Maya Kapsokavadis describes her experience of maintaining her breastfeeding journey while undergoing heart surgery

In November 2023, I had the shock of my life: I found out I needed urgent heart surgery. I was still breastfeeding my second child who was then 15 months old. We were on three to four feeds per day). I had an amazing nurse practitioner who was determined to find a way to keep me breastfeeding, which would involve pumping after surgery. I was told I would need to spend a day in the ICU, followed by three or four more days in the step-down cardiac unit.

I had a lot of questions:

1) Could I safely continue to breastfeed after a general anaesthetic? The surgery would be almost 5 hours long.

2) How safe are the anti-a-fib drugs?

3) How do you breastfeed with an incision? I was luckily avoiding a sternotomy, but there will be a long incision on my right-side. My son was 15-months so a very handsy/active feeder.

4) - If I have to wean, how do I do it so quickly? I'm not looking forward to the hormone hit during a major life event.

My condition

I was suffering from mitral valve prolapse (MVP) with severe mitral valve regurgitation (MVR). The MV posterior leaflet had flail with a severe eccentric, anterior directed jet of MVR. I had been symptomatic for well over a year, and the chances of having a heart attack or stroke one-year after symptoms onset is > 52%.

The surgery

Mini-thoracotomy. Even though it is called a “minimally invasive surgery” it is still open-heart surgery. I was put on a heart-lung bypass machine, had chest tubes and pacer wires when I woke up, a groin incision, was intubated, with a catheter, central line, and two other access IV lines). This surgery is typically 4 to 6 hours.

The plan

It changed a lot! Why? Because it was based on two constantly changing factors:

(1) The drugs (see drug notes below) since these impacted breastfeeding.

(2) The delta between my final feed with the baby and the first (assisted) pumping session. We only got my surgery time the night before surgery, which made planning tricky.

My plan was:

1.        Drop as many feeds as possible without tanking supply and upsetting baby:

We were bf 4-6x/day when I found out I needed surgery. To prepare, we proactively dropped feeds to 3-4x/day over a two-week period. I had plans to get the feeds down to 2x/day, but 3 was really his limit.

2.        Start supplement feeding: My husband and nanny started taking him up for naps and offering a bottle filled with a goat milk organic formula. With both of my children I had a milk oversupply issue and never supplemented feeding. However, I wanted to have something to offer him for comfort while I was in the hospital to avoid any shocks and to avoid any rejection issues later.

3.        3 am on surgery day: Wake up the baby and breastfeed him before I had to initiate pre-op surgery prep activities (shower with a CHD solution to make sure your skin is sterile).

4.        Pre-op: Alert the anesthesiologist about my breastfeeding and ask that they not administer drugs that were contraindicated.

5.        Hospital: Line up hospital lactation support, although not regularly used for cardiac patients. The plan was to have lactation support available to me in the ICU immediately after surgery to help me pump. I packed my own pump as a back-up. I wasn’t sure how long I might be in the ICU or if there would be complications, but the plan was to have lactation visit and help me pump, if necessary, for as long as needed. Once I was transferred to the cardiac step-down unit, my plan was to pump as I needed, when needed, on my former feeding schedule.

6.        Transition home: Follow my baby’s lead and buffer my body with pillows. Husband would position the baby (you have a lift restriction following open heart surgery of not more than 15 pounds for six to eight weeks post-op, which was honestly one of the worst things ever). This course of action was dependent on me (1) NOT TAKING ANY OTHER DRUGS WITH PASS-THROUGH SIDE EFFECTS ON THE BABY or (2) LONG HALF-LIVES while in hospital.

What Actually Happened

Planned last feed: 3 am day of surgery           Real last feed: 6:30 pm night before surgery

I woke the baby to feed him at 3 am, before my surgery day pre-op showers. But, my milk wouldn’t let down. Whether from the stress or the dropped feeds, it just wouldn’t come, and I hadn’t factored in allowing time for something like that to happen. I cannot overstate how stressful this was. I was doing mental math trying to work out how long it would be between his last feed the night before (6:30 pm) and my “get out of surgery time” of probably near 3 pm the following day. At the end of the day, there was nothing else to do. I couldn’t pump at the hospital before surgery because I had to keep my body 100% sterile.

