Diagnosing and Managing Breast Disease During Pregnancy and Lactation

, University of Iowa College of Medicine

Disclosures
In This Article

Benign Problems of Lactation

During lactation, a spectrum of inflammatory and infectious complications may occur, ranging from milk stasis and mastitis to frank abscess formation.[19] Ductal obstruction may result in localized collections of milk called galactoceles.

Breast infections. Nasopharyngeal organisms from the infant are the usual source of breast infections. Terminal ducts emptying into the nipple serve as a portal of entry. Sometimes cracked or fissured nipples facilitate colonization of the nipple with organisms. An important risk factor is milk stasis. Milk is an excellent culture medium; hence, breast infections are particularly apt to occur when the milk is allowed to stagnate within the breast.[19,20]

The earlier classification of sporadic (endemic) versus epidemic mastitis is still used but has given way to a recognition that these infections form a spectrum of illnesses, depending upon the virulence of the infecting organism and the degree of bacterial colonization of the milk. Epidemic mastitis is a hospital-acquired infection caused by virulent strains of Staphylococcus aureus. This infection is rare, and it usually occurs within 4 days of delivery. Even with prompt antibiotic therapy, progression to abscess formation may occur. In contrast, nonepidemic or sporadic mastitis is a milder infection with less virulent organisms and generally responds well to treatment without hospitalization.[21,22] Hospitalization may be required, however, if the infection fails to respond.

Keeping the breast empty of milk promotes healing by helping to drain the culture medium that facilitates growth of organisms. Hence, the earlier recommendations that breast-feeding cease while mastitis is being treated have been superseded by the knowledge that breast-feeding is generally not harmful to the infant--when using appropriate antibiotics--and may speed resolution of the infectious process.[23] Milk leukocyte counts and cultures guide antibiotic therapy selection and help in gauging the severity of the infection and progress of treatment.[19] Even when frank abscess formation occurs, serial aspirations may be a useful alternative to surgical drainage in selected cases.[23] When an abscess is drained surgically, it is important to break down loculations and to biopsy the wall of the cavity to exclude the rare case of carcinoma masquerading as an abscess. General anesthesia is usually required. Treatment failure may be indicated by persistence or progression of symptoms, often followed by impaired lactation.[23,24]

Galactoceles. Galactoceles (Fig. 2) form as a result of ductal obstruction.[25] They can occur during lactation but more commonly are noted after cessation of lactation, when the milk is allowed to stagnate within the breast. These smooth, mobile, often tender masses are localized collections of milk. There is no known relationship between galactoceles and the large cysts often seen in fibrocystic breast disease. Aspiration is both diagnostic and curative, yielding fluid milk when performed during lactation or soon after cessation, and yielding more thickened, cheesy material from older lesions aspirated at a time remote from lactation. Several aspirations may be required. Ice packs and good mechanical support of the breast with a well-fitting brassiere are helpful.

Figure 2. Galactoceles are localized collections of milk that are felt as smooth, mobile, often tender masses and may be radiographically indistinguishable from other fat-containing breast lesions. Reprinted from University of North Carolina Teaching File © 1997, University of North Carolina Department of Radiology.

Mammography is rarely indicated, as aspiration is both diagnostic and curative. There is, however, a characteristic mammographic appearance best seen on an erect mediolateral view (which may show layering of fat density over water density). Older lesions containing thickened material may demonstrate a mixed water-fat density similar to that seen in mammary hamartoma.[26] Surgery is rarely required.

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