fluctuating milk supply with retained placenta

[Guest guest]

Dear Colleagues,

I have a puzzling case with permission to cross-post. The questions I want to

pose are: 1) Have you had a case in which a mom's milk supply still " came in "

despite retained placenta? 2)Can a remaining retained placenta fragment cause a

fluctuating (up and down) milk supply and if so, what is the hormonal basis for

this? 3)Have you seen good milk supply results with a case such as this

following a D & C?

This mom has a lot of history. In sum, she established a milk supply by pumping

for 2 previous premature babies that vacillated between adequate and oversupply.

Her third baby was near term (37 wks.) and breastfed from birth. All the

children breastfed when able and kept nursing for more than a year.

Mom gave birth to her fourth baby 15 days ago via unmedicated vaginal birth,

posterior presentation. Infant was 37 wks. +6. Infant did not stool until 48

hrs though mom reports frequent feedings and lots of colostrum. Birth wt. was 8

lbs. 7 oz. Discharge wt. 8 lbs. 1 oz. Her milk " came in " on day 3 and was

characterized by 24 hrs. of fullness (as compared with 4-5 days of hardness and

fullness with previous children).

At doc's visit on day 10, baby was still at discharge wt. Mom reported that

some feedings were good, and many not so good during this time and infant was

having adequate wet diapers with approx. 3 scant stools per day. Her breasts

have been soft since the milk coming in. One breast seemed to be producing

merely adequately while supply seemed very low in other and infant preferred

the better breast. Mom's supply seemed to fluctuate daily even in the better

breast. The baby was not latching consistently well (no tongue-tie) causing sore

nipples and was often unsettled at the breast. The latch has improved somewhat

lately.

On the evening of day 11, mom passed some retained placenta followed by some

brief hemorrhaging followed by stabilized lochia. Two days later, an ultrasound

showed a fragment of remaining placental tissue about a 1 cm. in size. Her

doctor recommended a 7-day course of Methergine. He said a D & C was a

possibility but preferred waiting to see if she passed the last bit of placenta

on her own or with the help of Methergine. She is still on heparin since her

pregnancy due to antiphospholipid antibody syndrome.

Mom did not start the Methergine due to concerns about cramping and possible

decreasing of her already low milk supply. The milk supply seemed to come up

for a few days after passing the initial larger portion of the retained

placenta, but supply seems to have decreased starting 24 hrs. ago. She has been

doing some supplemental pumping when possible to further stimulate her milk

supply. A wt. check by me today showed that baby has gained 6 oz. in the last

five days. He has now regained birth wt. at day 15.

Mom felt things were getting better so preferred to watch and wait, but now that

milk supply has decreased, she is considering requesting a D & C before the

weekend. Another unusual aspect of this is that mom reports breast pain that

" never seems to go away " and she feels hot in the chest, throat and breasts

during the days when her milk supply gets low.

Have you ever had a case like this and would you advise the D & C asap? How else

can I help this mom? My only theory is that her milk supply still came in

despite retained placenta because she has well developed prolactin receptors in

her breasts from her previous breastfeeding and that she was able to produce

milk even with low prolactin. But what about the continuous breast pain and

fluctuating milk supply? Maybe from an oxytocin/prolactin imbalance?

Thanks for any insights you may have,

Ellen Maughan, LLLL,JD,IBCLC

Highland Park, NJ