A 28-year-old primigravida on day 3 postpartum presents with severe breast engorgement, pain, and inability to breastfeed effectively. She is afebrile with no signs of mastitis. What is the drug of choice to suppress lactation and relieve symptoms?

Explanation

## Lactation Suppression in Postpartum Engorgement **Key Point:** Bromocriptine is the dopamine agonist of choice for suppressing lactation when medically indicated, acting by inhibiting prolactin secretion from the anterior pituitary. ### Mechanism of Action Bromocriptine binds to D₂ dopamine receptors on lactotroph cells, suppressing prolactin release and thereby halting milk production within 12–24 hours. This is the most effective pharmacological approach to lactation suppression. ### Clinical Use in Engorgement - **Timing:** Most effective when started early (day 1–3 postpartum) - **Dosing:** 2.5 mg once or twice daily for 10–14 days - **Onset:** Relief of engorgement within 24–48 hours - **Contraindications:** Hypertension, migraine with aura, cardiovascular disease **High-Yield:** Bromocriptine is superior to other agents because it directly addresses the hormonal driver of lactation (prolactin), whereas supportive measures (ice, analgesia, proper emptying) are adjunctive. ### Comparison with Other Lactation-Suppressing Agents | Agent | Mechanism | Efficacy | Current Status | |-------|-----------|----------|----------------| | **Bromocriptine** | Dopamine agonist (D₂ receptor) | Excellent | First-line; preferred | | **Cabergoline** | Dopamine agonist (longer-acting) | Excellent | Alternative; less side effects | | **Estrogen** | Inhibits prolactin | Moderate | Rarely used; thromboembolism risk | | **NSAIDs** | Anti-inflammatory | Supportive only | Adjunctive for pain | **Clinical Pearl:** In the modern era, bromocriptine is preferred over older estrogen-based regimens due to superior safety profile and lack of thromboembolism risk. ### Why Lactation Suppression May Be Indicated - Severe engorgement unresponsive to conservative measures - Maternal contraindication to breastfeeding (e.g., HIV, active tuberculosis, certain medications) - Maternal choice with informed consent - Breast abscess or severe mastitis in non-breastfeeding mothers [cite:Williams Obstetrics 26e Ch 37]