Breast Engorgement Induced by Antenatal Betamethasone Therapy in a Woman After Mammoplasty

Introduction

Breast engorgement and galactorrhea during pregnancy without ensued delivery have been previously described in reference to several medications but not in women with a history of breast augmentation mammoplasty. We report a case of acute breast engorgement and galactorrhea in a healthy 27-year-old woman with breast implants who was treated with betamethasone for threatened preterm labor at 30 weeks of gestation and developed breast engorgement and galactorrhea, without progression into labor. The rapid and spontaneous resolution of both galactorrhea and breast engorgement suggests an association between steroid therapy and symptoms.

Case Report

A healthy 27-year-old gravida 2 para 1 was admitted at 30 weeks of gestation complaining of sudden breast engorgement and galactorrhea. Her first pregnancy ended with spontaneous preterm delivery at 31 weeks of gestation as a result of chorioamnionitis. She underwent breast augmentation with intramuscular (IM) silicone implants 3 years before her current pregnancy and reported having mild breast engorgement and some difficulty in breastfeeding with her previous child.

This patient was followed at our high-risk pregnancy (HRP) outpatient clinic during her current pregnancy for threatened preterm labor and was treated with progesterone (transvaginal 200 mg/day) and pressolat (Nifedipine 20 mg qid), which she was already receiving for the past few weeks. Three days before her current admission, she received a course of two IM injections of betamethasone (Celestone Chronodose) 12 mg, due to the impression of progressive cervical dynamics (transvaginal ultrasound demonstrated shortening of the cervix from 22 to 7 mm) and impending preterm delivery.

Upon arrival to the emergency room (ER), she complained of intolerable tenderness and hardness of her breasts with enlarged, tender breast tail. She had no fever, no headache, and her blood pressure and pulse were normal. On physical examination, her breasts were significantly enlarged, congested, and tender without any signs of mastitis (Fig. 1). There was axillary tenderness with palpable milk nodes. Squeezing of the breast caused galactorrhea. Uterine monitoring did not show contractions and cervical length was 7 mm. The patient was admitted to the HRP department for observation and treatment. Augmentin 875 mg bid was administrated empirically to prevent mastitis. Blood cultures were negative and prolactin levels were within normal range. Breast engorgement and galactorrhea subsided gradually and she was discharged. At 36 weeks, she delivered by an emergency cesarean section because of bleeding and low lying placenta. A healthy girl, weighing 2,350 g with good Apgar scores, was born. No breast discomfort was reported during the early postpartum period.

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FIG. 1.

Bilateral breast engorgement at 30 weeks of gestation in a healthy 27-year-old woman with breast implants who was treated with betamethasone (with patient permission).

Discussion

Breast engorgement and galactorrhea were previously reported after ritodrine and magnesium sulfate treatment, for threatened preterm labor,^1–3 but the exact mechanism was not yet described.

The phenomenon of disrupted lactation after antenatal corticosteroid administration was found in ewes. Henderson et al. ⁴ showed that administration of steroids to pregnant sheep caused a marked precocious initiation of mammary secretion that was associated with alterations in the secretion of lactogenic hormones. After this report, a prospective cohort study of 87 pregnant women who received antenatal betamethasone for threatened preterm delivery was held. ⁴ In pregnant women at risk for preterm delivery who did not deliver subsequently, antenatal treatment with betamethasone was associated with transient galactorrhea and breast engorgement and a limited increase in the excretion of urinary lactogenic hormone metabolites. This process then triggered secretory activation of mammary glands in the presence of high levels of cortisol and prolactin. ⁴ Therefore, betamethasone therapy during pregnancy and the subsequent engorgement of the breasts, with or without galactorrhea is not a sign of initiation of labor.

With modern surgical techniques, pregnancy and breastfeeding experience are not influenced by augmentation mammoplasty, irrespective of the surgical approach used. ⁵ Postsurgery, galactorrhea was previously described with the conclusion that this event did not anticipate any future morbidity to the woman.^6,7

The overall prevalence of women with breast implants in the United States was 8.08:1000 in 1995 ⁸ with a rise of 39% in surgeries performed between 2000 and 2010 to an estimated prevalence of 4.93% of women at any age with 5,083,717 implants reported to be sold and an average age of 34 years at the time of operation. ⁹

Postoperative factors favoring galactorrhea after augmentation mammoplasty in nonpregnant patients were found to be the number of pregnancies, a history of recent and extensive nursing, and the intake of certain medications such as an estrogen-progestative pill. ¹⁰ In 69% of reported cases, the women were found to have hyperprolactinemia. Yang et al. ¹ describe galactorrhea and galactocele formation after augmentation mammoplasty in a woman during the 3rd trimester of pregnancy who was also unable to breastfeed. The authors assume that the presence of a large foreign body (i.e., silicone implants) may risk formation of fluid collection around the implant causing chronic congestion of lactiferous tissue that can lead to histologic changes in the mammary gland, which may progress to granulomatous lobular mastitis or areas of mammary gland necrosis. ¹

Interpretation of the this should be made with caution since massive engorgement attributable to blockage of milk secretion is unusual, infrequently encountered postoperatively, and that hormonal effects causing such complication are “rarely seen,” yet the association of a structural distortion of breast tissue and the effect of betamethasone may be harmonious and contribute to the clinical presentation.

Additional studies on the exact mechanism of breast engorgement and galactorrhea after corticosteroid therapy in pregnant women having breast implants are needed mainly due to increasing popularity of augmentation mammoplasty among reproductive age women.