Diagnosing and Managing Breast Disease During Pregnancy and Lactation

, University of Iowa College of Medicine

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In This Article

Abstract and Introduction

Abstract

Although carcinoma of the breast complicates 1:3000 deliveries in the US, most breast conditions unique to pregnancy and lactation are benign--for example, lactating adenoma, galactocele, gigantomastia, and benign bloody nipple discharge. Nevertheless, malignancy must be excluded by a thorough work-up, including breast biopsy if indicated; "watchful waiting" when a breast mass is discovered is no more appropriate than in a nonpregnant patient. During lactation, the major problems encountered often are part of a spectrum of inflammatory and infectious complications. Nasopharyngeal organisms from the infant are usually the source of breast infections in lactating women. Keeping the breast empty of milk promotes healing by helping to drain the culture medium that is facilitating growth of organisms. Hence, the earlier recommendations that breast-feeding cease during mastitis have been superseded by the knowledge that breast-feeding is generally not harmful to the infant and may speed resolution of the infectious process. The diagnosis and management of pregnancy-associated breast cancer (PABC) is reviewed. Pregnancy-associated masses are usually discovered by patient self-examination, and the clinician should proceed to fine-needle aspiration or biopsy, rather than mammography, which has poor sensitivity during pregnancy and lactation because of increased breast density. Management of a new breast mass in pregnancy should maximize diagnostic accuracy and minimize the chances of missing PABC, yet avoid harm to the fetus or interruption of lactation.

Introduction

Pregnant women may develop any of the breast lesions seen in the population at large and also are prone to certain pathologic entities unique to the puerperium.[1,2] It is helpful to conceptually divide the management into 2 steps: first, making the correct diagnosis, and second, managing the pathology in an appropriate and definitive manner that is as gentle as possible to the developing pregnancy and to the process of lactation. During pregnancy, 2 patients--not one--must be considered. During lactation, therapy for benign problems should be tailored to allow a woman to continue breast-feeding if she so desires.[3] An initial thorough breast examination should be part of the first prenatal visit. This establishes a baseline for comparison should changes be detected later. The best chance to find abnormalities is before the physiologic changes of pregnancy make detection difficult. Abnormalities should be promptly evaluated. "Following" an abnormal mass in the expectation that it will disappear is no more appropriate during pregnancy than at any other time. In fact, the clinician may be lulled into a false sense of security if a work-up is delayed, as small masses seem to disappear with progressive physiologic breast enlargement. Pregnant women can, and do, develop breast cancer. Prompt diagnosis and therapy are just as important in this population as in the population at large.

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