BREAST-FEEDING/ULTRASONOGRAPHY
From the 33rd annual Family Medicine Review Course, sponsored by the University of Vermont College of Medicine,
Burlington
| HELPING PATIENTS SUCCEED WITH BREAST-FEEDING —Anya S. Koutras, MD, Assistant Professor of Family
Medicine, University of Vermont College of Medicine, Burlington
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| Benefits of breast-feeding: infants—fewer infections and hospitalizations; reduced risk for allergic disease and asthma;
reduction in necrotizing enterocolitis in preterm infants; >20% reduction in risk for leukemia and lymphoma; reduced risk for
type 1 and 2 diabetes, obesity, heart disease, ulcerative colitis, inflammatory bowel disease, and Crohn’s disease; improved
retinal acuity and intelligence quotient (IQ); mothers—reduced postpartum hemorrhage and anemia; contraception for first 6
mo (requires exclusive breast-feeding); reduced risk for ovarian, endometrial, and breast cancer; fewer menstrual periods; improved
bone density; more successful postpartum weight loss; families—bonding; improved sleep; financial savings; convenience
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| American Academy of Family Physicians (AAFP) policy: for greatest benefits, encourage exclusive breast-
feeding for first 6 mo, then with complementary foods; after 1 yr, breast-feed as mutually desired by mother and baby;
World Health Organization encourages continuing for ≥2 yr
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| Recommendations about breast-feeding: during well-woman visits, mention reduced risk for cancer associated
with breast-feeding; avoid giving samples of formula; offer current breast-feeding resources; support breast-feeding in office;
know lactation consultants; before delivery—ask patient about intentions and feelings about breast-feeding; aim for
positive experience; talk with patient’s partner and family; discuss benefits; ask about procedures or problems with breasts;
possible to breast-feed after breast augmentation (slightly challenging; consider referral to lactation consultant); encourage
reading and classes on breast-feeding; in hospital—encourage patients to minimize analgesia and anesthesia; facilitate
breast-feeding within 30 to 60 min after delivery; delay unnecessary examinations and procedures (eg, circumcision); encourage
“rooming in”; fewer visitors and more “helpers”; breast-feed every 1 to 2 hr (8-12 times/day for first few days to 1
wk); educate about feeding cues (eg, licking lips, crying [late cue]); avoid pacifiers and supplements; provide breast-feeding
support and pumps (especially if mother and baby separated); consider help from lactation consultants; avoid gift packs
of formula; see patients 2 to 3 days after discharge to check infant’s weight
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| Assessment after delivery: listen to patient’s concerns; evaluate breast-feeding; establish open communication with
nurses (“what parents hear and what nurses say may not add up”); considerations for mother—comfort level and need
for pain medications; be aware of intrapartum and postpartum medications; retained products in milk may be seen on
days 2 to 4; flat or inverted nipples; breast size or anomaly; anxiety; obesity; polycystic ovary syndrome (PCOS); tobacco
smoking and PCOS may be associated with slight reduction or delay in breast milk production and lactogenesis
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| Nipple assessment: sandwich test—straddle areola with index finger and thumb; gently press inward; nipple should not
invert or retract; types of nipples—1) flat; 2) inverted-appearing nipple; everts on sandwich test; 3) retracted nipple; looks
normal, but inverts on sandwich test; 4) true inverted nipple; not common; more likely associated with pathology, especially
if unilateral or new; work up; good latch and successful breast-feeding best treatment for retracted or bilateral inverted nipple;
other strategies include breast pump (immediate use acceptable), everters, nipple shells (no supportive data), and nipple
shields (can be helpful for latching; discuss with lactation consultant)
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| Concerns for infant: medications can distort anatomy of breast and make latch difficult; tongue-tie (tight lingual frenulum
in ≤5% of infants); rare anomalies include hypotonia or hypertonia; poor latch; signs of good latch—asymmetric, with
more areola visible above mouth; audible swallowing; sucking above clavicle; no pain in nipple after latch; mother and infant
relaxed
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| Supplementation: diminishes mother’s confidence in breast-feeding; interferes with milk supply and feeding cues; associated
with early weaning; galactosemia requires nonhuman milk supplement; possible indications—severe hyperbilirubinemia;
persistent hypoglycemia; delayed milk (after day 5); dehydration or poor weight gain; preterm or very low birth weight;
breast-feeding difficulty; expressed breast milk first choice for supplementation; mothers unable to breast-feed should pump
at least every 2 to 3 hr to maintain milk production; alternative feeding methods—syringe; cup; spoon; supplemental nursing
system (preferred method for long-term [≥1 wk] supplementation)
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| Signs of sufficient milk transfer: infant—swallowing and stools; loss of birth weight <7%, with trend of not losing
