Gynecology Book



Aka: Mastitis, Breast abscess, Lactation Mastitis
  1. Epidemiology
    1. Incidence: 9-33% of lactating women
    2. Most common in first few weeks and nearly all cases within first 3 months
  2. Pathophysiology
    1. Generally occurs in Lactation several weeks postpartum
    2. Bacteria enter through a cracked nipple
  3. Etiology
    1. Staphylococcus aureus
    2. Escherichia coli
    3. HaemophilusInfluenzae
  4. Symptoms
    1. Fatigue
    2. Malaise
    3. Myalgias
    4. Headache
  5. Signs
    1. Fever
    2. Unilateral Breast inflammation
      1. Warmth
      2. Tenderness
      3. Erythema
    3. Observe for signs of Breast abscess
      1. Requires needle aspiration
  6. Labs: Milk Culture
    1. Indications (not routine)
      1. Severe Mastitis
      2. Refractory despite optimal antibiotics for at least 48 hours
      3. Hospital acquired infection
    2. Technique
      1. Cleanse nipple
      2. Hand express small quantity of Breast Milk and discard
      3. Hand express a sample into a sterile container
  7. Differential Diagnosis
    1. Inflammatory Breast Cancer
  8. Management: General Measures
    1. Continue with frequent Breastfeeding
      1. Risk of Breast abscess if Breast engorgement occurs
      2. Safe for infant to continue to feed despite infection (except if mother HIV positive)
      3. Ensure proper technique (see prevention below)
    2. Tylenol or Ibuprofen
    3. Ensure adequate hydration
    4. Apply warm packs and local massage
    5. Alternate feeding positions
    6. Antifungals (Monilial Infection)
      1. Topical Antifungals on Breast
      2. Oral Nystatin for infant
  9. Management: Antibiotics
    1. Course: 10 to 14 days
    2. Coverage: Staphylococcus aureus (or as directed by culture)
    3. May observe localized Breast redness, tenderness without systemic symptoms or abscess for 24 hours
      1. For first 24 hours may use general measures above and hold antibiotics
      2. Start antibiotics by 24 hours if not improving, systemic symptoms, other risks
    4. Antibiotics: Nursing Mothers
      1. Amoxacillin-Clavulanate (Augmentin) 875 mg orally twice daily
      2. Cephalexin (Keflex) 500 mg orally four times daily
      3. Dicloxacillin 500 mg orally four times daily
      4. Clindamycin 300 mg orally four times daily (for MRSA)
    5. Antibiotics: Non-Breast Feeding women
      1. Trimethoprim-sulfamethoxazole (Septra) 160mg/800 mg orally twice daily (for MRSA)
        1. May be used in Lactation after first 2 months of life
  10. Management: Breast abscess
    1. Obtain Bacterial culture
    2. Needle aspiration under Ultrasound guidance (preferred, 60% effective)
      1. Attempt to irrigate the abscess via the same needle used for aspiration
      2. May repeat up to 3 times if fails to resolve (then incise in drain if still refractory)
    3. Incision and Drainage
      1. Indicated in refractory cases (after 3 attempted needle aspirations)
      2. Also first-line measure in very superficial lesions, with skin thinning over the abscess
    4. References
      1. Sacchetti in Herbert (2016) EM:Rap 16(5): 1
  11. Follow-up
    1. Early antibiotics prevent abscess formation
    2. If not better in 48 hours examine Breast for abscess
      1. Consider Incision and Drainage
  12. Prevention
    1. Optimal Breast Feeding Technique with good latch-on by infant
    2. Address predisposing factors early
      1. Sore nipples suggest problems
        1. Correct latch-on problems
        2. Address dry nipples with lanolin
        3. Avoid plastic-backed Breast pads
        4. Evaluate infant for anatomic problems (e.g. short frenulum, Cleft Palate)
      2. Cracked nipples colonized with Staphylococcus aureus should be treated
        1. Oral antibiotics (e.g. Dicloxacillin) are preferred
        2. Livingstone (1999) J Hum Lact 15:241-6 [PubMed]
      3. Blocked milk ducts should be unblocked
        1. Blocked ducts will appear with a bleb overlying a tender, red area adjacent to nipple
        2. Remove bleb with moist cloth
      4. Yeast infection should be treated (both infant and mother)
        1. Infant: See Thrush for management options
        2. Mother
          1. Topical agents: Nystatin or Ketoconazole
          2. Oral agents: Fluconazole 400 mg on day #1, then 200 mg orally daily for 10 days
          3. Chetwynd (2002) J Hum Lact 18:168-71 [PubMed]
  13. References
    1. Barbosa-Cesnik (2003) JAMA 289:1609-12 [PubMed]
    2. Spencer (2008) Am Fam Physician 78(6): 727-32 [PubMed]
    3. Westerfield (2018) Am Fam Physician 98(6): 368-73 [PubMed]

Mastitis (C0024894)

Concepts Pathologic Function (T046)
MSH D008413
SnomedCT 155952005, 155955007, 266644004, 198099006, 266641007, 45198002
French MASTITE, Inflammation du sein, INFLAMMATION DU SEIN, Mammite, Mastite
English BREAST INFLAMMATION, MASTITIS, Breast inflammation, Breast inflammation NOS, mastitis (diagnosis), mastitis, Mastitis [Disease/Finding], Mastitis, breasts inflammation, Breast inflammation NOS (disorder), Mammitis, Mastitis (disorder), breast; inflammation, inflammation; breast, Mastitis, NOS, Mastitis NOS
Portuguese MASTITE, Inflamação da mama, INFLAMACAO DA MAMA, Mamite, Mastite
Spanish MASTITIS, Inflamación mamaria, MAMA, INFLAMACION, inflamación mamaria, SAI, Breast inflammation NOS, inflamación mamaria, SAI (trastorno), Mamitis, mastitis (trastorno), mastitis, Mastitis
German MASTITIS, Brustentzuendung, BRUSTENTZUENDUNG, Mammitis, Mastitis
Japanese 乳腺炎, ニュウセンエン, 乳房炎症, ニュウボウエンショウ
Swedish Bröstkörtelinflammation
Dutch mastitis, borstontsteking, mammitis, mamma; ontsteking, ontsteking; mamma, Mastitis
Italian Infiammazione mammaria, Mammite, Mastite
Czech mastitida, Zánět prsu, Mastitida
Finnish Mastiitti
Polish Zapalenie sutka
Hungarian Emlő gyulladás, mastitis, Mammitis
Norwegian Brystkjertelbetennelse, Brystbetennelse, Mastitt
Derived from the NIH UMLS (Unified Medical Language System)

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