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Pregnancy After a TRAM Flap Procedure: Principles of Nursing Care
JOGNN
PRINCIPLES
CF
PRACTICE
Pregnancy After a TRAM Flap Procedure: Principles of Nursing Care Linda Hedlund Wagner, RN, MS, CEN, Lisa A. Ruth-Sahd, RN, MSN, CEN, CCRN
=
Breast cancer is the most common malignan-
cy in women in the United States and affects more
than 200,000 women annually. The incidence increases exponentially with age from the 3rd to the 5th decade of life. Many women are now choosing to have a more natural breast reconstruction concomitantly with their mastectomy. A TRAM (transverse rectus abdominis myocutaneous) flap is a procedure to reconstruct the breast mound using autologous tissue. Women of childbearing age who have undergone a TRAM flap may safely consider pregnancy after such a procedure. The principles of nursing care for pregnant women who have undergone a T R A M flap surgery are presented in this article. A case report of pregnancy after a TRAM flap i s included. JOG", 29, 363-368; 2000. Keywords: Autologous breast reconstruction-Breast cancer-Breast reconstruction-Nursing care-Pregnancy-TRAM (transverse rectus abdominis myocutaneous) flap-Vaginal delivery Accepted: January 2000
Today, many patients who face breast reconstruction after mastectomy for breast cancer or for prophylaxis against breast cancer and patients with an anomaly in which they never developed a breast (Poland's syndrome) are choosing to have reconstructive surgery that uses their own tissue. For some women, breast reconstruction is an essential part of total and holistic breast cancer management. Reconstructive surgery helps restore self-image by preserving the way a woman perceives herself (Hart, 1996; Ivey & Gordon, 1994). Since 1982, major advances have occurred in the surgical treatment of breast cancer after mastectoJulylAugust 2000
my, primarily reconstructive surgery using the transverse rectus abdominis myocutaneous (TRAM) flap. This procedure uses a section of the woman's own skin and abdominal muscle to rebuild a natural-looking breast mound and has become a well-established and popular method for reconstruction (Clayton & Waller, 1996; Harden & Girard, 1994; Hartrampf, Anton, & Bried, 1997; Spear & Hartrampf, 1998). In the past, women facing breast reconstruction were told to choose silicone gel or saline filled implants if they planned to have children. It was assumed that TRAM flap surgery would weaken the woman's abdominal wall, rendering it incapable of supporting a pregnancy. To date, little has been published about pregnancy after a TRAM flap procedure (Hartrampf, Chen, & Bennett, 1996). Breast cancer is occurring more frequently in women of all ages, including women of childbearing age (Petrek, 1994). Women are delaying having children for academic, professional, and personal reasons, which increases the likelihood of their becoming pregnant during or after a battle with breast cancer. Pregnancy subsequent to
T h e TRAM flap procedure uses a section of the woman's own skin and abdominal muscle to rebuild a natural looking breast mound.
JOG"
363
breast cancer has been studied primarily for its effect on cancer recurrence and metastasis (Petrek, 1994; Sankila, Heinavaara, & Hakulinen, 1994; Schoultz, Johansson, Wilking, & Rutqvist, 1995). For women who choose TRAM flap reconstruction after a mastectomy, pregnancy poses other concerns, which have not previously been addressed. Women have many factors to consider when determining the type of reconstruction they will have (Townsend, 1997). In the wake of controversies about silicone gel and saline filled implants, more women are choosing breast reconstruction using their own tissue. The TRAM flap approach offers the patient advantages of (a) creating a softer, more natural-appearing breast mound composed of autogenous tissue without the risks associated with other types of manufactured implants; (b) producing an abdominal lipectomy or “tummy tuck” in the donor area (Maxwell & Hammond, 1997); and (c) avoiding implantation of foreign material into the body. Women of childbearing age have been denied TRAM flap surgery because of an incorrect assumption about abdominal wall integrity. Women also were informed that they needed to have a cesarean delivery if they gave birth after a TRAM flap procedure. However, according to Hartrampf et al. (1996), health care practitioners need to recall that the uterus is the major muscle which supports a pregnancy and aids in the delivery of a newborn. Hartrampf also states that the abdominal muscles are secondary in assisting with the delivery. Therefore, after a TRAM flap procedure a patient should be able to carry and vaginally deliver a full-term newborn.
T h e uterus i s the major muscle to support a pregnancy and aid in the delivery of the newborn. The abdominal muscles are actually secondary in assisting with the delivery.
TRAM Flap Procedure It is helpful for an obstetric and gynecologic nurse to have a basic understanding of the TRAM flap surgical procedure. Preoperatively, the patient will meet with. a plastic surgeon. During this visit the surgeon marks the patient’s lower abdomen from hip to hip and her breast to determine where the surgical incisions will be placed (see Figure 1). It is best to do this when the patient is in the standing position.
364 JOGNN
3
FIGURE 1
Abdominal markings display where the surgeon will incise the abdomen. Note. From “Breast Reconstruction Following Mastectomy,” by G. P Maxwell & D. C. Hammond, 1997, In S. J. Aston, R. W. Beasley, & C. H. Thorne, (Eds.), Grub6 and Smith’s Plastic Surgery (5th ed., p. 772). Philadelphia: Lippincott-Raven. Reprinted with permission.
Patient selection is important for the operation to be complication-free. Patients with an obese abdomen are at much higher risk for flap loss and are therefore poor candidates for the TRAM flap procedure (Shamoun & Hartrampf, 1996). Likewise, heavy smokers and diabetics are at risk for consequences of poor flap vasculature because of prolonged healing times and infection (Banerjee & Monypenny, 1998). Any previous abdominal incision that transected the rectus abdominis muscle may preclude the use of that particular muscle flap (Maxwell & Hammond, 1997). The surgery itself is a lengthy microsurgical procedure and may take up to 12 hours (Harden & Girard, 1994). Often two surgeons work together: As one surgeon performs the mastectomy, the other is working on the abdominal area to release the rectus abdominis flap. Once the flap is dissected, a tunnel is made medially to connect the abdominal dissection over the sternum to the mastectomy site. The flap is cautiously passed through this tunnel into the chest wall to form the breast mound (see Figure 2). Abdominal reconstruction can be accomplished by primary closure of the remaining medi-
Volume 29, Number 4
Flap
I
Y
\
FIGURE 2 Placement of contralateral single muscle TRAM flap, forming breast mound. Note: From “Breast Reconstruction Following Mastectomy,” by G. P Maxwell & D. C. Hammond, 1997, In S. J. Aston, R. W. Beasley, & C. H. Thorne, (Eds.), Grabb and Smith’s Plastic Surgery (5th ed., p. 772).Philadelphia: Lippincott-Raven. Reprinted with permission.
a1 anterior rectus muscle and sheath to the remaining lateral muscle and sheath (Maxwell & Hammond, 1997).