more by day 4; back to birth weight by day 10; ≥3 bowel movements/day by day 4 (look for yellow stool); ≥6 wet diapers/
day; weight gain of 20 to 50 g/day or 6 to 8 oz/wk after first 10 days; mother—by day 3, breasts feel full before feeding;
breasts soft after day 3; creamy white milk by days 3 to 5; tugging sensation only at nipples (ie, no pain); uterine cramping
and thirst with each feeding normal
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| Other recommendations: medications—should be given after feeding; use medications with shorter half-life, high protein
binding, high molecular weight, and low oral bioavailability; <1% of medication reaches baby; pseudoephedrine contraindicated;
bottles and pacifiers—avoid for first 2 to 3 wk to prevent early weaning; pacifier to console baby “might be
fine, but you might miss feeding cues”; nutrition—no specific foods to avoid or eat; vitamins recommended for anemic
mothers
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| Hyperbilirubinemia: defined as >5 mg/dL bilirubin; jaundice—occurs in 60% of term newborns; in first week after
birth, could be related to insufficient breast-feeding and dehydration; usually occurs in second week after birth; bilirubin
rarely >20 mg/dL; “generally, you don’t need to do anything about it”; breast-feeding can be continued
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| Engorgement: breasts swollen and hard; painful; not normal; breast-feeding should be continued; cool packs on breasts
reduce inflammation and pain; expressing milk helpful; see patient next day
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| Perceived insufficient milk supply: cause of early weaning; refer to lactation consultant if needed; reassure parents
breast-feeding likely to occur less frequently as infant matures; after first month of life, baby has fewer stools; be supportive
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| Contraception: criteria for lactational amenorrhea method (LAM)—breast-feeding for first 6 mo; exclusive breast-
feeding; no resumption of menstrual periods; 98% effective when all criteria met; barrier devices—condoms; diaphragm;
hormonal methods—slight reduction in breast milk with progesterone (medroxyprogesterone [eg, Depo-Provera];
avoid in immediate postpartum period); “mini pill” (progesterone-only oral contraceptive [OC]) not needed unless
preferred by patient (no significant reduction in milk, compared to combination pill; wait 2 wk); intrauterine devices
(IUDs)
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| Vitamin D: 15 min of indirect sunlight recommended; guidelines suggest minimum of 200 IU/day, starting at 2 mo of age
and continuing until infant eating enough foods with vitamin D
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| Sleeping guidelines: reducing risk for sudden infant death syndrome (SIDS)—“back to bed”; baby in same room, but
in separate crib; nighttime pacifier at 1 mo; not sleeping in same bed and breast-feeding encouraged; however, bed sharing
linked to higher rates of breast-feeding; pacifier data poor and undifferentiated for breast-fed infants (habitual use of
pacifiers previously linked with increased risk); supine position; firm mat-tress; dress for warmth; no blankets; parents
should be unimpaired; reduce risk for rollover
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| Recommendations for mothers who work outside home: longer maternity leaves; flexible schedules; working
part-time; inverse breast-feeding (breast-feeding more frequent when mother and baby together, vs when baby at eg, day
care) normal; relaxation strategies; peer support
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| Mastitis: treat early with antibiotics and rest; underlying causes include insufficient rest, tight bras, yeast on nipple (burning
sensation in breast between and after feedings); when untreated, can lead to breast abscess (surgery required)
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| ULTRASONOGRAPHY FOR DIAGNOSING GYNECOLOGIC PROBLEMS —Elisabeth K. Wegner, MD, Associate
Professor, Department of Obstetrics and Gynecology, University of Vermont College of Medicine and Fletcher Allen Health
Care, Burlington
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| Ultrasonography (US): resolution limited by wavelength; 12-MHz transducers used in thyroid or breast US; resolution increases
with higher frequency, but less efficient at penetrating tissue; pulsed echo—ultrasound waves sent from transducer
and bounce back; potential harm low; high energy can cause thermal or mechanical injury (nonissue with modern equipment)
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| Definitions: echogenic—refers to ability to reflect sound waves; denser tissues reflect sound waves better; bone echogenic,
appears white on imaging; water not echogenic; hypoechoic—less dense; anechoic—no reflection of sound waves; appears
black on imaging; hyperechoic—dense, eg, bone; shadows—dense tissue changes way sound wave travels around
tissue and creates shadows; key factor in breast cancer; helpful for finding fibroids
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| Gynecologic US: transabdominal US (TAUS)—for visualizing large structures outside of pelvis; used with transvaginal
US (TVUS); transducer looks straight down to show uterus; TVUS—superb detail; advantages include no radiation and
