What are the management considerations for a 33-year-old postpartum woman with endometritis, hepatitis B (HBV) and hepatitis C (HCV) infections, and a history of cocaine use, who wishes to breastfeed after a cesarean delivery?

From the Guidelines

The patient should not breastfeed due to her active cocaine use, which poses significant risks to the infant. Cocaine is excreted in breast milk and can cause serious adverse effects in infants, including irritability, vomiting, diarrhea, tremors, seizures, and hypertension. While her hepatitis B and C infections are not absolute contraindications to breastfeeding, her ongoing substance abuse is. According to the most recent guidelines, hepatitis C infection is not a contraindication to breastfeeding, except in the case of bleeding or cracked nipples 1. The patient's history of lactational mastitis with her first child also suggests she may benefit from additional lactation support if she were to breastfeed in the future after achieving sobriety.

Regarding her hepatitis status, she has chronic hepatitis B (positive HBsAg, negative IgM anti-HBc, positive IgG anti-HBc, negative HBsAb) with undetectable viral load, and is also hepatitis C positive. The appropriate prophylaxis has been given to her infant (HBIG and HBV vaccine), which is effective in preventing vertical transmission of hepatitis B. The patient should be referred to substance abuse treatment and counseled about the importance of maintaining sobriety before considering breastfeeding any future children. She should also receive follow-up care for her hepatitis B and C infections, including evaluation for potential treatment, as recommended by the Society for Maternal-Fetal Medicine 1.

Some key points to consider in the management of this patient include:

• The importance of substance abuse treatment and counseling to prevent harm to future infants
• The need for follow-up care for hepatitis B and C infections, including evaluation for potential treatment
• The benefits of breastfeeding for infants, including reduced risk of sudden infant death syndrome (SIDS), lower respiratory tract infection, and severe or persistent diarrhea, as well as long-term benefits such as reduced risk of childhood obesity, type 1 and 2 diabetes, and certain types of cancer 1
• The potential risks and benefits of breastfeeding in the context of hepatitis B and C infections, and the importance of individualized counseling and care for each patient.

From the FDA Drug Label

Nursing Mothers Limited published data based on breast milk sampling reports that clindamycin appears in human breast milk in the range of less than 0.5 to 3. 8 mcg/mL at dosages of 150 mg orally to 600 mg intravenously. Clindamycin has the potential to cause adverse effects on the breastfed infant's gastrointestinal flora. If oral or intravenous clindamycin is required by a nursing mother, it is not a reason to discontinue breastfeeding, but an alternate drug may be preferred Monitor the breastfed infant for possible adverse effects on the gastrointestinal flora, such as diarrhea, candidiasis (thrush, diaper rash) or rarely, blood in the stool indicating possible antibiotic-associated colitis

The patient can breastfeed while taking clindamycin, but it is recommended to monitor the breastfed infant for possible adverse effects on the gastrointestinal flora, such as diarrhea, candidiasis, or blood in the stool 2.

From the Research

Patient's Postoperative Course and Treatment

• The patient is being treated with intravenous gentamicin and clindamycin for endometritis, which is a common complication after cesarean delivery 3.
• The combination of gentamicin and clindamycin is an appropriate treatment for endometritis, and regimens with activity against penicillin-resistant anaerobic bacteria are more effective than those without 3.
• Once-daily dosing with gentamicin and clindamycin has been shown to have a similar success rate as the standard every 8-hour dosing schedule 4.

Hepatitis B and C Infection

• The patient is positive for hepatitis B surface antigen and hepatitis C virus antibody, indicating a current or past infection with these viruses.
• The patient's infant received hepatitis B immunoglobulin and the hepatitis B vaccination after delivery, which is the standard treatment for preventing hepatitis B transmission from mother to child.
• Cocaine use has been associated with an increased risk of hepatitis C infection, and the patient's history of cocaine use may have contributed to her infection 5.
• Antiviral medications are available for the treatment of hepatitis B and C infection, but some of these medications may have nephrotoxic effects and require close monitoring of renal function 6.

Cocaine Use and Cardiovascular Risks

• The patient's cocaine use is a significant concern, as it can cause irreversible structural damage to the heart, accelerate cardiovascular disease, and initiate sudden cardiac death 7.
• Cocaine use has been associated with myocardial infarction, arrhythmia, heart failure, and sudden cardiac death, and the patient's history of cocaine use may increase her risk for these complications 7.
• Treatment for cocaine-related cardiovascular disease is similar to treatment for traditional cardiovascular disease, but the use of certain medications, such as beta-receptor antagonists and class Ia and III anti-arrhythmics, is strongly discouraged if the patient is likely to continue cocaine use 7.