Even though most changes in the breast during and after pregnancy are benign, a word of caution: breast cancer can and does happen in pregnant women and new mothers. Any unusual symptoms, such as a lump or irritated area, should be reported to your doctor right away. If you have a breast mass, your doctor likely will examine the breast and order an imaging study or studies. Mammography with an abdominal shield a special shield to protect the fetus from exposure to the X-rays is considered safe. However, ultrasound — which uses sound waves rather than X-rays — is usually the test of choice.
However iterations of Cooper's work has lead to a more extensive arterial network that includes branches of both the intercostal arteries and the thoracoacromial artery [ 30 ]. Also, breast feeding can be safely performed during antibiotics therapy [ 2935 ]. The IMA supplies the breast via the posterior and anterior medial branches and the Lateral Thoracic Artery supplies the lateral portion of the breast via the lateral mammary branch. You may find your breasts feel heavy, uncomfortable and sore for a few days. Fine needle aspiration of benign and malignant breast masses associated with pregnancy. Thoresen M, Wesche J. The real-time survey of the breast can be made using several different approaches. Insights into Imaging. During a period of lactation, breast displays the lobular expansion as well as the accumulation Retro waitress adult costume ductal secretion Fig.
Free hard core pron. ECR 2017 / C-2114
Related Products. Hormonal prevention of breast cancer: significance of promotional environment. Diffuse — often an area of increased echogenicity associated with a palpable solid region. Galactocele of the breast. Breast fat and fallacies: more than years of anatomical fantasy. There is a broad spectrum of ultrasonic appearances. Int J Cell Gry ero. Central blood flow may or may not be evident on Colour Breast ultrasound pregnancy induced changes Pregnzncy. Dense breast tissue can ultraskund a mammogram more difficult to interpret because both dense breast tissue and breast tumors appear as solid white areas in the image. If an abnormality is detected, targeted ultrasound changez multiple planes and palpation, if possible should be performed. If your order qualifies for more than one discount, the greatest discount will apply. Severe engorgement may exhibit ultrasonic signs similar to mastitis see below. The mammary branch of the LTA can be located laterally and superiorly to the breast near the axilla.
Breast is a typical female sexual physiologic organ that is influenced by steroid hormone from menarche until menopause.
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- Ultrasound imaging has been used extensively to detect abnormalities of the non-lactating breast.
- Oct 6, Common Issues.
- You may have just received an abnormal mammogram result, or perhaps you or your health care provider found a breast lump or other breast change.
Metrics details. Ultrasound imaging has been used extensively to detect abnormalities of the non-lactating breast. In contrast, the use of ultrasound for the investigation of pathology of the lactating breast is limited.
Recent studies have re-examined the anatomy of the lactating breast highlighting features unique to this phase of breast development. These features should be taken into consideration along with knowledge of common lactation pathologies in order to make an accurate diagnosis when examining the lactating breast. Scanning techniques and ultrasound appearances of the normal lactating breast will be contrasted to those of the non-lactating breast. In addition ultrasound characteristics of common pathologies encountered during lactation will be described.
The lactating breast produces milk of a complex composition that is tailored for the optimal growth and development of the term infant [ 1 ], yet the knowledge regarding pathology and treatment of the lactating breast is limited compared to that of the non-lactating breast.
Ultrasound imaging provides a non-invasive method of investigating the breast during lactation and this paper will review ultrasound techniques used during lactation along with normal and abnormal appearances of the lactating breast. In the last 20 years imaging modalities have become more sophisticated however research has focused extensively on the abnormal non-lactating breast and little attention has been given to the normal and abnormal lactating breast.
Mammography of the lactating breast is limited due to increased glandular tissue and the secretion of breast milk [ 2 ] causing an increase in radio-density that makes the radiographs difficult to interpret [ 3 ].
Galactography the injection of radio-opaque contrast media into the duct orifice at the nipple and subsequent radiography has illustrated only a portion of the ductal system, and few studies have examined lactating women. This procedure risks the introduction of pathogens into the breast and is therefore inappropriate for investigation of the lactating breast.