Nursing Implications A Collaborative Approach to Pregnancy Management A collaborative approach is recommended for careful monitoring of the patient before, during, and after the pregnancy. This collaboration may include a perinatologist, dietician, physical therapist, plastic surgeon, obstetrician, oncologist, perinatal clinical nurse specialist, and clinical social services staff. Family care conferences also may be appropriate for interdisciplinary planning between the health care providers and the woman’s family. This approach can enhance patient and family involvement and feelings of autonomy and control during what may be a frightening experience. This collaborative, holistic approach made by the health care team can affect the patient’s adherence to treatment and may positively affect maternal and neonatal outcomes. Continuity of care by a primary care nurse and education about the pregnancy, potential complications, and the importance of regular prenatal care are key. Women may be fearful about the effects of the pregnancy on their cancer. However, findings are inconclusive as to the effects of the hormonal influence of pregnancy on breast cancer recurrence or metastasis. Some physicians think that pregnancy may actually pro]uly/August 2000
tect against recurrence (Petrek, 1994). Pregnancy safety after cancer treatment has been evaluated extensively, and no decrease in survival was found (Petrek, 1994; Sankila et al., 1994; Schoultz et al., 1995). An accurate psychosocial assessment of the woman’s feelings about the pregnancy must be made. Because some of these women have felt devastated after dealing with cancer and having major abdominal surgery, they may find it difficult to seek pregnancy confirmation or identify with the pregnancy. As a result, they may be at risk of avoiding preconception or early prenatal care. Others might see the pregnancy as a sign of hope and greet it with joy and anticipation. Once the woman begins to receive care, there is an opportunity to encourage significant others to participate in prenatal visits. The family plays a dynamic role in supporting the mother, who may find this pregnancy overwhelming and need explanations about physical changes she may experience, her health status, and that of her fetus.
Prenatal Care Ideally, the patient should be assessed before conception to evaluate her recovery from the cancer. Sankila et al. (1994) and Petrik (1994) suggest that a woman wait 2 years after cancer treatment before considering pregnancy. This should be individualized to the patient and based on the stage of her cancer, her age, and her personal desires. The surgeon who performed the TRAM flap procedure and an obstetrician specializing in high-risk care should evaluate the patient. An obstetric case manager should be assigned to work with the client. One consistent health care provider should be available to address the patient’s anxieties, fears, and concerns as well as build a therapeutic relationship with her. While the pregnancy is progressing the abdominal wall should be assessed for areas of weakness or hernias. In the TRAM flap patient the lateral muscles of the abdomen are repositioned to substitute for the vertical rectus muscle that has been repositioned to form the breast mound. In patients with normal musculature, the right and left rectus abdominis muscles bear much of the load of late pregnancy. Separation of the rectus muscles, known as diastasis recti abdominis (Burroughs, 1997), may occur if the muscles are weak, because of gradual stretching during pregnancy. Hogan (1998), contrary to Hartrampf et al. (1996), states that if diastasis recti abdominis occurs before or during delivery, pushing could become difficult or impossible because these muscles help push the fetus through the birth canal. Further, after delivery, there would be less support for the abdomen, resulting in a pendulous abdomen and backache. Petit et al. (1997) studied the abdominal sequelae of the TRAM flap procedure and found impairment in abdominal
JOGNN 365
strength in almost 50% of patients. Thus, it can be assumed that the pregnant woman who had the TRAM flap procedure would be at increased risk for abdominal weakness and hernias. Prenatally and in early pregnancy strengthening exercises may be prescribed for the woman who has had TRAM flap surgery to decrease the occurrence of rectus muscle separation. If separation is noted, as evidenced by a soft bulge below the umbilicus, exercises should be restricted to pelvic rocking and leg sliding. The client should avoid leg raises and sit-ups with knees or back straight (Kitzinger, 1996).An abdominal support belt or binder may offer support to the back and area of herniation as well as provide comfort to the patient. During pregnancy the woman needs to decide how she is going to feed the newborn. Breastfeeding is a viable option, using the unaffected breast. Women need to be informed that one breast is indeed sufficient to nourish an infant. A lactation consultant would be an appropriate resource for the woman, as would the LaLeche League, support groups, and breastfeeding classes.
Intrapartum Care During the last trimester, the obstetrician or the case manager should arrange for the patient to meet with the anesthesiologist and to discuss management of possible complications at the time of delivery. Issues to be addressed in planning intrapartum care involve the following: planned mode of delivery, monitoring, and analgesia-anesthesia options. These issues should be addressed with every woman facing delivery and are no different for this woman. Vaginal delivery is preferred: The woman who has had TRAM flap reconstruction is in no additional danger and the vaginal delivery should progress in an uncomplicated manner (Hartrampf et al., 1996). The abdominal wall should be assessed frequently to observe for areas of herniation, which may occur in any pregnant woman, and would require splinting during labor. While caring for the patient, the nurse must watch for any abnormal maternal and fetal physiologic changes, just as with any other laboring woman.
Postpartum and Newborn Care During the postpartum, the woman may express concern about the effect of the pregnancy on her breast cancer status and may ask what kind of follow-up treatment is needed. This is a period where the obstetric nurse needs to educate the patient and collaborate with the case manager to arrange for follow-up visits with the oncologist. The significance of emotional support cannot be overstated. Many new mothers, including the woman who has had TRAM flap reconstruction, may be preoccupied with self-care and may not be ready to learn new366 JOG"
born care by the time they are discharged from the hospital. Therefore, written handouts and pamphlets may be helpful. Follow-up care may include telephone calls, home visits, or both during the 1st and 2nd weeks after delivery.
