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48 hours after initial treatment when further prolongation of pregnancy is contraindicated
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Klein LL et al Infection and preterm birth Obstet Gynecol Clin North Am 2005 Sep;32(3):397 410 [PMID: 16125040] Mackenzie R et al Progesterone for the prevention of preterm birth among women at increased risk: a systematic review and meta-analysis of randomized controlled trials Am J Obstet Gynecol 2006 May;194(5):1234 42 [PMID: 16647905]
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Breast-feeding should be encouraged by education throughout pregnancy and the puerperium Mothers should be told the benefits of breast-feeding it is emotionally satisfying, promotes mother-infant bonding, is economical, and gives significant immunity to the infant The period of amenorrhea associated with frequent and consistent breast-feeding provides some (although not completely reliable) birth control until menstruation begins at 6 12 months postpartum or the intensity of breast-feeding diminishes If the mother must return to work, even a brief period of nursing is beneficial Transfer of immunoglobulins in colostrum and breast milk protects the infant against many systemic and enteric infections Macrophages and lymphocytes transferred to the infant from breast milk play an immunoprotective role The intestinal flora of breast-fed infants inhibits the growth of pathogens Breast-fed infants have fewer bacterial and viral infections, less severe diarrhea, and fewer allergy problems than bottle-fed infants and are less apt to be obese as children and in adult life Frequent breast-feeding on an infant-demand schedule enhances milk flow and successful breast-feeding Mothers breast-feeding for the first time need help and encouragement from providers, nurses, and other nursing mothers Milk supply can be increased by increased suckling and increased rest Nursing mothers should have a fluid intake of over 2 L/d The United States RDA calls for 21 g of extra protein (over the 44 g/d baseline for an adult woman) and 550 extra kcal/ d in the first 6 months of nursing Calcium intake should be 1200 mg/d Continuation of a prenatal vitamin and mineral supplement is wise Strict vegetarians who eschew both milk and eggs should always take vitamin B12 supplements during pregnancy and lactation
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Drugs taken by a nursing mother may accumulate in milk and be transmitted to the infant (Table 18 4) The amount of drug entering the milk depends on the drug s lipid solubility, mechanism of transport, and degree of ionization
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The simplest and safest method of suppressing lactation after it has started is to gradually transfer the baby to a bottle or a cup over a 3-week period Milk supply will decrease with decreased demand, and minimal discomfort ensues If nursing must be stopped abruptly, the mother
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CHAPTER 18 B Hormonal Suppression
Table 18 4 Drugs and substances that require a careful assessment of risk before they are prescribed for breastfeeding women1
Category Analgesic drugs Antiarthritis drugs Anticoagulant drugs Antidepressant drugs and lithium Antiepileptic drugs Antimicrobial drugs Anticancer drugs Anxiolytic drugs Cardiovascular and antihypertensive drugs Endocrine drugs and hormones Immunosuppressive drugs Respiratory drugs Radioactive compounds Drugs of abuse Nonmedicinal substances Miscellaneous compounds
Specific Drugs or Compounds Meperidine, oxycodone Gold salts, methotrexate, highdose aspirin Phenindione2 Fluoxetine, doxepin, lithium2 Phenobarbital, ethosuximide, primidone Chloramphenicol, tetracycline All (eg, cyclophosphamide, methotrexate,2 doxorubicin2) Diazepam, alprazolam Acebutolol, amiodarone, atenolol, nadolol, sotalol Estrogens, bromocriptine2 Cyclosporine,2 azathioprine Theophylline All All Ethanol, caffeine, nicotine Iodides and iodine, ergotamine,2 ergonovine
Oral and long-acting injections of hormonal preparations were used at one time to suppress lactation Because of their questionable efficacy and particularly because of associated side effects such as thromboembolic episodes and hair growth, their use for this purpose has been abandoned Similarly, lactation suppression with bromocriptine is to be avoided because of reports of severe hypertension, seizures, strokes, and myocardial infarctions associated with its use
Dyson L et al Interventions for promoting the initiation of breastfeeding Cochrane Database Syst Rev 2005 Apr 18;(2): CD001688 [PMID: 15846621]
PUERPERAL MASTITIS (SEE ALSO CHAPTER 16)
Postpartum mastitis occurs sporadically in nursing mothers shortly after they return home, or it may occur in epidemic form in the hospital Staphylococcus aureus is usually the causative agent Inflammation is generally unilateral, and women nursing for the first time are more often affected Rarely, inflammatory carcinoma of the breast can be mistaken for puerperal mastitis Mastitis frequently begins within 3 months after delivery and may start with a sore or fissured nipple There is obvious cellulitis in an area of breast tissue, with redness, tenderness, local warmth, and fever Treatment consists of antibiotics effective against penicillin-resistant staphylococci (dicloxacillin or a cephalosporin, 500 mg orally every 6 hours for 5 7 days) and regular emptying of the breast by nursing followed by expression of any remaining milk by hand or with a mechanical suction device Failure to respond to usual antibiotics within 3 days should prompt consideration of resistant staphylococci If the mother begins antibiotic therapy before suppuration begins, infection can usually be controlled in 24 hours If delay is permitted, breast abscess can result Incision and drainage are required for abscess formation Despite puerperal mastitis, the baby usually thrives without prophylactic antimicrobial therapy
Data modified from Ito S Drug therapy for breast-feeding women N Engl J Med 2000 Jul 13;343(2):118 26 Drugs for which there is no information are not included, although a careful risk assessment is necessary before such drugs are prescribed 2 The use of this drug or these drugs by breast-feeding women is contraindicated according to the American Academy of Pediatrics
should avoid nipple stimulation, refrain from expressing milk, and use a snug brassiere Ice packs and analgesics can be helpful If suppression is desired before nursing has begun, use this same technique Engorgement will gradually recede over a 2- to 3-day period
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