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Any inappropriate secretion of milky discharge from the breast is called galactorrhea. Galactorrhea often results from abnormally elevated levels of prolactin, although some women have normal prolactin levels on testing. Hyperprolactinemia may be caused by inadequate inhibition of secretion or increased production of prolactin. Causes of elevated prolactin levels are listed in Table 104-1.
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Prolactinomas, benign anterior pituitary neoplasms, are distinguished by symptoms of galactorrhea, amenorrhea, hirsutism, facial acne, visual field deficits, and headaches. Chronic renal failure results in a diminished capacity to clear circulating prolactin. Hypothyroidism causes increased levels of thyrotropin-releasing hormone, which result in increased pituitary secretion of prolactin. Hypercortisolism (Cushing's disease) and acromegaly due to elevated growth hormone levels are both associated with galactorrhea.
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Evaluation of the patient with galactorrhea focuses on any history of associated menstrual abnormalities and the presence of acne, hirsutism, infertility, or libido changes. Symptoms of increased intracranial pressure and hypothyroidism should be investigated. All medications and dietary supplements should be reviewed.
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The physical examination includes evaluations of the visual fields, breasts, skin, and thyroid gland. ED studies include a urine or serum pregnancy test and may include neuroimaging (CT or MRI) and neurosurgical consultation if there is concern for an intracranial mass. Treatment for galactorrhea, other than the discontinuation of a medication suspected to be causative, is deferred to the primary care physician or the follow-up specialist.
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COMPLICATIONS OF LACTATION
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Breast engorgement usually presents on the third to fifth postpartum day, with symptoms of painful, hard, and enlarged breasts. The pain may be accompanied by nausea and low-grade fever. Engorgement results from inadequate removal of milk from the breast. This may be due to infant separation, sore nipples, or improper breastfeeding techniques.4 Ensuring proper latch-on while breastfeeding or pumping usually alleviates the pain and allows for decompression of the nipple-areola complex. Warm showers or manual massage may also help facilitate milk letdown and relieve pain due to engorgement.
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Nipple irritation or soreness is common and usually caused by poor positioning or latch-on techniques. Other causes include trauma, plugged ducts, candidiasis, and inflammatory skin disorders. Purified lanolin cream, analgesics, and breast shields may help facilitate healing. There may be some benefit to applying expressed breast milk to nipples.4,5 There is controversy regarding the role of antifungals for treatment of breast and nipple pain associated with breastfeeding.6 Reynaud's phenomenon can cause nipple pain in some women and may respond to topical nefedipine.7
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Puerperal mastitis, or endemic mastitis, presents with severe pain, tenderness, swelling, and redness. Patients may also develop fever, chills, and myalgias. Mastitis is more common in primiparous women in the first few weeks to months of breastfeeding. There is often an associated history of nipple pain or breakdown and inadequate milk drainage that leads to bacterial colonization and infection. Differentials include marked breast engorgement, clogged milk duct, and inflammatory carcinoma, a rare condition.
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Mastitis, like other inflammatory processes, has the US appearance of hypoechoic fluid surrounding subcutaneous fat lobules without a discrete fluid collection (Figure 104-2), in contrast to abscess (Figure 104-3), which presents as a hypoechoic (dark) fluid collection in the tissue with the absence of vascular signals.
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Puerperal mastitis is caused by Staphylococcus aureus in 40% of cases, although Escherichia coli and Streptococcus species are also known pathogens. Mastitis can be associated with S. aureus nasal carriage in the breastfeeding infant.8 Consider community-acquired methicillin-resistant S. aureus and methicillin-resistant S. aureus infections associated with puerperal mastitis and abscess.5 There is no need to interrupt breastfeeding. Treatment requires frequent analgesia, breast emptying, and early antibiotics with antistaphylococcal penicillins or cephalosporins (Table 104-2). Sulfamethoxazole-trimethoprim cannot be given to lactating mothers with infants <2 months old. If the infection fails to respond rapidly to antibiotics, suspect abscess and broaden antibiotic coverage.
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Breast abscess complicates mastitis in approximately 3% of cases. An abscess may present with the signs and symptoms of mastitis or may demonstrate only minimal focal induration, making clinical differentiation difficult. If US examination identifies a subcutaneous fluid collection, US-guided drainage is an initial first-line treatment (Figures 104-2 and 104-3). Breastfeeding should be continued throughout the course of treatment unless the antibiotic regimen is contraindicated with newborns.4,6,9 Surgical drainage may be necessary for large multiloculated fluid collections but is reserved as a last resort in lactating patients to avoid the potential for milk fistulas.10 Management also includes antibiotic coverage for possible drug-resistant Staphylococcus such as oral cephalosporins or clindamycin. Intravenous vancomycin is a good choice for septic patients requiring inpatient hospitalization. In a subset of patients with recurrent infections, the surgeon may need to perform an excisional biopsy of tissue to rule out an associated inflammatory carcinoma.11