Case Report The following case report represents an example of a successful pregnancy with vaginal delivery after a TRAM flap procedure for breast cancer.
Antepartum A 38-year-old woman became pregnant 1 4 years after undergoing a left modified radical mastectomy for a 5-cm ductal carcinoma in situ with negative lymph node involvement. At that time, she underwent simultaneous reconstructive TRAM flap surgery. According to the woman's surgeon, the hormone receptor status of the breast tumor was not assessed because there was no infiltrating cancer. This first pregnancy came as a surprise to this woman who had severe endometriosis. Nine and one half years prior to this pregnancy she had a left salpingo-oophorectomy and partial right oophorectomy because of endometriosis. Laparoscopic surgery 2 years later revealed a twisted right fallopian tube caused by adhesions. She had laser surgery performed in an attempt to open the tube. Additionally, her husband had a low sperm count secondary to an orchiectomy for testicular seminoma. The couple was given less than a 15% chance of conceiving. Two years later, after several unsuccessful artificial inseminations, the couple adopted a daughter. They were using no contraception at the time of conception because they did not believe they could conceive. The woman had been on birth control pills as a treatment for endometriosis prior to her diagnosis of breast cancer, but had to discontinue using them because of the hormonal effects on her breast cancer. After her mastectomy and reconstructive surgery the woman experienced increased abdominal pain because of the endometriosis. She started acupuncture treatments for the pain and had been getting them for 3 months before she conceived. The pregnancy was a welcomed surprise for this couple. Fear of ectopic pregnancy because of her twisted fallopian tube was the first hurdle to overcome. However, an ultrasonogram revealed an intrauterine pregnancy at 5 weeks gestation. The next concern was not being able to carry the pregnancy because of her TRAM flap surgery. She knew she was at risk for herniation of her abdominal wall and feared that a pregnancy would add to this risk. Her obstetrician had never cared for a pregnant woman who had undergone a TRAM flap procedure. This concern Volume 29, Number 4
was compounded by the fact that her plastic surgeon, although he did not anticipate any problems, did not have any data to allay her fears. So, with vague reassurance that all should be fine, the woman began a pregnancy that progressed normally. At 4 months she developed moderate pain in her right lower middle abdomen at the site where her abdominal muscle was previously removed to form her TRAM flap. She also noted that the area bulged approximately 2.5 cm in circumference. An ultrasonogram revealed a uterine fibroid as the likely cause. A support belt and occasional acetaminophen offered some relief, and the pain gradually diminished over the next few months.
Labor and Delive y The pregnancy was without additional complication until the woman reached term. At 40 weeks her labor was induced because of the onset of blurred vision, blood pressure of 145/85, and hyperactive reflexes. She was diagnosed as having pregnancyinduced hypertension. On admission her cervix was 1-2 cm dilated and was effaced 50%, with intact membranes. No cervical ripening was performed. Oxytocin was used to induce labor. When labor failed to progress after 6 hours, the medication was turned off for the night and restarted in the morning. By noon, her cervix was 3-4 cm dilated and 80% effaced, with vertex at -2 station. Artificial rupture of membranes was performed, and clear amniotic fluid was noted. An epidural was started because her labor had progressed. This decreased the pain to a manageable level. Three hours later she began to push successfully. Two hours after she began pushing, she vaginally delivered a full-term, 7 lb, 7 oz male. The infant had Apgar scores of 8 at one minute and 9 at five minutes. Because of meconium-stained amniotic fluid, the neonatal intensive-care nursing staff had been summoned for the delivery. The newborn’s airway was quickly suctioned and visualized with a laryngoscope, revealing that he had not aspirated meconium.
Postpartum The postpartum period proceeded without difficulty. There were no abdominal complications such as herniation noted. The patient’s pregnancy-induced hypertension quickly resolved, as evidenced by her blood pressure remaining stable at normal levels and normal reflexes. The mother attempted breastfeeding with moderate success. The newborn had difficulty latching on, and nipple soreness was exacerbated because the mother had only one breast. A lactation consultant assisted the mother several times during the first 2 months. The best method for the mother was to use a breast pump JulylAugust 2000
and to bottle-feed the breast milk to the infant. This compromise reduced nipple trauma but gave the infant the nutritional advantage of breast milk. Breast milk was the infant’s only source of nutrition for the first 2 months. The mother expressed feelings of satisfaction, accomplishment, and life affirmation at being able to successfully nourish her infant after having had breast cancer. The breast milk was supplemented with formula until the infant was weaned from breast milk and onto formula at 5 months. The mother noted exaggerated breast asymmetry during the 5-month breastfeeding period, and needed a nursing bra that would accommodate both breast sizes. She found that using a breast form over the TRAM flap was the best way to handle this problem. At 21 months postpartum, an elective mastopexy, a surgical procedure to correct a pendulous breast, was performed on her right breast to achieve more symmetry. It has been 2 years since this pregnancy and there have been no reported abdominal complications. The couple plans no more pregnancies, primarily because of the mother’s age. She continues to be screened for breast cancer recurrence with a yearly mammogram of the right breast, monthly breast self examinations, and yearly follow-up with the surgeon for evaluation of her right breast for masses and fibrocystic disease.
Conclusion TRAM flap surgery is usually followed by resumption of a normal lifestyle and sexual function. The desire for pregnancy in some patients raises the need for appropriate health care counseling. The TRAM flap patients identified in the literature have been able to tolerate pregnancy well, both in terms of carrying a full-term pregnancy and having a healthy vaginal delivery. Nurses caring for these patients must be able to recognize the woman’s concerns and reassure them and their families throughout pregnancy. By using a holistic approach that includes health promotion, prevention, restoration, and maintenance, nurses can effectively manage care of the pregnant patient who has had TRAM flap reconstruction, resulting in optimal maternal and fetal health.
W o m e n who have undergone a TRAM flap procedure may safely consider pregnancy.