A recent report using MRI illustrated a duct after its injection with contrast [ 4 ] and another demonstrated dilated ducts and a high proportion of glandular tissue in seven lactating women [ 5 ]. However it is likely these modalities may provide much more useful information in the future. In the past, ultrasound investigation of the lactating breast has been limited for the same reasons as mammography; increased density of glandular tissue and the accumulation of milk [ 6 ].
More recently, however, malignancies have been confirmed during pregnancy and lactation with both mammography and ultrasound [ 7 ]. Ultrasound has undergone enormous technical advances that have improved the resolution of the images dramatically thus allowing imaging of very small structures within the breast.
Ultrasound has the added advantage of being non-invasive thus allowing the breast to be examined without distortion. It follows that ultrasound would be the initial modality of choice for investigation of the lactating breast [ 8 ] however this requires a sound knowledge of breast anatomy and pathology and the development of imaging techniques unique to lactation. This paper describes the ultrasound technique used to investigate the anatomy of the lactating breast, current findings as well as breast pathologies associated with lactation.
Standard descriptions of the human mammary gland are based on Cooper's dissections of the breasts of women who died during lactation Figure 1 [ 9 ]. Recently Ramsay and colleagues re-investigated the anatomy of the lactating breast using high-resolution ultrasound [ 10 ]. We found fewer main ducts mean 9; range 4—18 compared with the quoted 15—20 of conventional texts [ 11 ] which is in agreement with both Love and Barsky's [ 12 ] observations mean 5; range 1—17 and Going and Moffatt's [ 13 ] dissection of one lactating breast four patent ducts.
Interestingly Cooper found seven to twelve patent ducts in a lactating cadaver although he could cannulate up to 22 ducts [ 9 ]. In addition we did not observe the typical sac like 'lactiferous sinus'. Instead ductal branches draining glandular tissue immediately below the nipple often merged into the main collecting duct very close to the nipple Figure 2 [ 10 ].
An additional study showed that the milk ducts in the lactating breast only distend at the time of milk ejection, accommodating the transport of milk to the infant rather than storing milk for removal [ 14 ].
Cooper's illustration of the ductal system of the lactating breast. The breast of a woman who died during lactation, was injected with coloured wax and dissected.
Artist's illustration of the ductal system of the lactating breast based on ultrasound studies of lactating breasts. Reproduced with permission from Medela AG. It is widely believed that the predominant tissue in the lactating breast is glandular. Using a semi-quantitative ultrasound measurement of the glandular and adipose tissue in lactating Caucasian mothers it was found that there was approximately twice as much glandular tissue as adipose tissue in the lactating breast.
In addition it was found the amount of fat situated between the glandular tissues was highly variable which has also been observed in the non-lactating breast [ 16 ]. Breast ultrasound requires the highest resolution of almost all imaging procedures.
In particular it requires high resolution of the near field subcutaneous portion of the breast. The appropriate transducer is an electronically focused linear array with a frequency of 7—12 MHz with multiple focal zones to increase resolution of the area of interest [ 17 ].
However, in the case of the large lactating breast a 5 MHz probe may be desirable to both increase penetration of the breast and improve focusing at depth. Features that will improve imaging are: continuous electronic focusing, broad bandwidth and short pulse width. More recent developments such as coded harmonics and spatial compounding improve contrast resolution thus providing more detailed images of the structures of the breast.
The time compensation curve compensates for the normal attenuation of the sound waves in the tissue ranges between a gentle slope for predominately fatty breasts to a steep slope for dense breasts.
The gain setting compensates for attenuation without discriminating for depth thus amplifying all of the returning echoes [ 8 ]. Too high a setting will eliminate visualization of small structures and reduce the demarcation between adipose and glandular tissue. One or two focal zones are used to improve resolution of the image, by narrowing the ultrasound beam, at selected depths of insonation.
The power setting should be high enough to ensure adequate visualisation of all the tissues of the breast from the skin to the pectoral muscle [ 8 , 17 ]. Some ultrasound systems default to low power settings therefore one may need to increase the power before choosing a lower frequency transducer [ 18 ].