real-time imaging (allows mapping of areas of tenderness); helps assess mobility and relationship between structures
(pushing on abdomen helpful); limited to 15 to 20 cm; transducer sits in vagina next to uterus
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| Abnormal uterine bleeding: anovulatory—often age-related; causes include obesity, PCOS, and thyroid dysfunction;
US not effective for diagnosis; structural—US useful; causes include fibroids, endometrial polyps, adenomyosis, hyperplasia,
cancer, and endometritis; dysfunctional uterine bleeding (diagnosis of exclusion); atrophic—in older women; consider
other sources of bleeding near uterus; adolescents—rarely structural, often anovulatory; US not useful; occasionally due to
bleeding disorder (eg, von Willebrand’s disease); if bleeding problems continue after work-up and trial of OCs, consider US;
US useful in young women who have not started menstruating and if anomaly (eg, obstructed hymen) suspected; perimenopausal
women—often anovulatory; structural problems common; combination of anovulatory and structural problems; consider
cancer (age threshold for endometrial biopsy, 35-40 yr of age); less concern about endometrial cancer when performing
US after completion of menses (ie, when lining thin); postmenopausal women—≤10% of women who have bleeding have
endometrial cancer; many women have atrophic bleeding; polyps common; bleeding may be from other organs; pregnancy—
should always be considered; abnormal bleeding not uncommon in perimenopausal women (pregnancy may be unplanned or
unexpected; often not normal viable pregnancies [eg, higher chromosomal miscarriage rates]); ectopic pregnancy
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| Work-up of abnormal bleeding: goal to distinguish benign self-limited problem from serious problem; obtain history;
perform urine pregnancy testing (UPT); assess severity of bleeding; US—useful for women >38 yr of age; scheduling immediately
after bleeding stops helpful (thin [<5 mm] endometrium rules out significant problem within lining); fluid test
(sonohysterography) if indicated (eg, polyp); consider endometrial biopsy if patient at risk for hyperplasia and has thickened
endometrium; cystic endometrium often due to polyp; patients on tamoxifen—subendometrial tissue becomes edematous;
if US abnormal and patient has no bleeding, pathology unlikely; saline-infusion sonohysterography—used to assess abnormal
bleeding, uterine anomaly, scarring in uterus, infertility, and to evaluate patients before or after surgery; no data about
worse outcomes in patients with potential cancer or hyperplasia; fibroids—cause bleeding when hanging into cavity or
pushing against it, or if distorting endometrium; can be delivered and become pedunculated; outside fibroids cause pressure
problems or associated with possible adnexal masses; adenomyosis—common in women 40 to 50 yr of age; myometrium
of uterus causes painful and heavy menstrual bleeding; appears cystic and heterogeneous; definitive diagnosis based on surgical
specimen, but US helpful in women who had hysterectomy; benign
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| Pelvic mass: may be ovarian pathology, pedunculated fibroid, fluid-filled tube (hydrosalpinx), peritoneal inclusion cyst,
mesodermal mass, lipoma, or stool; obesity and scarring (from, eg, cesarean delivery) can make normal-sized uterus feel
enlarged; cysts—ovaries normally make cysts; cysts ≤3 cm (“simple” or “black”) likely normal and not cause of pain;
corpus luteum normal after ovulation and often bleeds into self, causing hemorrhagic cyst; hemorrhagic cysts—often
painful and mimic other pathology (eg, cancer); thick blood coagulates, resulting in fibrin stranding and clotting; layered
appearance; black anechoic fluid; no blood flow seen on color Doppler US (ie, not tumor, no viable tissue); can be confused
with endometrioma; endometrioma—“old chocolate blood”; echogenic material; causes chronic pain; common;
no blood flow; distinguishing pedunculated fibroid on stalk from ovarian tumor—blood flow or uteroovarian vessels
seen with pedunculated fibroid; if separate normal ovary seen, fibroid ovarian cyst likely; cysts separate from ovaries
remnants of embryology (black and simple on US; benign)
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| Identifying malignancy: no absolute predictive indicators; sensitivity up to 90%, specificity “not great”; consider complexity
and classic findings (eg, cyst with tooth likely benign dermoid); short-term follow-up recommended unless absolutely
clear that benign process in young patient; consider age, history, past studies, and need for blood studies for known
mass; signs of malignancy—multilocular and multiple cysts; thick and irregular septum or wall; poorly defined borders;
nodules growing in (usually with vascularity); solid components with vascularity; hypoechoic findings on US
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| Management of asymptomatic mass: no follow-up for simple cyst, with or without hemorrhage; cyst >3 cm likely
functional, but follow to rule out endometrioma or dermoid; postmenopausal women—simple cyst ≤5 cm likely benign,
but follow with CA-125; if cyst >5 cm, consider surgery and risk factors; if mass complex, difficult to rule out cancer unless
it resolves during follow-up; young women—if findings classic for dermoid or endometrioma, follow and discuss removal;
large benign cysts can cause pelvic pressure