JOGNN 367
REFERENCES Banerjee, D., & Monypenny, I.J. (1998). Management of a breast wound with complications. Journal of Wound Care, 7, 116-117. Burroughs, A. (1997). Maternity nursing (7th ed.), Philadelphia: W.B. Saunders Co. Clayton, B. J., & Waller, A. L. (1996). The TRAM flap in breast reconstruction. Plastic Surgical Nursing, 16, 133-138,176-178. Harden, J.T., & Girard, N. (1994). Breast reconstruction using an innovative flap procedure. American Operating Room Nurses Journal, 60, 184-192. Hart, D. (1996).The psychological outcome of breast reconstruction. Plastic Surgical Nursing, 16, 167-171, 176-178. Hartrampf, C . R., Anton, M. A., & Bried, J.T. (1997). Breast reconstruction with the transverse abdominal island (TRAM) flap. In G. S. Georgiade, R. Reifkohl, & L.S. Levin, (Eds.), Georgiade plastic, maxillofacial and reconstructive surgery (3rd ed., pp. 786-797). Baltimore: Williams & Wilkins. Hartrampf, C., Chen, L., & Bennett, B. (1996). Successful pregnancies following TRAM flap surgery. Retrieved March 9, 1999 from the World Wide Web: Ner@plasticsurgery. org. Hogan, M. (1998). Immediate recovery and home care. In E.J. Dickason, B. L. Silverman, & J. A. Kaplan, Maternal-infant nursing care (3rd ed., pp. 389430). Baltimore: Mosby. hey, C. L., & Gordon, S. I. (1994). Breast reconstruction: New image, new hope. R N , 57 (7),48-53. Kitzinger, S. (1996). The complete book of pregnancy and childbirth. New York: Alfred A. Knopf. Maxwell, G. P., & Hammond, D. C. (1997). Breast reconstruction following mastectomy. In S. J. Aston, R. W. Beasley, & C. H. Thorne, (Eds.), Grab6 and Smith’s plastic surgery (5th ed., pp. 763-784). Philadelphia: Lippincott-Raven.
Petit, J.Y., Rietjens, M., Ferreira, M.A.R., Montrucoli, D., Lifrange, E., & Martinelli, P. (1997). Abdominal sequelae after pedicled TRAM flap breast reconstruction. Plastic and Reconstructive Surgery, 99, 723-729. Petrek, J.A. (1994). Pregnancy safety after breast cancer. Cancer, 74, 528-531. Sankila, R., Heinavaara, S., Hakulinen, T. (1994). Survival of breast cancer patients after subsequent term pregnancy: “Healthy mother effect.” American Journal of Obstetrics & Gynecology. 170, 818-823. Schoultz, E., Johansson, H., Wilking, N. ,& Rutqvist, L. E. (1995). Influence of prior and subsequent pregnancy on breast cancer prognosis. Journal of Clinical Oncology, 13,430-434. Shamoun, J.M., & Hartrampf, C.R. (1996). Mastectomy specimen weight and skin dimensions as an adjunct in breast reconstruction. Annals of Plastic Surgery, 36, 251-254. Spear, S.L., & Hartrampf, C. R. (1998). The double pedicle TRAM flap and the standard of care. Plastic and Reconstructive Surgery, 102, 586-588. Townsend, C. M. (1997). Treatment of breast cancer. Clinical Symposia, 49, 3-32.
Linda Hedlund Wagner is a nursing faculty member, Lancaster Institute for Health Education, School of Nursing, Lancaster, PA, and an adjunct faculty member at Immaculata College, Immaculata, PA. Lisa A. Ruth-Sahd is a nursing faculty member, Lancaster Institute for Health Education School of Nursing, Lancaster, PA, and un adjunct faculty member at York College of Pennsylvania in York. Address for correspondence: Linda Hedlund Wagner, RN, MS, CEN, Lancaster Institute for Health Education, 143 E. Lemon Street, Lancaster, PA 17602.
J O G NN Review Panel: 2000 Rebecca Attenborough, RN, M N Jana L. Atterbury, RNC, MSN Linda Bell, RN, MSc Caroline Brown, RNC, MS, DEd Mary Brucker, CNM, DNSc Lynn Clark Callister, RN, PhD Sandra K. Cesario, RNC, PhD Barbara Dion, RNC, ICCE, MA, MSN Grace-Elizabeth Djupe, RNC, MS Patricia M. Dunphy, MSN, CS, RNC Susan M. Ellerbee, RNC, PhD, IBCLC Robin G. Fleschler, RNC, CNS, MSN Catherine Ingram Fogel, RNC, PhD, FAAN Peggy Gordin, RNC, MS, FAAN Jeanne T. Grace, RNC, PhD Annette Gupton, RN, PhD Carol Hartwig, RN, MS, CNAA Mary Henrikson, RNC, MN, ARNP, WHCNP
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JoAnne Kirk Henry, RN, CS, EdD M. Katherine Hutchinson, RNC, MS, PhD Debra Jackson, RNC, BSN, MPH Shirley L. Jones, RNC, PhD Suzan Kardong-Edgren, RNC, MS, FACCE Margaret H. Kearney, RNC, PhD Cheryl P. Kish, RN, EdD, WHCNP Linda J. Kobokovich, RNC, MScN Judith Lewis, RNC, PhD, FAAN Kelly Lindgren, RN, PhD Sharon Lock, RNC, FNP, PhD M. Cynthia Logsdon, DNS, ARNP Laura Mahlmeister, RN, PhD Cathleen R. Maiolatesi, RN, MS Judith Maloni, RN, PhD Linda J. Mayberry, RN, PhD Tara McComb, RN, MSN, PhD Emily S. McKinney, RN, C, MSN
Dianne Morrison-Beedy, RNC, WHNP, PhD Paulina G. Perez, RN, BSN, LCCE, FACCE, CD Cynthia Amstrong Persily, RN, PhD Martina Letko Porter, RNC, MS, MBA Kristen D. Priddy, RNC, MSN, CNS Diana J. Reiser, RN, MAEd, MN Beth Collins Sharp, RN, PhD Mary Ann Stark, RNC, PhD Rosemary Theroux, RNC, MS Suzanne Thoyre, RN, PhD Cecilia Tiller, RNC, DSN, WHNP Judith Carveth Trexler, RN, PhD, CNM M. Terese Verklan, RNC, PhD Tina Weitkamp, RNC, MSN Luanne Wielichowski, RNC, MSN Lenore R. Williams, RN, MSN
Volume 29, Number 4
PRINCIPLES
CF
PRACTICE
Pregnancy After a TRAM Flap Procedure: Principles of Nursing Care Linda Hedlund Wagner, RN, MS, CEN, Lisa A. Ruth-Sahd, RN, MSN, CEN, CCRN
=
Breast cancer is the most common malignan-
cy in women in the United States and affects more
than 200,000 women annually. The incidence increases exponentially with age from the 3rd to the 5th decade of life. Many women are now choosing to have a more natural breast reconstruction concomitantly with their mastectomy. A TRAM (transverse rectus abdominis myocutaneous) flap is a procedure to reconstruct the breast mound using autologous tissue. Women of childbearing age who have undergone a TRAM flap may safely consider pregnancy after such a procedure. The principles of nursing care for pregnant women who have undergone a T R A M flap surgery are presented in this article. A case report of pregnancy after a TRAM flap i s included. JOG", 29, 363-368; 2000. Keywords: Autologous breast reconstruction-Breast cancer-Breast reconstruction-Nursing care-Pregnancy-TRAM (transverse rectus abdominis myocutaneous) flap-Vaginal delivery Accepted: January 2000