When investigating the non-lactating breast for abnormalities the patient is often placed in the posterior oblique position with the breast to be examined raised. The objective of this position is to flatten the breast and bring the internal structures more parallel to the ultrasound beam. Thus the degree of obliquity depends on the size and shape of the breast and may vary during scanning. Upright positions are used occasionally to determine if there is either floating debris or dependent levels within cystic lesions.
For the lactating breast it may be necessary to use a combination of oblique and upright positions to adequately examine the entire breast, particularly in women with very large breasts. Warm ultrasonic gel is used for scanning to enhance the transmission of sound through the skin into the breast and maintain good contact [ 3 , 18 , 19 ]. Moderate compression of the non lactating breast during scanning is often used for improving both image quality, by changing the orientation of normal tissue so that it is perpendicular to the insonating beam, and visualization of small masses located deep within the breast [ 18 , 20 ] However, mild to moderate compression of the lactating breast will either compress or obliterate milk ducts thereby hindering visualization.
It is prudent therefore to use moderate compression of the breast when targeting lesions but light compression when investigating the ductal system for abnormalities in the lactating breast Figure 3.
Cross-sectional ultrasound image of milk ducts in the lactating breast. On the left image, milk ducts appear as oval hypoechoic black structures. On the right image, milk ducts have collapsed under minimal to moderate compression with the ultrasound transducer.
Ultrasound can be targeted to the area of a palpable abnormality in both the non-lactating and lactating breast. Location of the abnormality and simultaneous scanning should elucidate any distortion of the normal structures of the breast. When no abnormality is detected comparison to the opposite breast may be useful. Further investigation should be considered in the absence of ultrasound changes.
The aim of the ultrasound examination of the breast is to survey the entire breast for abnormalities. When an abnormality is detected targeted ultrasound is employed. The real-time survey of the breast can be made using several different approaches. Commonly the breast is divided into quadrants and each quadrant is scanned using transverse and longitudinal planes ensuring that they overlap Figure 4.
Radial and anti-radial scanning planes are often favoured to demonstrate normal ductal anatomy particularly in the nipple-areola region Figure 5 [ 3 , 18 , 21 ]. Quadrant ultrasound scanning technique of the breast.
The breast is divided into four quadrants as shown and then each quadrant is scanned both vertically and horizontally. Care should be taken that all scans overlap to ensure scanning of the entire breast. Radial ultrasound scanning technique of the breast. The breast is divided into four quadrants. Each quadrant is scanned in a radial fashion to accommodate the arrangement of ducts in the breast.
However a more radial and flexible approach is required in the lactating breast to interrogate the ductal system as the ducts have proliferated and often display an erratic course. Lobes are indistinguishable due to the intertwining nature of the ducts and lobules. If an abnormality is detected, targeted ultrasound using multiple planes and palpation, if possible should be performed.
Assessment of the proportion of adipose and glandular tissue in the non-lactating breast is generally subjective with classifications one to four being made according to the proportion of echogenic tissue parenchyma.
Grade one represents mainly adipose tissue and with grade four the breast is predominantly comprised of echogenic tissue [ 22 ]. Using the clock face method images of the breast tissue are documented along eight radii The images are taken sequentially along the particular axis from the base of the nipple to the outer portion of the breast until the glandular tissue is no longer visualized. Three to four images are documented along the radius.
Each image includes all of the breast tissue from the skin to the chest wall and the full extent of glandular tissue from the nipple to the periphery of the breast. Measurements are made of the depth of glandular tissue G , subcutaneous S , intraglandular fat I and retromammary fat R at 30 mm intervals along the 8 radii of the breast from the base of the nipple.
The thickness of each tissue is summed for the axis. The cumulative total of each tissue in the entire breast is therefore the sum of the total tissue measurements of each axis.
For example total subcutaneous fat is given as:. To describe the proportion of tissues within the breast, cumulative totals of all tissues are calculated T. Results are expressed as totals of the tissue in millimetres and as a percentage of the total tissue of the breast [ 10 ].
When obstruction of milk flow is suspected such as with nipple piercing or previous surgery special consideration should be given to scanning the nipple-areola area.
