Question

Case scenario 4: You see a 23-year-old in post-natal ward who has been diagnosed with lactational mastitis. Her breasts are engorged, painful, red and warm to touch.

Explain the pathogenesis of lactational mastitis. Develop a management plan for this patient’s condition. Recommend three (3) strategies to minimize the recurrence of lactational mastitis.

Answer 1

Lactational mastitis is a condition in which a woman's breast becomes painful, swollen, and red; it is most common in the first three months of breastfeeding. Initially, engorgement occurs because of poor milk drainage, probably related to nipple trauma with resultant swelling and compression of one or more milk ducts.

Most breast abscesses develops as a complication of lactational mastitis. The incidence of breast abscess ranges from 0.4 to 11 % of all lactating mothers. The traditional management of breast abscesses involves incision and drainage of pus along with antistaphylococcal antibiotics, but this is associated with prolonged healing time, regular dressings, difficulty in breast feeding, and the possibility of milk fistula with unsatisfactory cosmetic outcome.

Types of Breast Abscesses

Lactational Abscess

Risk factors for lactational breast abscess formation include the first pregnancy at maternal age over 30 years, pregnancy more than 41 weeks of gestation, and mastitis . It is relatively common for lactating women to develop a breast abscess as a complication of mastitis.

Nonlactational Abscesses

Nonlactational abscesses can be classified as central, peripheral, or skin associated. Patients with nonlactational abscesses, diabetics, and smokers are likely to develop recurrent infections. Central (periareolar) nonlactational abscesses are usually due to periductal mastitis.

Pathology and Bacteriology

The organism most commonly implicated is Staphylococcus aureus, which gains entry via a cracked nipple. Occasionally, the infection is hematogenous. In the early stages, the infection tends to be confined to single segment of the breast, and it is relatively late that extension to other segments may occur. Milk provides an ideal culture medium, so bacterial dispersion in the vascular and distended segment is easy. The pathological process is identical to acute inflammation occurring elsewhere in the body, although the loose parenchyma of the lactating breast and the stagnant milk of an engorged segment allow the infection to spread rapidly both within the stroma and through the milk ducts, if unchecked. The bacteria are excreted in the milk.

Management of Breast Abscess

Assessment

The clinical problem may be resolved into cellulitis without pus formation and abscess. The importance of an accurate assessment of the situation cannot be overemphasized. Surgery in the early cellulitic phase is unnecessarily destructive, and continued antibiotic therapy in the presence of an abscess may lead to tissue destruction by the disease process. Test-needle aspiration of the cellulitic area, preferably preceded by ultrasound examination, should be performed. If ultrasound shows an abscess, the needle can be guided into the cavity. It is wrong to wait for the development of fluctuation and pointing before proceeding to drainage, because further destruction of the breast tissue will occur. Even if no pus is aspirated, the opportunity should be used to carry out bacteriological examination of the aspirated material. A useful bonus of this approach is that the rare case of inflammatory carcinoma may be diagnosed on the smear, thus avoiding operation in this difficult condition.

Treatment

Taylor and Way clearly enunciated the principles of treatment: curtail infection and empty the breast. The methods of achieving this differ in the cellulitic and abscess stages.

General measures are listed as follows:

• Analgesics

• Breast support

• Role of cold cabbage leaves

• Breast emptying and continuation of breastfeeding

• Antistaphylococcal antibiotics

Specific measures are listed as follows:

• Aspiration of pus

• Ultrasonography (USG) guided

  • Needle aspiration

  • Catheter drainage

• Incision and drainage

General Measures

1. Analgesics: Ibuprofen is regarded as most efficient, and it also helps to reduce inflammation and edema. Paracetamol can be used as an alternative. Tramadol and other opioids are avoided as they have central nervous system depressant effect on newborn.

2. Providing adequate breast support: Breast support garment helps in relaxing the stretched Cooper’s ligament, reducing the movement of painful organ and reducing edema.

3. Role of cabbage leaves: Women have been using cabbage leaves to relieve engorgement symptoms for centuries. However, does this natural remedy actually work? Few research studies have been able to medically prove whether cabbage leaves actually alleviate engorgement.