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| Pelvic pain: acute—US has high predictive value; in patients with sudden pain and normal gynecologic examination and
US, likelihood of gynecologic pathology low (unless ongoing infection or pelvic inflammatory disease [PID] suspected);
ovarian cysts common (look for tenderness); ruptured endometriomas can cause severe peritonitis; ovarian torsion; PID;
chronic—US useful for mapping areas of tenderness; US shows obvious signs of endometriosis (eg, endometriomas), but
not other signs of endometriosis; rectovaginal nodularity on pelvic examination may be seen with higher-resolution US
(not definitive); adhesions (not clearly seen on US, but may see odd positioning or immobility of ovaries; cause pain); ovulation;
adenomyosis associated with endometriosis; large masses that do not resolve; fibroids pressing on pelvis, bladder,
or rectum; other diseases, eg, interstitial cystitis, diverticulitis in older women, musculoskeletal disorders; US can help locate
embedded or dislodged IUD in uterus (plastic levonorgestrel-releasing intrauterine system [Mirena] not as echogenic
as copper IUDs); “hard” findings include large cyst or fibroid or old hydrosalpinx tube; “soft” markers at time of laparoscopy
include site-specific tenderness, ovarian adhesion, and loculated peritoneal fluid; ≈50% of women with normal findings
have soft markers (of those, 75% have pathologies)
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| Mullerian anomalies: increase risk for miscarriage and preterm labor; often renal anomaly; consider evaluating uterus
in women who have one kidney and planning pregnancy
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| Newer methods: newer equipment with rotating heads may be helpful in overweight patients; postmenopausal
women—limited motility with TVUS; occasionally, may need to image transrectally with transvaginal probe
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Suggested Reading
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome: The changing concept
of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables
to consider in reducing risk. Pediatrics 116:1245, 2005; Bau A et al: Acute female pelvic pain: ultrasound evaluation. Semin
Ultrasound CT MR 21:78, 2000; Cattaneo A: The benefits of breastfeeding or the harm of formula feeding? J Paediatr
Child Health 44:1, 2008; Cooke M et al: A description of the relationship between breastfeeding experiences, breastfeeding
satisfaction, and weaning in the first 3 months after birth. J Hum Lact 19:145, 2003; Edmond KM et al: Delayed
breastfeeding initiation increases risk of neonatal mortality. Pediatrics 117:e380, 2006; Eidelman AI et al: Bed sharing
with unimpaired parents is not an important risk for sudden infant death syndrome: to the editor. Pediatrics 117:991, 2006;
Goldstein SR: Abnormal uterine bleeding: the role of ultrasound. Radiol Clin North Am 44:901, 2006; Helewa M et al:
Breast cancer, pregnancy, and breastfeeding. J Obstet Gynaecol Can 24:164, 2002; Hill LM et al: The role of ultrasonography
in the detection and management of adnexal masses during the second and third trimesters of pregnancy. Am J Obstet Gynecol
179:703, 1998; Kanizsai B et al: Ovarian cysts in children and adolescents: their occurrence, behavior, and
management. J Pediatr Adolesc Gynecol 11:85, 1998; Kramer MS et al: Effects of prolonged and exclusive breastfeeding
on child behavior and maternal adjustment: evidence from a large, randomized trial. Pediatrics 121:e435, 2008; Okaro E et
al: Diagnostic and therapeutic capabilities of ultrasound in the management of pelvic pain. Curr Opin Obstet Gynecol 17:611,
2005; Okaro E et al: The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with
chronic pelvic pain--can we reduce the need for laparoscopy? BJOG 113:251, 2006; Perkins KY et al: Simple ovarian
cysts. Clinical features on a first-trimester ultrasound scan. J Reprod Med 42:440, 1997; Schack-Nielsen L et al: Long
term effects of breastfeeding on the infant and mother. Adv Exp Med Biol569:16, 2005; Turck D: Later effects of breastfeeding
practice: the evidence. Nestle Nutr Workshop Ser Pediatr Program 60:31, 2007.
Educational Objectives
| The goal of this program is to help patients succeed with breast-feeding, and to improve diagnosis of gynecologic problems
by reviewing the role of ultrasonography (US). After hearing and assimilating this program, the clinician will be better able
to:
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 | 1. List benefits of breast-feeding.
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| 2. Counsel patients about use of pacifiers and supplements.
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| 3. Inform patients about contraception and sleeping guidelines.
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| 4. Identify causes of abnormal uterine bleeding in adolescents and older women.
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| 5. Evaluate findings seen on US in patients with pelvic masses and/or pelvic pain.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgments
Drs. Koutras and Wegner spoke in Burlington, VT, at the 33rd annual Family Medicine Review Course, presented June 5-
8, 2007, by the University of Vermont College of Medicine. The Audio-Digest Foundation thanks the speakers and the University
of Vermont College of Medicine for their cooperation in the production of this program.
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