I woke up in the ICU room after surgery just after being extubated. My mom and husband were in the room, along with someone from lactation. Lactation pumped me although I was in and out of consciousness. I recall being worried because the breastmilk had blood in it on the side that had the incision (it makes sense, but it surprised me). We struggled to get much milk out and I remember being worried about that, too. My pump time of 3 pm was about 21 hours after my last feed, equating to two dropped feeds.  After I moved to my ICU bedroom, I tried to pump with the hospital pump and then my own breast pump later that night (probably 10 pm) after they took out the catheter and the central line. My breasts offered up murky, gray, and pink breastmilk in very small quantities. I started to get worried I was going to get mastitis and asked the nurse to arrange for someone in lactation to stop by the next day.

Low and behold, the next day my breasts were incredibly lumpy and painful. I joked that the worst part of the open-heart surgery was my boobs. I called my husband crying and he came to the hospital to help support me. I was stuck in a vicious pump-cycle of needing to pump to remove the clogged milk, but then the breasts immediately becoming swollen and lumpy again. I ended up taking tramadol (see below, an NSAID) and packing ice on my breasts. I used lymphatic drainage massage techniques. I tried to not be stressed and watched the clock to intentionally move to a twice day pump schedule to not overstimulate them. After another day, we were back to normal.

I ended up staying in the hospital four days. (Notes below follow on the drugs I took – when and why, and how these affected our planning). I returned home at night on day four, and was confronted with two new forgotten realities. I could not pick up my baby with the weight-limit and had incisions circling my right-breast. Two under the boob from chest tube drains, one port access on the boob near my heart, and the large incision under my right arm on the ribs. Not to mention a groin incision on the opposite leg side. We ended up going up to bed. I put one pillow over my left leg groin. I put another pillow over my major incision below the boob, sort of wedged under my arm, and then my husband plunked the baby head down on top of that side. He stayed by for the feed to make sure that he wouldn’t roll off me after and hit any of my other points of injury.  

The Drugs

These broke into two camps - heart/surgery related drugs and pain medications. I spoke at length with my surgeon’s office about the fact that I was breastfeeding and that I wanted to continue through and after surgery. The NP in the surgeon’s office and I discussed at length the potential drugs I may be given both pre- and post-op that could be administered both with and without my knowledge and consent.  I was not on any beta-blockers prior to heart surgery since my heart itself was strong (0 calcium score – no heart failure/stenosis, and otherwise quite healthy).

Amiodarone – By far the scariest drug in the mix that my surgeon wanted to give me, amiodarone is typically administered as a pre-op course of treatment to PREVENTATIVELY reduce the risk of post-operative atrial fibrillation. It can also be administered either orally or intravenously in-op and post-op should you go into atrial fibrillation at any point in time (the highest risk of a-fib is the first 30 days after open heart surgery, after which the risk drops dramatically).

Amiodarone is an L5 - Limited Data-Hazardous drug, extremely risky to both mothers and breastfeeding infants. My aunt (who is a former oncological nurse) referred to it as “drug of last resort” – in other words, a drug you take if you must, but not something you take electively due to its nasty side effects. It also has a very long half-life of 24 to 107 days (see materials copied below from the Infant Risk Center) and the two links below.

https://www.ncbi.nlm.nih.gov/books/NBK500560/

https://www.e-lactancia.org/breastfeeding/amiodarone/product/

From the Infant Risk Center information on AMIODARONE:

Amiodarone is a potent antiarrhythmic drug that requires close supervision by clinicians as it has numerous serious adverse effects.[1] Although poorly absorbed by the mother (35%-65%), maximum serum levels are attained after 3-7 hours. This drug has a very large volume of distribution, resulting in accumulation in the liver, spleen, lungs, and the adipose tissue.