Today, many patients who face breast reconstruction after mastectomy for breast cancer or for prophylaxis against breast cancer and patients with an anomaly in which they never developed a breast (Poland's syndrome) are choosing to have reconstructive surgery that uses their own tissue. For some women, breast reconstruction is an essential part of total and holistic breast cancer management. Reconstructive surgery helps restore self-image by preserving the way a woman perceives herself (Hart, 1996; Ivey & Gordon, 1994). Since 1982, major advances have occurred in the surgical treatment of breast cancer after mastectoJulylAugust 2000
my, primarily reconstructive surgery using the transverse rectus abdominis myocutaneous (TRAM) flap. This procedure uses a section of the woman's own skin and abdominal muscle to rebuild a natural-looking breast mound and has become a well-established and popular method for reconstruction (Clayton & Waller, 1996; Harden & Girard, 1994; Hartrampf, Anton, & Bried, 1997; Spear & Hartrampf, 1998). In the past, women facing breast reconstruction were told to choose silicone gel or saline filled implants if they planned to have children. It was assumed that TRAM flap surgery would weaken the woman's abdominal wall, rendering it incapable of supporting a pregnancy. To date, little has been published about pregnancy after a TRAM flap procedure (Hartrampf, Chen, & Bennett, 1996). Breast cancer is occurring more frequently in women of all ages, including women of childbearing age (Petrek, 1994). Women are delaying having children for academic, professional, and personal reasons, which increases the likelihood of their becoming pregnant during or after a battle with breast cancer. Pregnancy subsequent to
T h e TRAM flap procedure uses a section of the woman's own skin and abdominal muscle to rebuild a natural looking breast mound.
JOG"
363
breast cancer has been studied primarily for its effect on cancer recurrence and metastasis (Petrek, 1994; Sankila, Heinavaara, & Hakulinen, 1994; Schoultz, Johansson, Wilking, & Rutqvist, 1995). For women who choose TRAM flap reconstruction after a mastectomy, pregnancy poses other concerns, which have not previously been addressed. Women have many factors to consider when determining the type of reconstruction they will have (Townsend, 1997). In the wake of controversies about silicone gel and saline filled implants, more women are choosing breast reconstruction using their own tissue. The TRAM flap approach offers the patient advantages of (a) creating a softer, more natural-appearing breast mound composed of autogenous tissue without the risks associated with other types of manufactured implants; (b) producing an abdominal lipectomy or “tummy tuck” in the donor area (Maxwell & Hammond, 1997); and (c) avoiding implantation of foreign material into the body. Women of childbearing age have been denied TRAM flap surgery because of an incorrect assumption about abdominal wall integrity. Women also were informed that they needed to have a cesarean delivery if they gave birth after a TRAM flap procedure. However, according to Hartrampf et al. (1996), health care practitioners need to recall that the uterus is the major muscle which supports a pregnancy and aids in the delivery of a newborn. Hartrampf also states that the abdominal muscles are secondary in assisting with the delivery. Therefore, after a TRAM flap procedure a patient should be able to carry and vaginally deliver a full-term newborn.
T h e uterus i s the major muscle to support a pregnancy and aid in the delivery of the newborn. The abdominal muscles are actually secondary in assisting with the delivery.
TRAM Flap Procedure It is helpful for an obstetric and gynecologic nurse to have a basic understanding of the TRAM flap surgical procedure. Preoperatively, the patient will meet with. a plastic surgeon. During this visit the surgeon marks the patient’s lower abdomen from hip to hip and her breast to determine where the surgical incisions will be placed (see Figure 1). It is best to do this when the patient is in the standing position.
364 JOGNN
3
FIGURE 1
Abdominal markings display where the surgeon will incise the abdomen. Note. From “Breast Reconstruction Following Mastectomy,” by G. P Maxwell & D. C. Hammond, 1997, In S. J. Aston, R. W. Beasley, & C. H. Thorne, (Eds.), Grub6 and Smith’s Plastic Surgery (5th ed., p. 772). Philadelphia: Lippincott-Raven. Reprinted with permission.
Patient selection is important for the operation to be complication-free. Patients with an obese abdomen are at much higher risk for flap loss and are therefore poor candidates for the TRAM flap procedure (Shamoun & Hartrampf, 1996). Likewise, heavy smokers and diabetics are at risk for consequences of poor flap vasculature because of prolonged healing times and infection (Banerjee & Monypenny, 1998). Any previous abdominal incision that transected the rectus abdominis muscle may preclude the use of that particular muscle flap (Maxwell & Hammond, 1997). The surgery itself is a lengthy microsurgical procedure and may take up to 12 hours (Harden & Girard, 1994). Often two surgeons work together: As one surgeon performs the mastectomy, the other is working on the abdominal area to release the rectus abdominis flap. Once the flap is dissected, a tunnel is made medially to connect the abdominal dissection over the sternum to the mastectomy site. The flap is cautiously passed through this tunnel into the chest wall to form the breast mound (see Figure 2). Abdominal reconstruction can be accomplished by primary closure of the remaining medi-
Volume 29, Number 4
Flap
I
Y
\
FIGURE 2 Placement of contralateral single muscle TRAM flap, forming breast mound. Note: From “Breast Reconstruction Following Mastectomy,” by G. P Maxwell & D. C. Hammond, 1997, In S. J. Aston, R. W. Beasley, & C. H. Thorne, (Eds.), Grabb and Smith’s Plastic Surgery (5th ed., p. 772).Philadelphia: Lippincott-Raven. Reprinted with permission.
a1 anterior rectus muscle and sheath to the remaining lateral muscle and sheath (Maxwell & Hammond, 1997).
