The Experience of Breast Symptoms after Second-Trimester Abortion or Loss

Introduction Lactogenesis is a two-stage physiologic process of developing the ability to secrete milk that starts from 16th week of pregnancy and continues after delivery of the placenta regardless of the birth outcome. Breast engorgement and milk leakage following second-trimester perinatal loss and abortion can cause both physical pain and emotional distress. Limited data exists to the prevalence, duration, and bother of breast symptoms after second-trimester abortion and loss; thus, we aimed to characterize breast symptoms (engorgement, tenderness and leakage) following this experience. Method We collected real-time data via electronic survey on breast symptoms and bother experienced by pregnant people following second-trimester abortion or loss using the validated Bristol Breast Inventory (assessing engorgement, tenderness leakage, and pain relief) sent at six time points in the two weeks following the procedure. Bother was assessed using the Facial Pain Score (scale range: 0, not at all-6, extremely). Participants were enrolled in the placebo arm of a study on the effect of cabergoline on breast engorgement following second-trimester abortion (NCT04701333). We enrolled pregnant people 18-28-weeks gestation, English- or Spanish-speaking, with access to the internet. We performed a logistic regression to evaluate for associations with breast engorgement and significant bother from breast symptoms. Variable selection used stepwise methods considering all available variables with at least 5% prevalence. We included receiving maternal age, gestational age, parity, prior breast-feeding experience, indication for procedure, and procedure type. Results Of the 47 participants randomized to the placebo group, 1 person withdrew consent prior to receiving allocate intervention and 3 people were lost to follow-up. Median gestational age 21 weeks (range: 18-26), 68% nulliparous, 35% self-identified as Hispanic, 35% used public insurance to obtain care. 53% of people did not expect to lactate post-procedure prior to counseling. At baseline, 54.1% of people reported any breast symptoms with a median bother of 1 (range: 0-4). At day 4, 97.0% of people reported any breast symptoms: engorgement (84.6%), tenderness (93.9%), milk leakage (54.5%), requiring pain relief (45.5%). By day 14, 48.3% of people were still experiencing breast symptoms. The median bother from breast symptoms on day 4 was 4 (range 0-6); those reporting significant bother from breast symptoms (score>4) was 29.3%. For those less than 20 weeks gestation (n=8), 100% of people reported any breast symptoms on day 4 with a median bother of 2.5 (0-5). In unadjusted and adjusted analysis, there were no demographic associations with breast engorgement or significant bother on day 4. Conclusions Most people do not expect to experience breast engorgement after second-trimester abortion or loss. Regardless, nearly all people – irrespective of demographics (prior pregnancy, breastfeeding experience), indication, or type of procedure – experience symptoms of engorgement and breast tenderness, and most are bothered by these symptoms. Clinicians caring for patients ending and losing pregnancies in the second trimester should provide anticipatory guidance and evidence-based non-pharmacologic and pharmacologic modalities to prevent this discomfort. Lactogenesis is a two-stage physiologic process of developing the ability to secrete milk that starts from 16th week of pregnancy and continues after delivery of the placenta regardless of the birth outcome. Breast engorgement and milk leakage following second-trimester perinatal loss and abortion can cause both physical pain and emotional distress. Limited data exists to the prevalence, duration, and bother of breast symptoms after second-trimester abortion and loss; thus, we aimed to characterize breast symptoms (engorgement, tenderness and leakage) following this experience. We collected real-time data via electronic survey on breast symptoms and bother experienced by pregnant people following second-trimester abortion or loss using the validated Bristol Breast Inventory (assessing engorgement, tenderness leakage, and pain relief) sent at six time points in the two weeks following the procedure. Bother was assessed using the Facial Pain Score (scale range: 0, not at all-6, extremely). Participants were enrolled in the placebo arm of a study on the effect of cabergoline on breast engorgement following second-trimester abortion (NCT04701333). We enrolled pregnant people 18-28-weeks gestation, English- or Spanish-speaking, with access to the internet. We performed a logistic regression to evaluate for associations with breast engorgement and significant bother from breast symptoms. Variable selection used stepwise methods considering all available variables with at least 5% prevalence. We included receiving maternal age, gestational age, parity, prior breast-feeding experience, indication for procedure, and procedure type. Of the 47 participants randomized to the placebo group, 1 person withdrew consent prior to receiving allocate intervention and 3 people were lost to follow-up. Median gestational age 21 weeks (range: 18-26), 68% nulliparous, 35% self-identified as Hispanic, 35% used public insurance to obtain care. 53% of people did not expect to lactate post-procedure prior to counseling. At baseline, 54.1% of people reported any breast symptoms with a median bother of 1 (range: 0-4). At day 4, 97.0% of people reported any breast symptoms: engorgement (84.6%), tenderness (93.9%), milk leakage (54.5%), requiring pain relief (45.5%). By day 14, 48.3% of people were still experiencing breast symptoms. The median bother from breast symptoms on day 4 was 4 (range 0-6); those reporting significant bother from breast symptoms (score>4) was 29.3%. For those less than 20 weeks gestation (n=8), 100% of people reported any breast symptoms on day 4 with a median bother of 2.5 (0-5). In unadjusted and adjusted analysis, there were no demographic associations with breast engorgement or significant bother on day 4. Most people do not expect to experience breast engorgement after second-trimester abortion or loss. Regardless, nearly all people – irrespective of demographics (prior pregnancy, breastfeeding experience), indication, or type of procedure – experience symptoms of engorgement and breast tenderness, and most are bothered by these symptoms. Clinicians caring for patients ending and losing pregnancies in the second trimester should provide anticipatory guidance and evidence-based non-pharmacologic and pharmacologic modalities to prevent this discomfort.