A woman taking amiodarone 400 mg daily throughout pregnancy and lactation was followed for 2 months postpartum.[2] Milk samples were drawn on day 1, 4, 7, 14, and 31 postpartum. The concentrations of amiodarone and desethylamiodarone (active metabolite) in milk ranged from 1.06-3.65 mg/L and 0.5 to 1.24 mg/L, respectively. The highest levels correspond with a relative infant dose of about 9.6%. In this case the child was euthyroid and no concerns with goiter, growth, or corneal deposits were found.

Pitcher et al. reported amiodarone concentrations in milk from a woman receiving amiodarone 600 mg daily at 37 weeks, 400 mg daily at 36 weeks and 200 mg daily at 39 weeks.[3] In samples taken on the second and third day postpartum the concentrations of amiodarone and desethylamiodarone in milk ranged from 0.5 to 1.8 mg/L and 0.4 to 0.8 mg/L, respectively. In this case, the patient chose not to breastfeed her infant.

In one publication, the amount of drug secreted into breast milk was higher than the maternal plasma levels.[4] Breast milk samples obtained from birth to 3 weeks postpartum in two patients, receiving amiodarone 200 mg daily, contained levels of amiodarone and desethylamiodarone ranging 1.7 to 3.04 mg/L and 0.75 to 1.81 mg/L, respectively. In a third patient receiving amiodarone 200 mg/day in pregnancy and for one week postpartum, milk samples were checked at week 4 and 6 after delivery. The concentrations of amiodarone and desethylamiodarone in milk declined from 0.55 to 0.03 mg/L and 0.44 to 0.002 mg/L, respectively. Despite the concentrations of amiodarone in milk, the amounts were apparently not high enough to produce infant plasma levels higher than about 0.03 mg/L of amiodarone, which were minimal compared to the maternal plasma levels of 0.13 to 0.66 mg/L of amiodarone. In one case where an infant was exposed to the medication in pregnancy and lactation, the infant was hypothyroid at day 9 of life. Because this persisted at day 24 of life, the infant was initiated on treatment and breastfeeding was stopped at 5 weeks.

McKenna et al. reported amiodarone milk levels in a mother treated with 400 mg daily.[5] In this study, at 6 weeks postpartum, breast milk levels of amiodarone and desethylamiodarone varied during the day from 2.8-16.4 mg/L and 1.1-6.5 mg/L respectively. Reported infant plasma levels of amiodarone and desethylamiodarone were 0.4 mg/L and 0.25 mg/L respectively. The dose ingested by the infant was approximately 1.5 mg/kg/day. The authors suggest that the amount of amiodarone ingested was moderate and could expose the developing infant to a significant dose of the drug and should be avoided.

In another case, a woman took 200 mg of amiodarone twice daily to treat fetal ascites and tachycardia.[6] Upon delivery, the mother stopped taking amiodarone. Her breast milk was tested and the amiodarone levels in milk were 0.6 mg/L, 2.1 mg/L, and undetectable on days 5, 11, and 25, respectively. The baby was monitored closely during this lactation period and thyroid function was reported as normal.

Khurana et al. published a case report of a woman started on an IV amiodarone infusion a few hours after delivery until 6 days postpartum (total 7.6 g given IV) for a cardiac condition diagnosed around the time of delivery.[7] The patient was also given two oral doses of amiodarone 200 mg on day 6 and 7 postpartum. The patient manually expressed and discarded her milk until her care providers were able to assess her new medication in milk. Samples were initially taken on day 18 postpartum (11 days after the last dose); the estimated infant dose was 1.81 mg or 0.72 mg/kg/day. A subsequent sample was drawn 5 days later and the estimated infant dose was 0.32 mg/kg/day. In this case report the infant was never given any maternal milk.

In a more recent case report of a breastfeeding mother who received a single intravenous dose of 450 mg, milk levels peaked at day 4 at 233 µg/L.[8] Milk to plasma ratio was reported at 3.5 at this time. Levels in milk were still detectable on day 10 at 132 µg/L. The authors calculated the maximum relative infant dose at 0.6%. This dose is far less than used clinically in an infant.