Nursing Implications A Collaborative Approach to Pregnancy Management A collaborative approach is recommended for careful monitoring of the patient before, during, and after the pregnancy. This collaboration may include a perinatologist, dietician, physical therapist, plastic surgeon, obstetrician, oncologist, perinatal clinical nurse specialist, and clinical social services staff. Family care conferences also may be appropriate for interdisciplinary planning between the health care providers and the woman’s family. This approach can enhance patient and family involvement and feelings of autonomy and control during what may be a frightening experience. This collaborative, holistic approach made by the health care team can affect the patient’s adherence to treatment and may positively affect maternal and neonatal outcomes. Continuity of care by a primary care nurse and education about the pregnancy, potential complications, and the importance of regular prenatal care are key. Women may be fearful about the effects of the pregnancy on their cancer. However, findings are inconclusive as to the effects of the hormonal influence of pregnancy on breast cancer recurrence or metastasis. Some physicians think that pregnancy may actually pro]uly/August 2000
tect against recurrence (Petrek, 1994). Pregnancy safety after cancer treatment has been evaluated extensively, and no decrease in survival was found (Petrek, 1994; Sankila et al., 1994; Schoultz et al., 1995). An accurate psychosocial assessment of the woman’s feelings about the pregnancy must be made. Because some of these women have felt devastated after dealing with cancer and having major abdominal surgery, they may find it difficult to seek pregnancy confirmation or identify with the pregnancy. As a result, they may be at risk of avoiding preconception or early prenatal care. Others might see the pregnancy as a sign of hope and greet it with joy and anticipation. Once the woman begins to receive care, there is an opportunity to encourage significant others to participate in prenatal visits. The family plays a dynamic role in supporting the mother, who may find this pregnancy overwhelming and need explanations about physical changes she may experience, her health status, and that of her fetus.
Prenatal Care Ideally, the patient should be assessed before conception to evaluate her recovery from the cancer. Sankila et al. (1994) and Petrik (1994) suggest that a woman wait 2 years after cancer treatment before considering pregnancy. This should be individualized to the patient and based on the stage of her cancer, her age, and her personal desires. The surgeon who performed the TRAM flap procedure and an obstetrician specializing in high-risk care should evaluate the patient. An obstetric case manager should be assigned to work with the client. One consistent health care provider should be available to address the patient’s anxieties, fears, and concerns as well as build a therapeutic relationship with her. While the pregnancy is progressing the abdominal wall should be assessed for areas of weakness or hernias. In the TRAM flap patient the lateral muscles of the abdomen are repositioned to substitute for the vertical rectus muscle that has been repositioned to form the breast mound. In patients with normal musculature, the right and left rectus abdominis muscles bear much of the load of late pregnancy. Separation of the rectus muscles, known as diastasis recti abdominis (Burroughs, 1997), may occur if the muscles are weak, because of gradual stretching during pregnancy. Hogan (1998), contrary to Hartrampf et al. (1996), states that if diastasis recti abdominis occurs before or during delivery, pushing could become difficult or impossible because these muscles help push the fetus through the birth canal. Further, after delivery, there would be less support for the abdomen, resulting in a pendulous abdomen and backache. Petit et al. (1997) studied the abdominal sequelae of the TRAM flap procedure and found impairment in abdominal
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strength in almost 50% of patients. Thus, it can be assumed that the pregnant woman who had the TRAM flap procedure would be at increased risk for abdominal weakness and hernias. Prenatally and in early pregnancy strengthening exercises may be prescribed for the woman who has had TRAM flap surgery to decrease the occurrence of rectus muscle separation. If separation is noted, as evidenced by a soft bulge below the umbilicus, exercises should be restricted to pelvic rocking and leg sliding. The client should avoid leg raises and sit-ups with knees or back straight (Kitzinger, 1996).An abdominal support belt or binder may offer support to the back and area of herniation as well as provide comfort to the patient. During pregnancy the woman needs to decide how she is going to feed the newborn. Breastfeeding is a viable option, using the unaffected breast. Women need to be informed that one breast is indeed sufficient to nourish an infant. A lactation consultant would be an appropriate resource for the woman, as would the LaLeche League, support groups, and breastfeeding classes.
Intrapartum Care During the last trimester, the obstetrician or the case manager should arrange for the patient to meet with the anesthesiologist and to discuss management of possible complications at the time of delivery. Issues to be addressed in planning intrapartum care involve the following: planned mode of delivery, monitoring, and analgesia-anesthesia options. These issues should be addressed with every woman facing delivery and are no different for this woman. Vaginal delivery is preferred: The woman who has had TRAM flap reconstruction is in no additional danger and the vaginal delivery should progress in an uncomplicated manner (Hartrampf et al., 1996). The abdominal wall should be assessed frequently to observe for areas of herniation, which may occur in any pregnant woman, and would require splinting during labor. While caring for the patient, the nurse must watch for any abnormal maternal and fetal physiologic changes, just as with any other laboring woman.
Postpartum and Newborn Care During the postpartum, the woman may express concern about the effect of the pregnancy on her breast cancer status and may ask what kind of follow-up treatment is needed. This is a period where the obstetric nurse needs to educate the patient and collaborate with the case manager to arrange for follow-up visits with the oncologist. The significance of emotional support cannot be overstated. Many new mothers, including the woman who has had TRAM flap reconstruction, may be preoccupied with self-care and may not be ready to learn new366 JOG"
born care by the time they are discharged from the hospital. Therefore, written handouts and pamphlets may be helpful. Follow-up care may include telephone calls, home visits, or both during the 1st and 2nd weeks after delivery.