Warm gel is advisable to avoid contraction of the muscle of the areola and nipple. Due the uneven and fibrous nature of the nipple distortion of the ultrasound beam may occur resulting in posterior acoustic shadowing rendering visualisation of the parenchyma behind the nipple poor [ 3 , 17 ].
Either the application of extra gel and pressure or angling around the nipple will ensure satisfactory documentation of this area [ 17 , 23 ].
We have found that an adapted version of rolled-nipple technique most useful in visualization of the ducts within the nipple Figure 6 [ 18 ]. Stavros recommends placing the index finger on one side of the nipple and placing the probe on the other side of the nipple thus rolling the nipple onto the finger [ 18 ].
This re-orientates the nipple ducts so that they are perpendicular to the ultrasound beam thus improving resolution. Since mothers' nipples tend to enlarge during pregnancy and lactation, the nipple can often be re-orientated with the transducer and frequently the upright position can facilitate scanning.
Ultrasound image of the nipple of a lactating breast. Ducts can be observed in the nipple as hypoechoic tubular structures. Visualization depends upon both the size of the duct and the resolution of the ultrasound equipment.
In addition we did not observe the typical sac like 'lactiferous sinus'. Severity of mastalgia in relation to milk duct dilatation. If the blocked duct becomes infected, you may feel a lump under the nipple. Journal of the American College of Surgeons. Additional File 2: Ultrasound video of milk ejection in the non-expressed breast during a pumping session. We provide you with a certificate of proof for your records and maintain our own meticulous record of the CME credit you earn through Davies.
Breast ultrasound pregnancy induced changes. RELATED POSTS
Breast is a typical female sexual physiologic organ that is influenced by steroid hormone from menarche until menopause. Therefore various diseases can be developed by continuous action of estrogen and progesterone. Breast diseases are mainly categorized as benign and malignant. It is very important to distinguish the malignancy from breast diseases.
However, it is very difficult to diagnose malignancy in pregnant and lactating women even though the same breast diseases took place. Therefore, we will review breast diseases such as breast carcinoma during pregnancy and lactation.
During pregnancy and lactation, a woman's breasts face several physiological changes. These changes can be attributed to various hormones, which may also cause vascular hyperplasia and hyperplastic lobules [ 1 ]. Such changes may hinder the interpretation of physical and medical imaging examinations of the breasts. It is important to note that most breast lesions that are diagnosed during pregnancy and lactation are benign; however, the different diagnosis of breast cancer is challenging during these periods.
Therefore, the aim of this article was to review the changes occurring in the breast, which are related to pregnancy and lactation, and to identify methods for the different diagnosis and treatment of breast disease. Breast begins to change under the influence of estrogen, progesterone, and prolactin from the mid-term in the first trimester of pregnancy.
Particularly, by the influence of estrogen the blood vessels show remarkable growth, and lobules are proliferated. For the meantime, fibrolipoma substrate decreases, blood flow increases, and infiltration of mononuclear cell are often accompanied. During the second and the third period of pregnancy, the proliferation of lobules and the decrease in the substrate become more apparent. Normally, due to progesterone, cell proliferation in the unit of lobule appears apparently, and due to estrogen, the ductal proliferation comes to be much intense.
Under the influence of the hormones prolactin and oxytoxin secreted by the posterior pituitary gland , during late pregnancy, the alveolar cells produce early breast milk called colostrum by taking up nutrients from the blood. Foremilk and hindmilk, whose compositions are different from that of colostrum, are subsequently produced with the help of the hormone progesterone lactogenesis I. In a period of lactation, due to drastic reduction of progesterone, prolactin levels increase.
Shape of myoepithelial cell becomes much thinner and flatter, and along with insulin, thyroid hormone and other metabolic hormones, the myoepithelial cell synthesizes the basic nutrients of breast milk-fat, lactose, and protein lactogenesis II.
During a period of lactation, breast displays the lobular expansion as well as the accumulation of ductal secretion Fig. The breast milk is secreted by oxytocin and neuroendocrine interactions. To producing of breastfeeding constantly being generated during a period of lactation, a certain amount of oxytocin from the posterior pituitary needs to secrete by stimulating that comes from sucking lactogenesis III [ 2 - 6 ].