4. Emptying the breast: This important aspect of the management of puerperal breast infection is sometimes ignored. The breast may be emptied either by suckling or by expression. Although bacteria are present in the milk, no harm appears to be done to the infant if breastfeeding is continued. After open surgical drainage of an abscess, suckling may be difficult for a few days because of pain of a cut and the dressing over the affected side, but the mother should be encouraged to feed on the unaffected side. The infected breast, however, should be emptied either by manual expression or by a pump.

   Regular natural milk emptying of the breast is an essential part of the treatment. Breast emptying with mechanical devices is recommended only for a subareolar localization of the abscess, or when the drain or dressing placement renders natural feeding impossible. In such cases, mother can continue breastfeeding from the other breast, and the affected breast must be emptied mechanically. The milk from that breast may be given to the baby without pasteurization if it does not contain pus or blood. Such a procedure is also safe for the baby because mother’s milk provides immunological protection by the oral supply of specific antibody and immunocompetent cells acting against mother’s causative microbiologic agents. There is consensus that lactation should be continued, allowing for proper drainage of ductolobular system of the breast. Continuing breastfeeding does not present any risk to the nursing infant.

Suppression of Lactation

Drug-induced blockade of lactation dramatically affects the hormonal status of breastfeeding women, resulting in nausea, vomiting, and bad general feeling. All these symptoms lower the quality of life and may adversely affect mental state of patients. Drug-induced blockade of lactation is contraindicated because of its negative impact on the immune system as well as physical and mental development of the suckling baby. If it is decided to abandon breastfeeding, lactation should be suppressed as quickly as possible. The most effective suppressant currently available is probably cabergolamine, which is effective as a single dose and so is preferable to bromocriptine 2.5 mg twice daily for 14 days. The engorged breast should be emptied as far as possible mechanically. Fluid restriction and firm binding seem unnecessary.

Technique of breast emptying is presented as follows:

1. The breast distal to the area of mastitis is squeezed firmly between the thumb and the rib cage; then the thumb, with pressure maintained, is moved up to the areola.

   

   Technique of breast emptying

2. With downward pressure maintained, the index finger is placed on the opposite side of the areola.

3. The pus is squeezed out between the thumb and the index finger.

4. Roleof oral and systemic antibiotics: Most cases of mastitis that progress to breast abscess involve infections with S. aureus. Though other infective organisms may cause mastitis, an antibiotic effective against penicillin-resistant staphylococci has been recommended to decrease the possibility of breast abscess.

Choice of Antibiotics

The choice of antibiotics should depend on following considerations:

1. Drug should be secreted and concentrated in good concentration in milk.

2. The drug should remain active in acidic pH of milk.

3. It should not harm the suckling baby.

Percutaneous aspiration

The suction drain insertion is recommended only in large abscesses or which refill rapidly after aspiration.

Ultrasound-guided drainage in combination with oral antibiotics was shown to be an effective treatment for breast abscess, especially for the group with puerperal abscesses. No other factors, including whether treatment was conducted using needle aspiration or catheter drainage, had any independent effect on the recovery.

The beta lactamase-resistant penicillins have been recommended in the treatment of mastitis. These include cloxacillin, dicloxacillin, or flucloxacillin. Because penicillins are acidic, they are poorly concentrated in human milk, which is also acid. Therefore, cloxacillin and its congeners tend to treat cellulitis well, but they are less effective in eradicating adenitis, the most likely precursor of breast abscess. Erythromycin, being alkaline, is well concentrated and remains active in human milk. Though some rare strains of staphylococci are resistant to erythromycin, this drug may be the best antibiotic in the treatment of adenitis of the breast, where the infection resides primarily in the milk ducts. Both cloxacillin and erythromycin can safely be given to infants, but erythromycin is less likely to trigger antibiotic-sensitivity reactions. When patients are allergic to penicillins, cephalexin or clindamycin may be the alternative to erythromycin. Combination like co-amoxiclav should be avoided because of fear of inducing MRSA.

Antibiotics most appropriate for treating breast infections

Duration of Antibiotics

The recommended duration of antibiotic therapy is 10 days.

Specific Measures: USG-guided Drainage Versus Incision and Drainage