Breast Abscess in Lactation

Jennifer G. Martin, CNM, MS

Disclosures

J Midwifery Womens Health. 2009;54(2):150-151. 

In This Article

Discussion

Lactational breast abscess is an accumulation of pus in an area of the breast and frequently develops as a result of inadequately treated infectious mastitis.[2] Between 5% and 11% of lactating women with infectious mastitis will develop a breast abscess, which usually occurs at 3 to 8 weeks postpartum. The causative agent is typically S aureus which enters the breast tissue through a milk duct or crack in the nipple. Risks for developing breast abscess include primiparity, birth after 41 weeks' gestation, age > 30 years, and recent mastitis.[2,3,4,5]

Clinical presentation of lactational breast abscess usually includes fever, chills, malaise, and recent or recurrent mastitis. Pain, erythema, and firmness over an area of the breast are typically present. However, a mass is not always palpable, especially if it is located deep within a large breast. Diagnosis is made via signs and symptoms, physical examination, and ultrasound. Mammography is not suitable for diagnosis because of the amount of pain that the woman experiences in obtaining this test.[3]

Treatment of lactational breast abscess may involve surgical incision and drainage or needle aspiration and antibiotic therapy. First-line treatment for most abscesses is currently needle aspiration with antibiotics.[6,7] Surgical treatment is typically reserved for recurrent or extremely large abscesses.[8] The surgically-treated abscess is left open to heal by secondary intention, during which milk may leak out of the wound area. In the past, surgical treatment was the standard of care, but this requires a breast or general surgeon, general anesthesia, longer healing time, and causes scarring. Needle aspiration, with or without ultrasound guidance, can be performed by a radiologist and is effective and minimally invasive.[3] In either case, breast emptying should not be interrupted. Although the affected breast may heal more slowly, continued breast emptying, through nursing or pumping, prevents engorgement and mastitis and continues to confer the benefits of breastfeeding to the infant.[4]

Eryilmaz et al.[8] conducted a randomized clinical study of 45 lactating women with breast abscesses. The participants were randomized to treatment with surgical incision and drainage or needle aspiration. Both groups were also treated with ampicillin-sulbactam. Cultures were performed on all drainage samples and 55% were positive for S aureus. There were no significant differences among the participants in terms of age, parity, nipple damage, duration of symptoms and lactation, size of abscess, history of abscess or mastitis, or drainage culture results. The results of this investigation contrasted the success rates and characteristics of each treatment modality. Women who underwent surgical incision and drainage experienced significantly longer healing times than the needle aspiration group (mean of 12.43 vs. 6.36 days). In addition, 70% of the women in the surgical group were displeased with the amount of scarring resulting from surgical treatment. Women who were randomized to the needle aspiration group required a mean of 3.5 aspirations to achieve resolution of the abscess. A 100% success rate was achieved among women with abscesses < 5 cm in diameter. However, 25% of women presenting with abscesses > 5 cm in diameter were unsuccessfully treated with needle aspiration and required surgical incision and drainage. Longer duration of symptoms and greater volume of pus aspirate were identified as predictors of failure of needle aspiration. This study did not use ultrasound guidance for performing the needle aspiration treatment. There are conflicting recommendations in the literature as to whether or not ultrasound is necessary to achieve equally effective results.

Based on the results of this and other studies,[2,3,6,8] needle aspiration with or without ultrasound guidance and antibiotic therapy are recommended as the first-line treatment of lactational breast abscesses measuring < 5 cm in diameter. Repeated needle aspiration is frequently required, and as many as five aspirations may be necessary.[3] Larger abscesses (> 5 cm in diameter) and some recurrent abscesses require surgical incision and drainage.[8]

The midwife's role in the treatment of lactational breast abscess is prevention, consultation, and referral. Lactational breast abscess may be prevented by rapid diagnosis and complete treatment of mastitis. There are a number of risk factors for mastitis, including blocked ducts, poorly fitted bra, incorrect latch, nipple damage, past history of mastitis, and high stress levels.[9] Signs and symptoms of mastitis include rapid onset of fever > 100.4°F (38.4°C), chills, malaise, intense breast pain, and heat and erythema in one or both breasts. Antibiotic courses of 10 to 14 days are recommended with a penicillinase-resistant penicillin, such as dicloxacillin (500 mg every 6 hours).[10] Breast pain is typically managed with ibuprofen and warm, moist heat. Some clinicians diagnose and initiate antibiotic treatment for mastitis over the telephone. This approach to initial treatment avoids the added stress of arranging face-to-face contact with an already ill woman in need of rest and recuperation. If symptoms worsen or improvement is not noted by the woman within 24 to 36 hours, arrangement for in-person consultation should be arranged. In addition to pharmacologic therapy, continued breastfeeding and adequate rest, nutrition, hydration, and stress reduction are necessary in healing mastitis.[9] Some experts suggest obtaining midstream milk culture and sensitivity testing in recurrent cases of mastitis in order to ensure selection of the correct antibiotic.[10] If abscess is suspected, ultrasound imaging of the breast may be ordered and treated as indicated. Support of continued breastfeeding is essential, and midwives are in an effective position to do this.

Although lactational breast abscess is an infrequent complication of infectious mastitis, it needs to be considered as a differential diagnosis in recurrent mastitis. Lactational breast abscess typically requires physician consultation and referral for treatment. Positive cosmetic results and effective treatment can be achieved with ultrasound-guided needle aspiration and antibiotic therapy. Large or recurrent abscesses may require surgical incision and drainage. Continued support of breastfeeding is essential to the health of the infant and healing of the mother.[4,10]

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