Although not demonstrated in the data above, amiodarone concentrations could theoretically accumulate in the infant with ongoing maternal use because of its long half-life and distribution in various organs.[2-8] This product should only be used under rare conditions when other alternative therapies are not appropriate. If used briefly (3-7 days) a 24-48 hour interruption is recommended before re-instating breastfeeding; the infant should be closely monitored for cardiovascular and thyroid function. Breastfeeding is not recommended if this product is used chronically.

T ½ 26-107 days

M/P 4.6-13

Tmax 3-7 h

PB 96%

MW 645

Oral 35%-65%

Vd 18-148

pKa 6.6

RID 0.54%-43.1%

Adult Concerns - Headache, insomnia, malaise, altered sense of smell, hypothyroidism and hyperthyroidism, hypotension, arrhythmias, heart failure, pulmonary toxicity, anorexia, nausea, vomiting, serious liver injury, tremor, abnormal gait, blue-gray skin pigmentation.

Adult Dose 200-800 mg once to twice daily (variable based on indication).

Pediatric Concerns - Hypothyroidism has been reported in one case with exposure in utero and breast milk.[4]

Infant Monitoring - Drowsiness, lethargy, pallor, changes in feeding, or weight gain. Based on clinical symptoms some infants may require monitoring of thyroid or liver function.

Alternatives - Disopyramide, mexiletine.

References

1.Pharmaceutical manufacturers prescribing information.

2.Strunge P, Frandsen J, Andreasen F, et al. Amiodarone during pregnancy. Eur Heart J. 1988;9:106-109.

3.Pitcher D, Leather HM, Storey GCA, et al. Amiodarone in pregnancy. Lancet. 1983;321(8324):597-598.

4.Plomp TA, Vulsma T, de Vijlder JJ. Use of amiodarone during pregnancy. Eur J Obstet Gynecol Reprod Biol. 1992;43(3):201-207.

5.McKenna WJ, Harris L, Rowland E, Whitelaw A, Storey G, Holt D. Amiodarone therapy during pregnancy. Am J Cardiol. 1983;51(7):1231-1233.

6.Hall CM, McCormick KPB. Amiodarone and breast feeding. Arch Dis Child Fetal Neonatal Ed. May 2003;88(3):F255-F254.

7.Khurana R, Bin Jardan YA, Wilkie J, et al. Breast milk concentrations of amiodarone, desethylamiodarone, and bisoprolol following short-term drug exposure: two case reports. J Clin Pharmacol. 2014;54(7):828-831.

8.Javot L, Pape E, Yelehe-Okouma M, et al. Intravenous single administration of amiodarone and breastfeeding. Fundam Clin Pharmacol. June 2019;33(3):367-372.

The surgeon’s office wanted to prescribe me amiodarone for the five days prior to surgery (oral 200 mg x 3 times daily = 600 mg per day). 

I received lots of conflicting advice on the risks to my infant.  When I discussed the need to take amiodarone with the surgeon’s nurse practitioner, we agreed that we would each research the drug. I reached out to the NWL Breastfeeding Forum seeking advice and resources. The nurse practitioner asked a group of local midwives practicing at GW hospital in Washington, DC. I called the Infant Risk Center in Texas who advised me to stop breastfeeding entirely should I take the drug because of its long half-life. I emailed Dr. Wendy Jones, who also shared resources with me that I share with you here. When I returned to my surgeon’s office, the nurse practitioner and I exchanged our findings. She then said that I could always elect not to take the amiodarone. I took a few more days to think. There would be risks in not taking the drug – and there was always a chance that even if I did not take it pre-operatively that I would go into a-fib on the operating table and the surgeon would need to administer it intravenously without my consent to save my life.

After many ups and downs, I spoke with my aunt (a nurse of 40 years) and we both agreed that I would take the amiodarone and discontinue breastfeeding, because the most important thing was that I get through the surgery with the best outcome possible.

As soon as I decided to take the drug – also, the night before I would need to start my medication, I received a call from the NP telling me that my blood pressure was too low to take amiodarone and that if I started taking the drug as planned that I was in all likelihood going to be passing out regularly for the next five days.

At this stage, I was both relieved and terrified. In the end, I did not take amiodarone and I also did not go into a-fib, either in the operating room, or after surgery.

