• abortion, induced
• Abortion, Spontaneous
• family planning services

Breast engorgement and milk leakage following second-trimester perinatal loss and abortion is common and can cause both physical pain and emotional distress.1 2 Currently, there is limited clinical guidance regarding counselling or available treatment modalities.3 Therefore, we aimed to characterise current practice patterns in anticipatory guidance and use of non-pharmacological or pharmacological therapies to manage symptomatic breast engorgement after second-trimester abortion or pregnancy loss.

We conducted a web-based, cross-sectional survey of reproductive healthcare professionals between August and October 2022.3 With the intention to target clinicians providing abortion care across the United States, we distributed the survey nationally to a sample of abortion care providers recruited via a digital Facebook member group (total members, N=234). To protect the anonymity of respondents, we collected limited demographic information regarding clinician demographic region and specialty training. We presented respondents with multiple statements regarding clinical experience managing breast symptoms to rate their agreement using a five-point Likert scale (1=strongly disagree to 5=strongly agree). We present descriptive statistics of clinician demographics and practice patterns.

Overall, 130 (55.5% total response rate, 91.5% survey initiation to completion) respondents completed the survey with representative geographic diversity: 32.3% East Coast, 7.5% Midwest, 29.0% South Southwest and 31.2% Mountain/West Coast. Nearly half of the respondents were Complex Family Planning fellowship-trained (47.7%). Almost all (92.3%) respondents reported a patient ever experiencing breast pain after second-trimester abortion or loss.

Many respondents reported that they are more likely (answering ‘agree’ or ‘strongly agree’) to provide counselling regarding breast symptoms for those with a fetal anomaly compared with an undesired pregnancy (38.5%) and for stillbirth compared with abortion (25.4%) .

Most respondents (73.1%, n=95) reported that they currently counsel patients to expect breast pain. The majority of respondents (55.4%) started counselling patients at 20 weeks’ gestational duration or later (figure 1). All (100%) suggested the use of non-pharmacological modalities. Half (50.5%) of those that counsel to expect pain disagreed (answering ‘disagree’ or ‘strongly disagree’) that existing non-pharmacological and pharmacological strategies are sufficient to manage patients.

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Figure 1

Gestational duration when providers initiate counselling surrounding breast symptoms after second-trimester abortion or pregnancy loss.

A minority of respondents (26.9%, n=35) offer pharmacological prevention or treatment of breast engorgement, including (in decreasing order of frequency reported): oral nonsteroidal anti-inflammatory drugs, pseudoephedrine, cabergoline and diphenhydramine. The most common reason for not providing pharmacological modalities (n=95) is lack of awareness of available options (44.2%) and concern that current pharmacological modalities are not effective (37.9%).

Of those who do not routinely provide anticipatory guidance regarding breast symptoms (n=35), the most cited reasons included a belief that most patients do not experience (60.0%) and/or are not bothered (91.4%) by breast symptoms.

In this exploratory convenience sample obtained from an online Facebook group of those who provide abortion care, we found that many clinicians are currently providing anticipatory guidance for breast symptoms after second-trimester abortion care or pregnancy loss. However, there appears to be variation in counselling by clinical indication and gestational duration. In this survey, few respondents routinely prescribed pharmacological interventions for breast engorgement prevention. Emerging data around the frequency of breast symptoms following second-trimester abortion or pregnancy loss and evidence-based management strategies may aid in the standardisation of practice patterns.1 3 4

Survey responses should be viewed as exploratory given the potential for nonresponse bias in our sample. It is also possible that we captured unintended snowball sampling if the survey link was shared beyond the social media platform. We must also consider exclusion bias or outgroup bias as not all people use social media. As we collected limited demographic information for respondents, we are unable to report how respondent experience with prior breastfeeding or pregnancy loss may influence counselling. This survey intentionally targeted those who are most likely to manage patients with a second-trimester abortion or stillbirth; these findings may not be generalisable to all practising obstetricians and gynaecologists who may have less frequent encounters with this patient population and potentially less knowledge of experience and treatment.

In the absence of consistent society guidelines, this survey suggests significant practice variation exists in both counselling and management of breast engorgement after second-trimester abortion or pregnancy loss.