Click for larger image. It takes three months after discontinuation of breast-feeding in order to pre-pregnancy state, and during this process pronounced atrophy of lobules is detected [ 3 ].
In this period, it is very difficult to distinguish between tumor and normal breast by clinical examination or imaging test. Since the breasts continue to grow and feel firm and nodular during pregnancy, it is possible that a tumor mass may appear as normal tissue during this period.
Furthermore, as the breast increases its size, the tumor mass may be located deeper, making it more difficult to identify via palpation. The physiological changes as stated above proliferates the breast parenchyma so that it increases the size, and increases the density of cells, blood vessels, or amount of moisture, therefore, the mammographic parenchymal density increase and diffuse Fig.
Especially, during the lactation period, breast parenchymal density is further increased so that expansion of the lactic duct seems to be nodular and hyperdensity appearance by breast milk filling nipples. Therefore, in pregnant and lactating women, it is difficult to diagnose a tumor by mammography because of the architectural distortion and asymmetric density of the tumor. In such cases, ultrasonography is a more suitable diagnostic procedure than mammography. If a biopsy is indicated by ultrasonography, further mammography must be performed to identify the range of lesions, including microcalcification lesions [ 7 - 12 ].
It is thought that fetal abnormalities, which may occur due to radiation during pregnancy, would appear in case of more than 0.
Yet, the radiation that fetus can receive through the mammography introduced in 4 times, is very small as 0. However, except special cases, it is recommended not conduct radiation tests during the first quarter of pregnancy. A Type 2 American College of Radiology classification shows before pregnancy. B Mammogram during lactation shows a marked diffuse increase in density.
One of the characteristics of breast ultrasonography conducted during pregnancy is that nonfatty fibroglandular tissue with diffuse feature becomes larger, as showing hypoechogenicity Fig. The other is that during a period of lactation, the nonfatty fibroglandular tissue displays hyperechogenicity, and both vascular tissue and vascular characteristic increase Fig. Ultrasonic waves can be used as the most dependable medical imaging examination to diagnose pregnancy and breast diseases that may appear during lactation period.
In case of malignant breast lumps, ultrasonic represents its higher sensitivity against the lumps, rather than mammography [ 8 , 9 ]. Click for larger image Fig. A Ultrasound US image shows irregular margined, hypoechoic dilated duct black arrowhead.
B US image reveals diffuse enlargement of the glandular component with diffuse hyperechogenicity. C Color Doppler US image reveals increased vascularity. It is not recommended to use magnetic resonance imaging MRI as a general inspection for the diagnosis and treatment of breast disease during pregnancy. According to American College of Radiology, in terms of diagnosis of breast diseases during pregnancy, MRI should only be used in cases that it would be regarded to have obvious benefits.
It is also said that except special cases, contrast media should not be used [ 16 ]. However, in recent studies, it was reported that contrast media would not be closely related to foetal abnormalities [ 17 , 18 ].
European Committee on Radiation Risk reported that gadolinium based contrast could be safely utilized during pregnancy, because it would be less absorbed into placenta and also, it would be rapidly excreted to kidney [ 19 ].
For MRI using gadolinium based contrast during a period of lactation makes less excretion to breast milk, it is known to be safe relatively [ 18 , 19 ]. Since the mammary epithelial cells undergo several cellular morphological changes during pregnancy and lactation, a false-positive result may be obtained during the diagnosis of breast cancer. Therefore, the results of these diagnostic procedures must be carefully interpreted.
A core biopsy examination of the suspected malignant lesion must be conducted and interpreted by a skilled pathologist [ 20 , 21 ]. Core biopsy, most appropriate method of tissue diagnosis in pregnancy and lactation period, is safe and economical cost-effective.
The process of breast milk production is characterized by increased blood flow to the breast, which increases the risk of bleeding, and expansion of the milk ducts increases the risk of infection, which can cause a milk fistula because breast milk is generated in this stage.
Milk fistula is known to occur more in central than in peripheral. Thus feeding temporarily suspend before aseptic surgery and a biopsy, biopsy is in the correct location and after the procedure, hemostasis using compresses or ice packs will help [ 22 ]. Microcalcification can be the result due to gestational hyperplasia associated with pregnancy and secretory hyperplasia associated with breast-feeding in mammography.