Breastfeeding after General Anesthesia: A conversation with my anesthesiologist on the day of surgery helped me understand that the two drugs I would be receiving (relaxants and medication to decrease secretions) had very short-half-lives (i.e., would be out of my system and out of my milk before I left the hospital).

Pain medications: These were up to me. Because I live in America, the biggest struggles I had were (believe it or not) (1) getting information on the drug in my hazy post-op state, and (2) turning the drug down.

 I had different rules depending where I was in my recovery. That said, I had a hard rule for myself that I refuse any opioid offered following surgery.

·      Rules for the ICU (overnight day 1) - After I was extubated and reawakened, I would say yes if: (a) I was in pain and (b) it would be out of my system before leaving the hospital. These were two questions I constantly asked my nurses when they asked if I needed medication. What is the drug’s half-life? What are the side effects?

·      Rules for the step down unit (days 2-4): After the first day and I transferred to the step-down unit my rule evolved to be “if okayed by lactation.”

Tramadol: Advice from Infant Risk Center and lactation was “Tramadol is rated an L3-limited data-probably compatible. The amount that transfers into breast milk is 2.86% of the dose. Tramadol peaks at 2 hours and the half-life is 7 hours. Advice is to generally take the medicine right after nursing or pumping so that you have a break before nursing again. Short term use is probably ok as long as your infant is not symptomatic. Monitor for sedation, slowed breathing rate/apnea, pallor, constipation, not waking to feed/poor feeding.”

I decided to use tramadol sparingly and only for the most severe pain. I had ended all use of tramadol by the second day in hospital to make sure it was out of my system by the fourth day.

Ketorolac (commonly known as Toradol) (an L2 drug): Based on my discussions with lactation, 99% of the drug in the mother’s blood is bound to protein, so only 1% of the already tiny amount of drug in the mother’s blood can actually get into the milk. Most of the nonsteroidal anti-inflammatory drugs (NSAIDs), have similar protein binding. Infant Risk Center also told me that the risks were negligible at best.

Gabapentin (an L2 drug): Gabapentin is a medication that is used to prevent and control seizures and nerve pain. The amount that transfers into breast milk is 6.6% of your dose. Infant Risk Center advice was to check the dosing, but to monitoring the infant for symptoms including sedation or irritability, not waking to feed/poor feeding, vomiting and tremor. Take the medication after nursing, it is most concentrated in the milk in 1-3 hours after taking the medication.

The issue with gabapentin (that no one mentioned to me when I started taking it in hospital) is that you really need to be weaned off your dose. Stopping abruptly can cause adverse reactions. Because of this fact, I could not stop taking gaba when I wanted (it gave me a visual aura). I stopped as soon as possible, but took it as advised by the infant risk center (only after feeds) and I started halving my doses as soon as I returned home under the advice of a nurse friend of mine.

Surprise medications:

·      In surgery, the anesthesiologist hooked me up to an anesthesia nerve block to preventatively manage pain that was directly administered in my back through an epidural. I forced the hospital to clamp it after I made it down to the cardiac step-down unit, since I was going toxic (making my tongue and feet numb). They strongly advised me to continue clamping, but I won the battle to have it removed. I was right, I did not need it.

·      Heparin: I received daily heparin shots in the hospital. The drug is used to prevent clotting of the blood, an anticoagulant. It is too large to get into the milk. I did not worry about its effects on breastfeeding since the shots were time-bound to my stay in the hospital and would discontinue once home.

Helpful Resources:

Infant Risk - https://infantrisk.com – For US patients, there is a free 1-800 number that you can reach a person to ask your questions of.

Caroline Warden referred me to Dr. Wendy Jones (Pharmacist) - Wendy@breastfeeding-and-medication.co.uk

Questions you’ll want to ask and answer about drugs that you are receiving:

·      Drug class (e.g., is there pass through from the mother’s milk to the breastfeeding infant? And how well-researched is it?)

·      What is the planned dosing?

·      Drug half-life? When will it be out of your system based on the half-life.

·      Are there any effective alternatives that are safer for breastfeeding mothers and babies?

·      Be prepared for how you want to navigate receiving conflicting advice.