OBSTETRICS

Mastitis

Epidemiology

  • Incidence: Affects approximately 20% of breastfeeding Australian women in the first 6 months postpartum.
  • Timing: Most common in the first 6 weeks of breastfeeding, with the highest incidence during the second and third weeks.
  • Spread: Initially localized to one segment of the breast; if untreated, it can spread to the entire breast.
  • Breast Abscess: Around 3% of lactating women with mastitis will develop a breast abscess, though an incidence of up to 11% has been reported.

Risk Factors and Prevention

  • Primary Risk Factor: Breastfeeding during the early postpartum period.
  • Common causes:
    • poor attachment to breast
    • nipple damage
    • too long btw feeds
    • breasts too full
    • blocked milk ducts
    • stopping breastfeeding too quickly
    • overly tight bra
  • Contributing Factors:
    • Milk stasis and cracked nipples, although evidence for this is inconclusive.
    • Previous mastitis.
    • Maternal fatigue.
    • Primiparity.
  • Risk Factors for Breast Abscess:
    • Past history of mastitis.
    • Maternal age over 30 years.
    • Gestational age greater than 41 weeks.
  • Prevention Strategies:
    • BF as often as your baby needs (8-12x/24hrs for new baby)
    • don’t miss or put off BF
    • wake your baby for a feed if breasts become too full or if baby doesn’t want to feed express a small amount for comfort
    • ensure attaching correctly
    • offer both breasts if baby only feeds at one offer the alternate breast at next feed
    • express a small amount of milk after feeds
    • A Cochrane review found no significant impact from anti-secretory factor cereal, mupirocin ointment, fusidic acid ointment, or breastfeeding advice on mastitis incidence.

Microbiology

  • Common Causative Organism: Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections.
  • Other Organisms: Streptococci, Staphylococcus epidermidis.
  • Mixed Flora: Higher incidence in patients with recurrent breast abscesses, including anaerobic organisms.
  • Rare Cases: Candida albicans, which can cause parenchymal infection.

Clinical Assessment

History and Physical Examination

  • Symptoms:
    • Breast pain as the primary symptom.
    • High fever.
    • Generalized flu-like symptoms: malaise, lethargy, myalgia, sweating, headache, nausea, vomiting, occasionally rigors.
  • Physical Examination:
    • Signs of inflammation: erythema, localized tenderness, heat, engorgement, swelling.
    • Signs of nipple damage.
    • General observations: temperature, pulse, blood pressure to exclude sepsis.

Breast Abscess

  • Symptoms:
    • Similar to mastitis but includes a discrete tender lump (tense or fluctuant).
    • Skin necrosis suggesting the abscess is “pointing” (close to the skin surface).
    • Occasionally presents as a non-tender lump without erythema (“cold abscess”).

Examination of the Infant and Breastfeeding

  • Infant Examination: Ensure adequate growth and hydration, examine the mouth for candida infection (white film on buccal mucosa) or anatomical conditions (e.g., cleft palate, tongue-tie).
  • Breastfeeding Observation: Check for difficulties with attachment, potentially involving a lactation consultant.

Investigation

  • Initial Diagnosis: Clinical, without need for initial investigations.
  • Non-Improving Infection: Breast ultrasound to differentiate between inflammation (mastitis) and abscess, guide aspiration, and exclude malignancy if necessary.
  • Mammography: Not first-line but indicated if there are clinical, sonographic, or biopsy features suspicious for malignancy.

Differential Diagnosis

  • Inflammatory Breast Cancer: Consider if mastitis is unresponsive to treatment.
  • Non-Breast Causes of Fever: Urinary tract infection or endometritis, especially if fever is the primary symptom rather than breast pain and erythema.

Management

    • Ibuprofen or paracetamol for pain

    • early antibiotic therapy is important to prevent abscess formation.

    • Abx =
      • dicloxacillin 500 mg orally, 6-hourly. For 10 days    OR

      • flucloxacillin 500 mg orally, 6-hourly. for 10 days

    • Nb: if Candida infection (Intense pain, particularly after breast empties, absence of breast erythema🡪 fluconazole 200-400mg daily for 2-4wks

    • Nb: if tenderness & redness persist beyond 48hrs & an area of induration develops then a breast abscess has formed 🡪 hospital for IV abx, USS +/- aspiration OR rarely surgical drainag

    • Analgesia: Regular oral paracetamol as first-line treatment. Nonsteroidal anti-inflammatory drugs can be added; both are safe in breastfeeding.
    • Hot and Cold Packs:
      • Gentle massage and warm compress prior to feeding may encourage milk flow.
      • Cold packs after feeding may help alleviate pain.
      • Cabbage leaves show inconsistent effects, similar to ice packs in some studies but no effect in others.

    Support for Continued Breastfeeding

    • Goals: Continue breastfeeding, fully empty the breast with each feed to relieve symptoms and reduce abscess risk.
    • Breast Pump: Use if attachment is painful until infection settles.
    • Lactation Consultant: Referral may be helpful.
    • Australian Breastfeeding Association: Useful for support and resources.

    Early and Frequent Review

    • Initial Review: Within 24-48 hours to ensure inflammation is settling.
    • Follow-Up: If minimal improvement, breast ultrasound to detect abscess and guide aspiration.
    • Other Causes: Identify or exclude other causes of inflammatory breast signs, facilitate biopsy if needed.

    Identification and Drainage of Breast Abscess

    • Presentation: Often late with established, large-volume abscess.
    • Traditional Management: Surgical incision and drainage under general anaesthetic.
    • Preferred Management: Percutaneous aspiration under local anaesthetic in specialist clinics, better outcomes than surgical management.
    • Rural Settings: Surgical incision and drainage may be necessary due to limited access to specialist clinics.

    Psychological Issues

    • Emotional Impact: Mastitis is associated with severe physical pain and complex emotions (depression, distress, anxiety, tearfulness, helplessness).
    • Support: Acknowledge difficulties, provide support and reassurance about the safety and value of breast milk, encourage use of the Australian Breastfeeding Association.

    PERIDUCTAL INFECTION (non-breast feeding)

    • periductal inflammation causes areolar mastitis +/- abscess formation. 
    • It is caused by mixed organisms (gram negative + anaerobic.)
    • Ix: USS to exclude abscess
    • Mx: augmentin + metronidazole  +/- if chronic duct excision

    CELLULITIS

    • more common in women with large breasts, commonly excoriation / inflammation of mammary folds (intetrigo) given portal for staph 🡪 cellulitis
    • Mx: abx +/- drainage

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