Three days after an uncomplicated cesarean delivery, a 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to bilateral breast pain and fatigue. The patient has been attempting to breastfeed but has had difficulty getting the infant to latch, requiring her to supplement with formula. The patient's pregnancy was complicated by insulin-controlled gestational diabetes mellitus. She had a progestin-containing subcutaneous implant placed a day ago for contraception. Temperature is 37.4 C (99.4 F), blood pressure is 130/70 mm Hg, and pulse is 100/min. Bilateral breasts are full, erythematous, and diffusely tender. There is no axillary lymphadenopathy. The uterine fundus is firm, nontender, and palpable 3 cm below the umbilicus. Which of the following is the most likely diagnosis in this patient?

Question

Three days after an uncomplicated cesarean delivery, a 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to bilateral breast pain and fatigue.  The patient has been attempting to breastfeed but has had difficulty getting the infant to latch, requiring her to supplement with formula.  The patient's pregnancy was complicated by insulin-controlled gestational diabetes mellitus.  She had a progestin-containing subcutaneous implant placed a day ago for contraception.  Temperature is 37.4 C (99.4 F), blood pressure is 130/70 mm Hg, and pulse is 100/min.  Bilateral breasts are full, erythematous, and diffusely tender.  There is no axillary lymphadenopathy.  The uterine fundus is firm, nontender, and palpable 3 cm below the umbilicus.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da1f_b317_bc81_f95ef7ed00b5_MD0003_00 This patient has breast engorgement, which commonly occurs 3-5 days after delivery, when colostrum is replaced by milk, resulting in high milk production volumes. The engorgement is exacerbated by a physiologic increase in interstitial edema from decreasing progesterone levels after delivery. Engorgement may also occur during times when milk accumulation exceeds drainage (eg, breastfeeding weaning). Patients with breast engorgement have bilateral breast fullness with diffuse tenderness and erythema. 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. (Choices A and D) In contrast to this patient, those with lactational mastitis often have flulike symptoms (eg, fever, myalgias) and unilateral breast pain with a focal area of erythema and tenderness. Breast abscesses appear like mastitis and an associated area of fluctuance and axillary lymphadenopathy. lactational mastitis (Choices C and F) A galactocele and plugged ducts are common problems in breastfeeding women, but both typically present as a palpable mass. galactocele (Choice E) Mammary candidosis is a common breastfeeding complication. Patients typically have unilateral, stabbing breast pain that is out of proportion to examination and have associated scaling of the skin on the nipple of the affected breast. Educational objective: Breast engorgement is common 3-5 days after delivery when colostrum is replaced by milk. Symptoms include bilateral breast fullness, tenderness, and warmth, without fever. Improvement is expected as breastfeeding is established. References: Treatments for breast engorgement during lactation. (http://www.ncbi.nlm.nih.gov/pubmed/20824853) Pathological postpartum breast engorgement: prediction, prevention, and resolution. (http://www.ncbi.nlm.nih.gov/pubmed/25774443) Breast pain: engorgement, nipple pain, and mastitis. (http://www.ncbi.nlm.nih.gov/pubmed/26512442)

Three Days After an Uncomplicated Cesarean Delivery, a 23-Year-Old Woman