of a palpable breast mass
    • Mammography is the first-tine imaging study for women age more than 30 with a palpable mass.
    • Although screening mammograms are used in asymptomatic women, diagnostic (eg, multiple-view) mammograms are used to evaluate a palpated mass or an abnormal screening result
    • Targeted ultrasound is used with mammography to further characterize the mass (eg, solid versus cystic}.
    • In women less than 30 years, ultrasound is preferred for a palpable abnormality, although mammography can be used for further characterization if an abnormality (eg, irregular borders, complex cyst, indistinct borders) is seen on ultrasound.
  21. Management of simple breast cyst
    • The presentation of a simple breast cyst is variable, ranging from no symptoms to severe, localized pain.
    • Symptomatic patients may benefit from aspiration, which should yield clear fluid and result in the disappearance of the mass and thereby confirm the diagnosis.
    • As cystic fluld can reaccumulate, the patient should return in 2-4 months for a follow-up clinical breast examination if the patient has no further symptoms or signs of recurrence, annual screening can be resumed.
  22. Simple Breast Cyst
    Ultrasound shows posterior acoustic enhancement (indicative of fluid) and no echogenic debris or solid components
  23. Fat Necrosis of the breast
    • This benign condition is associated with breast surgery (eg, breast reduction/reconstruction) and trauma (eg. seatbelt injury).
    • Fat necrosis can mimic breast cancer in its clinical and radiographic presentation because it commonly presents as a fixed mass with skin or nipple retraction and gives the appearance of calcifications on mammography.
    • Ultrasonography can demonstrate a hyperechoic mass, which often correlates with a benign etiology. Biopsy is diagnostic and typically shows fat globules and foamy histiocytes.
  24. Treatment of Fat necrosis of Breast
    • Despite benign biopsy results, the entire mass is often excised due to concerning findings of calcifications on mammography and a fixed irregular mass on clinical examination.
    • Once the diagnosis is confirmed with pathologic analysis, routine annual screening is sufficient as the risk of breast cancer is not increased.
  25. Inflammatory breast carcinoma (IBC).
    • This is a rare but aggressive cancer classically presents as rapid-onset edematous cutaneous thickening with a "peau d'orange" appearance (eg, superficial dimpling, fine pitting).
    • The affected breast is edematous, erythematous, and painful. Itching, a palpable breast mass and nipple changes (eg, flattening/retraction) may also be present.
    • Patients commonly have axillary lymphadenopathy suggesting metastatic disease.
    • The next step in evaluation should include mammography and ultrasound.
    • Tissue biopsy is necessary to confirm the diagnosis.
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  26. Image Upload 6Intraductal Papilloma
    • Unilateral bloody nipple discharge is the hallmark of an intraductal papilloma.
    • It is a benign breast condition.
    • Patients may have brown, red, or pink nipple discharge confined to a single duct.
    • This discharge can range from frank blood to serosanguineous; the bleeding originates from the papilloma in the duct.
    • Imaging with breast mammography and ultrasound would reveal normal breast tissue or a single dilated breast duct.
    • Confirmation of the diagnosis is with biopsy or duct excision and subsequent pathologic evaluation
  27. S/E of risperidone
    It can lead to hyperprolactinemia, which subsequently can cause amenorrhea with bilateral galactorrhea.
  28. Lactational Mastitis
    • It is a common infection in postpartum women due to inadequate milk duct drainage (eg, poor latch, pumping breast milk instead of direct breastfeeding).
    • Bacteria are transmitted from the infant's nasopharynx or the mother's skin via the nipple, and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. This patient has the classic presentation (fever, breast erythema/warmth/pain,lymphadenopathy) of mastitis.
  29. Treatment of Lactational Mastitis
    • Treatment consists of analgesics (eg, Ibuprofen), continued nursing, and antibiotics.
    • Direct feeding with both breasts is the best way to completely drain the milk ducts.
    • Women should be encouraged to nurse the infant every 2 to 3 hours. It Is safe for infants to consume the breast milk as they are already colonized with the bacteria.
    • Pumping is an alternate method of milk drainage for women who experience nipple pain with nursing; however, pumping is not as effective as direct suckling by the infant.
  30. Antibiotic for Lactational Mastitis
    • Preferred empiric therapy against methicillin-sensitive Staph aureus consists of dicloxacillin or cephalexin.
    • Women with risk factors for methicillin-resistant S aureus (eg, recent antibiotic therapy, residence in a long-term care facility, incarceration) should be treated with clindamycin, trimethoprim sulfamethoxazole, or vancomycin.
  31. Diagnosing Menopause
    • Clinical signs of menopause, which occurs in women at an average age of 51, include irregular or absent menses, heat intolerance, flushing, insomnia, headaches, and night sweats.
    • During menopause, the circulating estrogen level decreases, resulting in a decrease in the feedback inhibition on the hypothalamic-pituitary axis. This results in the elevation of serum FSH and LH levels.
  32. Work up of nipple discharge
    • Diagnostic workup for pathologic (eg, unilateral and/or bloody) nipple discharge should begin with mammography to rule out carcinoma even without the presence of a palpable breast mass.
    • With small intraductal papillomas, mammography is often normal.
    • Ultrasound is also indicated for evaluation of ductal pathology and may demonstrate a dilated duct due to the space-occupying papilloma.
  33. Evaluation of a nipple discharge
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  34. Galactorrhea
    • It is defined as lactation in men or non-breastfeeding women.It should be evaluated.
    • Physiologic galactorrhea is usually bilateral and guaiac negative, the appearance is typically milky or clear but can also be yellow, brown, gray, or green.
    • Initial evaluation should focus on identifying the etiology and includes serum prolactin, TSH, and a pregnancy test.
    • Hyperprolactinemia is the most common cause of galactorrhea and can be due to pituitary prolactinoma, medications, hypothyroidism, pregnancy, or chest wall/nipple stimulation (eg, surgery, trauma, shingles).
    • Pituitary imaging (usually MRI) may be needed in patients with elevated prolactin and/or symptoms of a pituitary mass (eg, vision disturbances, headaches).
  35. Paget disease of the breast
    • It is suspected when a persistent. eczematous, and/or ulcerating rash is localized to the nipple and spreads to the areola.
    • Other characteristic findings include vesicles, scales, bloody discharge, and nipple retraction.
    • Patients experience pain, itching, and burning of the affected nipple and no resolution with topical corticosteroids.
    • Approximately 85% of patients with Paget disease of the breast have an underlying breast cancer, although a mass is not always palpable.
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  36. Malignancy associated with Paget's Disease of Breast
    • Adenocarcinoma which refers to carcinoma that starts in glandular tissue, is generally the most common type of breast cancer and is also found in Paget disease.
    • The nipple changes of Paget disease are thought to be caused by migration of neoplastic cells through the mammary ducts to the nipple surface.
    • Further workup should include mammography and biopsy.
Card Set
USMLE Obstetrics II Breast
breast feeding