Routledge offering a discount on the second edition of my book. Useful for healthcare professionals who care about supporting breastfeeding or peer supporters who get the questions or parents who want to be informed by the evidence
Sadly our family has recently experienced the tragedy of an ectopic pregnancy and the loss of a very brief dream. This has made me much more aware of the incidence and risk of this condition over and above the post I wrote in April. So some more facts – as my friend commented today I hate to waste any opportunity to educate!
Ectopic pregnancy is a common, occasionally life-threatening condition, that affects 1 in 80 pregnancies. An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes. Symptoms usually develop between the 4th and 12th weeks of pregnancy. Women with an ectopic pregnancy may still be breastfeeding and wish to continue which can be supported.
- Ongoing bleeding that is sometimes red or brown/black and watery (like “prune juice”) should be investigated. The bleeding may be heavier or lighter than usual, but pregnancy test is still positive
- One-sided pain in your tummy which may be persistent or intermittent or a generalised discomfort with bloating and a feeling of fullness (not associated with eating) when lying down.
- Shoulder tip pain which is often described as pain unlike any you have ever experienced before. (Ectopic Pregnancy Trust)
Your GP will refer you urgently to the early pregnancy unit at your local hospital. You may have your Human Chorionic Gonadotropin (HCG levels) measured over a period of several days. If you are having a normal pregnancy these should double approximately every 48 hours. A smaller increase can indicate a risk of of this being an ectopic pregnancy but this will be confirmed with ultrasound scans, initially across your tummy. It is likely that a transvaginal (internal) ultrasound scan will be required where a specialised probe is placed into the vagina to get a more detailed look at the reproductive organs.
Unfortunately, if it is confirmed over a period that you have an ectopic pregnancy it is not possible to save the pregnancy and it must be removed either by surgery or the use of methotrexate. The cells have not been able to be nourished and can never develop into the baby you thought you were expecting which can be hard to deal with.
Rupture of ectopic pregnancy
In a few cases, an ectopic pregnancy can grow large enough to split open the fallopian tube. This is known as a rupture which can be very serious, and surgery needs to be carried out as soon as possible.
Signs of a rupture include a combination of:
- a sharp, sudden and intense pain in your tummy
- feeling very dizzy or fainting
- feeling sick
- looking very pale (NHS Choices)
Methotrexate and breastfeeding
Mothers who are currently breastfeeding an older child can continue 24 hours after the methotrexate is administered.
“It is apparent that the concentration of methotrexate in human milk is minimal, although due to the toxicity of this agent and the unknown effects on rapidly developing neonatal gastrointestinal cells, it is probably wise to pump and discard the mother’s milk for a minimum of 24 hours post dose if given as a single dose (e.g. 50 mg/m2 IM for ectopic pregnancy)” (Hale 2018).
Infant Monitoring: Should patient resume breastfeeding more than 24 hours after the last dose of maternal therapy, monitor the infant for vomiting, diarrhoea, blood in the vomit, stool or urine. Lab work could be drawn if clinical signs of liver or renal dysfunction, anaemia, thrombocytopenia or an inability to fight infection.
Lactmed reports a study of one mother who was given a single intramuscular dose of 65 mg (50 mg/square meter) of methotrexate for ectopic pregnancy. Six milk samples were obtained from 1 to 24 hours after the dose. Methotrexate was undetectable (<22.7 mcg/L) in all milk samples (Tanaka 2009). In some 20% of cases more than one cycle of methotrexate is required to expel the products of conception. For each cycle breastfeeding should be avoided for 24 hours.
Hale quotes a milk plasma ratio of > 0.08 and relative infant dose of 0.13% – 0.95%. Peak serum concentrations appear 30-60 minutes after intra muscular dose (Jones 2018). Pharmacokinetic data is very variable as there in considerable inter individual variation (Martindale 2017).
For more information on methotrexate administration, side effects and monitoring see www.ectopic.org.uk/patients/treatment/
Ectopic pregnancy and breastfeeding fact sheetBreastfeeding after surgery
After surgery breastfeeding can continue as normal as soon as you are awake and alert. If your nursling is unable to stay in hospital with you, you may need to express to avoid engorgement/blocked duct and to maintain your supply. Your expressed milk can be given to your baby at home. There is no need to pump and dump.
This is my blog written for the Breastfeeding Network for maternal mental health awareness week. Perinatal mental health and its impact on breastfeeding and vice versa is becoming a specific passion of mine. So sad that women are repeatedly told you cant have medication UNLESS you stop breastfeeding. Incorrect and unhelpful
Sadly recently I have heard from several mothers who have been diagnosed with an ectopic pregnancy. They have variously been told that they cant breastfeed again for 2 months and 3 months. One distraught mother planned to pump and dump her milk for 3 months with the hope that she could return to breastfeeding later.
We should be using evidence based information sources as NICE PH11 recommended originally back in 2008. NICE Guidelines – prescribing
So here is the information based on research. A mother administered methotrexate 50 mg/m2 IM for ectopic pregnancy can breastfeed as normal after 24 hours, In the meantime she should pump and dump to maintain her supply. She should not attempt to conceive for 3 months.
Sadly dreams dont always come true and babies are lost during pregnancy. If that happens and you are still breastfeeding a toddler do you have to stop? Lots of information here I wrote for www.essentialparent.com. Extracts taken from Why Mothers Medication Matters
It seems that many more women with chronic illnesses are having babies and breastfeeding. I have
included a chapter in the second edition of Breastfeeding and Medication on this. This fact sheet on lupus and hydroxychloroquine whilst breastfeeding is taken from the book, due to be published May 2018
One of the advantages of breastfeeding is that for many it may be months or even years before menstrual bleeding returns regularly. However, some mothers do experience heavy flow which needs to be treated. Tranexamic acid is usually the drug of choice at a dose of 1 g 3 times a day for up to 4 days, to be initiated when menstruation has started; maximum 4 g per day (BNF 2018). Mothers can continue to breastfeed as normal. There is one reported case of restless in the baby in a study of 21 mothers but in general it seems anecdotally, to cause few problems.
I am frequently asked about taking prochlorperazine (Buccastem® or Stemetil ®) to treat nausea due to labarynthitis, vertigo or dizziness. It is a drug I would be happy to prescribe and have used it myself as have my two breastfeeding daughters. It seems a frequently asked question when the air pressure changes rapidly.
It is not acceptable to leave any mother in pain because she is breastfeeding nor to suggest that she could have more effective pain relief if she stopped breastfeeding.
I’m often asked about the safety of opioids during breastfeeding so this is a really interesting study
Despite opioids being used first line in emergency settings to treat severe acute extremity pain, there is limited evidence available to inform this practice.
In a study in JAMA (7 November 2017), researchers randomly assigned 416 patients in the emergency department with moderate-to-severe acute extremity pain to one of the following groups: 400mg ibuprofen/1000mg paracetamol; 5mg oxycodone/325mg paracetamol; 5mg hydrocodone/300mg paracetamol; or 30mg codeine/300mg paracetamol.