This calcification looks mostly round and focal or diffuse distribution, but rarely shows a irregular, linear distribution, branching pattern. Round and small punctate calcifications represent lobular acinar proliferation and linear distribution represents the growth of the cannulated Fig. A Image shows new cluster of indeterminate asymmetric microcalcification. B Craniocaudal spot-compression magnification mammograms: several clusters of heterogeneous and granular calcifications.
Some clusters display linear distribution. C Photomicrograph of histopathologic specimen: a Coarse microcalcification group is seen in the dilated duct.
The relatively bigger microcalcification thick arrow shows in the single duct with homogeneous and eosiophillic feature. Bloody nipple discharge does not occur commonly in pregnancy or in a period of lactation.
However, it can be cause by even small stimuli because the blood flow in breast increases rapidly and the change of epithelial cells gets even worst in 3rd trimester of pregnancy. This phenomenon mostly stops as the lactate feeding begins, but also has a possibility of a severe case that may persist throughout the whole lactation period.
Diagnostic cytology tests must be performed for the wounds of nipples by feeding. If the result, physical examination and ultrasound are normal, the follow up test should be recommended in a timely manner. If it seems to be abnormal in cytology, galactography should be performed especially when the bloody discharge is observed from one duct. However, it is important to help the patient to be relieved because this kind of bloody discharge is a rare symptom of PABC Figs.
A Magnification view mammogram of left breast in craniocaudal projection: extensive pleomorphic microcalcifications arrows. B Corresponding longitudinal ultrasound image: irregular solid hypoechoic mass long arrows with internal calcifications short arrows corresponding to mammographic finding. C A mammogram of 30 weeks of pregnant woman presented with bloody nipple discharge: Multilobulated filling defect long arrows , which focally expands duct.
Proximal duct is dilated short arrows. B The galactograms in patients with papillomatosis showing intra-ductal growth in a separate duct. Galactocele is a benign lesion, which is mostly detected after a few weeks or months from the time the patient stopped breast feeding, or during lactation or during the 3rd trimester of pregnancy [ 11 , 29 ]. This means it is surrounded by the epithelial cells and myoepithelial cells and contains liquid that is similar to lactate in cystic changed terminal duct and ductules.
Most of the galactoceles are found as painless palpable mass which contains protein, fat, lactose in aspiration analysis and are often accompanied by inflammation and necrosis. Therefore, it is considered that the galactocele is formed by the wall fibrosis due to the inflammatory response of extension of lactate ducts.
When the contents leak within the breast, chronic inflammation and fat necrosis are observed [ 30 ]. Needle aspiration biopsy is helpful for diagnosis and treatment, however, milk-like liquid during lactation and sticky milky contents after lactation, are found in aspiration [ 29 , 31 ].
If it recurrs even after several aspirations, imaging test is needed. Depending on the proportion of fat and protein in breast milk, mammographic findings of galactoceles may vary, which can be seen as follows. It is a diagnostic finding that is seen in the mediolateral oblique view of Mammography. Sonographic findings of galactoceles may also vary depending on the time and site of lesion.
In the acute phase, it may appear as an anechoic unilocular simple cyst or a multilocular cyst with thin septation. It is common multilocular cyst that occurs in peripheral region and it is common unilocular or bilocular cyst that occurs in central region.
The intensity of hypoechoic echo increases gradually due to the interface between the fat and water components. In this case, Doppler examination performed by the blood vessels in the center to make sure that no particles moving when you press the transducer lesions may be helpful in the diagnosis. In ultrasound, galactoceles only breast milk composition consists of benign solid masses as shown boundaries if and posterior acoustic enhancement seems clear.
A long time later, several ingredients are mixed and if you look inside looks mixed echogenic heterogeneous mass Figs. Galactoceles is rich in nutrients, and sometimes it can be infected. This finding is well observed in the ultrasound. Aspiration here, you can see that the purulent fluid and breast milk ingredients are mixed in Fig.
Most natural decay takes over several weeks, but occasionally a more long-lasting.