Case Report The following case report represents an example of a successful pregnancy with vaginal delivery after a TRAM flap procedure for breast cancer.
Antepartum A 38-year-old woman became pregnant 1 4 years after undergoing a left modified radical mastectomy for a 5-cm ductal carcinoma in situ with negative lymph node involvement. At that time, she underwent simultaneous reconstructive TRAM flap surgery. According to the woman's surgeon, the hormone receptor status of the breast tumor was not assessed because there was no infiltrating cancer. This first pregnancy came as a surprise to this woman who had severe endometriosis. Nine and one half years prior to this pregnancy she had a left salpingo-oophorectomy and partial right oophorectomy because of endometriosis. Laparoscopic surgery 2 years later revealed a twisted right fallopian tube caused by adhesions. She had laser surgery performed in an attempt to open the tube. Additionally, her husband had a low sperm count secondary to an orchiectomy for testicular seminoma. The couple was given less than a 15% chance of conceiving. Two years later, after several unsuccessful artificial inseminations, the couple adopted a daughter. They were using no contraception at the time of conception because they did not believe they could conceive. The woman had been on birth control pills as a treatment for endometriosis prior to her diagnosis of breast cancer, but had to discontinue using them because of the hormonal effects on her breast cancer. After her mastectomy and reconstructive surgery the woman experienced increased abdominal pain because of the endometriosis. She started acupuncture treatments for the pain and had been getting them for 3 months before she conceived. The pregnancy was a welcomed surprise for this couple. Fear of ectopic pregnancy because of her twisted fallopian tube was the first hurdle to overcome. However, an ultrasonogram revealed an intrauterine pregnancy at 5 weeks gestation. The next concern was not being able to carry the pregnancy because of her TRAM flap surgery. She knew she was at risk for herniation of her abdominal wall and feared that a pregnancy would add to this risk. Her obstetrician had never cared for a pregnant woman who had undergone a TRAM flap procedure. This concern Volume 29, Number 4
was compounded by the fact that her plastic surgeon, although he did not anticipate any problems, did not have any data to allay her fears. So, with vague reassurance that all should be fine, the woman began a pregnancy that progressed normally. At 4 months she developed moderate pain in her right lower middle abdomen at the site where her abdominal muscle was previously removed to form her TRAM flap. She also noted that the area bulged approximately 2.5 cm in circumference. An ultrasonogram revealed a uterine fibroid as the likely cause. A support belt and occasional acetaminophen offered some relief, and the pain gradually diminished over the next few months.
Labor and Delive y The pregnancy was without additional complication until the woman reached term. At 40 weeks her labor was induced because of the onset of blurred vision, blood pressure of 145/85, and hyperactive reflexes. She was diagnosed as having pregnancyinduced hypertension. On admission her cervix was 1-2 cm dilated and was effaced 50%, with intact membranes. No cervical ripening was performed. Oxytocin was used to induce labor. When labor failed to progress after 6 hours, the medication was turned off for the night and restarted in the morning. By noon, her cervix was 3-4 cm dilated and 80% effaced, with vertex at -2 station. Artificial rupture of membranes was performed, and clear amniotic fluid was noted. An epidural was started because her labor had progressed. This decreased the pain to a manageable level. Three hours later she began to push successfully. Two hours after she began pushing, she vaginally delivered a full-term, 7 lb, 7 oz male. The infant had Apgar scores of 8 at one minute and 9 at five minutes. Because of meconium-stained amniotic fluid, the neonatal intensive-care nursing staff had been summoned for the delivery. The newborn’s airway was quickly suctioned and visualized with a laryngoscope, revealing that he had not aspirated meconium.
Postpartum The postpartum period proceeded without difficulty. There were no abdominal complications such as herniation noted. The patient’s pregnancy-induced hypertension quickly resolved, as evidenced by her blood pressure remaining stable at normal levels and normal reflexes. The mother attempted breastfeeding with moderate success. The newborn had difficulty latching on, and nipple soreness was exacerbated because the mother had only one breast. A lactation consultant assisted the mother several times during the first 2 months. The best method for the mother was to use a breast pump JulylAugust 2000
and to bottle-feed the breast milk to the infant. This compromise reduced nipple trauma but gave the infant the nutritional advantage of breast milk. Breast milk was the infant’s only source of nutrition for the first 2 months. The mother expressed feelings of satisfaction, accomplishment, and life affirmation at being able to successfully nourish her infant after having had breast cancer. The breast milk was supplemented with formula until the infant was weaned from breast milk and onto formula at 5 months. The mother noted exaggerated breast asymmetry during the 5-month breastfeeding period, and needed a nursing bra that would accommodate both breast sizes. She found that using a breast form over the TRAM flap was the best way to handle this problem. At 21 months postpartum, an elective mastopexy, a surgical procedure to correct a pendulous breast, was performed on her right breast to achieve more symmetry. It has been 2 years since this pregnancy and there have been no reported abdominal complications. The couple plans no more pregnancies, primarily because of the mother’s age. She continues to be screened for breast cancer recurrence with a yearly mammogram of the right breast, monthly breast self examinations, and yearly follow-up with the surgeon for evaluation of her right breast for masses and fibrocystic disease.
Conclusion TRAM flap surgery is usually followed by resumption of a normal lifestyle and sexual function. The desire for pregnancy in some patients raises the need for appropriate health care counseling. The TRAM flap patients identified in the literature have been able to tolerate pregnancy well, both in terms of carrying a full-term pregnancy and having a healthy vaginal delivery. Nurses caring for these patients must be able to recognize the woman’s concerns and reassure them and their families throughout pregnancy. By using a holistic approach that includes health promotion, prevention, restoration, and maintenance, nurses can effectively manage care of the pregnant patient who has had TRAM flap reconstruction, resulting in optimal maternal and fetal health.
W o m e n who have undergone a TRAM flap procedure may safely consider pregnancy.
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REFERENCES Banerjee, D., & Monypenny, I.J. (1998). Management of a breast wound with complications. Journal of Wound Care, 7, 116-117. Burroughs, A. (1997). Maternity nursing (7th ed.), Philadelphia: W.B. Saunders Co. Clayton, B. J., & Waller, A. L. (1996). The TRAM flap in breast reconstruction. Plastic Surgical Nursing, 16, 133-138,176-178. Harden, J.T., & Girard, N. (1994). Breast reconstruction using an innovative flap procedure. American Operating Room Nurses Journal, 60, 184-192. Hart, D. (1996).The psychological outcome of breast reconstruction. Plastic Surgical Nursing, 16, 167-171, 176-178. Hartrampf, C . R., Anton, M. A., & Bried, J.T. (1997). Breast reconstruction with the transverse abdominal island (TRAM) flap. In G. S. Georgiade, R. Reifkohl, & L.S. Levin, (Eds.), Georgiade plastic, maxillofacial and reconstructive surgery (3rd ed., pp. 786-797). Baltimore: Williams & Wilkins. Hartrampf, C., Chen, L., & Bennett, B. (1996). Successful pregnancies following TRAM flap surgery. Retrieved March 9, 1999 from the World Wide Web: Ner@plasticsurgery. org. Hogan, M. (1998). Immediate recovery and home care. In E.J. Dickason, B. L. Silverman, & J. A. Kaplan, Maternal-infant nursing care (3rd ed., pp. 389430). Baltimore: Mosby. hey, C. L., & Gordon, S. I. (1994). Breast reconstruction: New image, new hope. R N , 57 (7),48-53. Kitzinger, S. (1996). The complete book of pregnancy and childbirth. New York: Alfred A. Knopf. Maxwell, G. P., & Hammond, D. C. (1997). Breast reconstruction following mastectomy. In S. J. Aston, R. W. Beasley, & C. H. Thorne, (Eds.), Grab6 and Smith’s plastic surgery (5th ed., pp. 763-784). Philadelphia: Lippincott-Raven.
Petit, J.Y., Rietjens, M., Ferreira, M.A.R., Montrucoli, D., Lifrange, E., & Martinelli, P. (1997). Abdominal sequelae after pedicled TRAM flap breast reconstruction. Plastic and Reconstructive Surgery, 99, 723-729. Petrek, J.A. (1994). Pregnancy safety after breast cancer. Cancer, 74, 528-531. Sankila, R., Heinavaara, S., Hakulinen, T. (1994). Survival of breast cancer patients after subsequent term pregnancy: “Healthy mother effect.” American Journal of Obstetrics & Gynecology. 170, 818-823. Schoultz, E., Johansson, H., Wilking, N. ,& Rutqvist, L. E. (1995). Influence of prior and subsequent pregnancy on breast cancer prognosis. Journal of Clinical Oncology, 13,430-434. Shamoun, J.M., & Hartrampf, C.R. (1996). Mastectomy specimen weight and skin dimensions as an adjunct in breast reconstruction. Annals of Plastic Surgery, 36, 251-254. Spear, S.L., & Hartrampf, C. R. (1998). The double pedicle TRAM flap and the standard of care. Plastic and Reconstructive Surgery, 102, 586-588. Townsend, C. M. (1997). Treatment of breast cancer. Clinical Symposia, 49, 3-32.
Linda Hedlund Wagner is a nursing faculty member, Lancaster Institute for Health Education, School of Nursing, Lancaster, PA, and an adjunct faculty member at Immaculata College, Immaculata, PA. Lisa A. Ruth-Sahd is a nursing faculty member, Lancaster Institute for Health Education School of Nursing, Lancaster, PA, and un adjunct faculty member at York College of Pennsylvania in York. Address for correspondence: Linda Hedlund Wagner, RN, MS, CEN, Lancaster Institute for Health Education, 143 E. Lemon Street, Lancaster, PA 17602.
J O G NN Review Panel: 2000 Rebecca Attenborough, RN, M N Jana L. Atterbury, RNC, MSN Linda Bell, RN, MSc Caroline Brown, RNC, MS, DEd Mary Brucker, CNM, DNSc Lynn Clark Callister, RN, PhD Sandra K. Cesario, RNC, PhD Barbara Dion, RNC, ICCE, MA, MSN Grace-Elizabeth Djupe, RNC, MS Patricia M. Dunphy, MSN, CS, RNC Susan M. Ellerbee, RNC, PhD, IBCLC Robin G. Fleschler, RNC, CNS, MSN Catherine Ingram Fogel, RNC, PhD, FAAN Peggy Gordin, RNC, MS, FAAN Jeanne T. Grace, RNC, PhD Annette Gupton, RN, PhD Carol Hartwig, RN, MS, CNAA Mary Henrikson, RNC, MN, ARNP, WHCNP
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JoAnne Kirk Henry, RN, CS, EdD M. Katherine Hutchinson, RNC, MS, PhD Debra Jackson, RNC, BSN, MPH Shirley L. Jones, RNC, PhD Suzan Kardong-Edgren, RNC, MS, FACCE Margaret H. Kearney, RNC, PhD Cheryl P. Kish, RN, EdD, WHCNP Linda J. Kobokovich, RNC, MScN Judith Lewis, RNC, PhD, FAAN Kelly Lindgren, RN, PhD Sharon Lock, RNC, FNP, PhD M. Cynthia Logsdon, DNS, ARNP Laura Mahlmeister, RN, PhD Cathleen R. Maiolatesi, RN, MS Judith Maloni, RN, PhD Linda J. Mayberry, RN, PhD Tara McComb, RN, MSN, PhD Emily S. McKinney, RN, C, MSN
Dianne Morrison-Beedy, RNC, WHNP, PhD Paulina G. Perez, RN, BSN, LCCE, FACCE, CD Cynthia Amstrong Persily, RN, PhD Martina Letko Porter, RNC, MS, MBA Kristen D. Priddy, RNC, MSN, CNS Diana J. Reiser, RN, MAEd, MN Beth Collins Sharp, RN, PhD Mary Ann Stark, RNC, PhD Rosemary Theroux, RNC, MS Suzanne Thoyre, RN, PhD Cecilia Tiller, RNC, DSN, WHNP Judith Carveth Trexler, RN, PhD, CNM M. Terese Verklan, RNC, PhD Tina Weitkamp, RNC, MSN Luanne Wielichowski, RNC, MSN Lenore R. Williams, RN, MSN
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