Mastitis
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Mastitis. Joe Breuner, M.D. Thanks to . Doug Trotter, who gave this talk 18 months ago. Case Presentation. Healthy 25 year-old woman, G2P2, with a 6 week-old infant Infant is fully breast-fed Patient is fatigued due to caring for 2 young children

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Mastitis

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Mastitis

Joe Breuner, M.D.


Thanks to

Doug Trotter, who gave this talk 18 months ago


Case Presentation

  • Healthy 25 year-old woman, G2P2, with a 6 week-old infant

  • Infant is fully breast-fed

  • Patient is fatigued due to caring for 2 young children

  • Husband is Boeing engineer, stressed because of likely upcoming layoff


Case Presentation

  • At 6 week visit, she reports 2 episodes of moderately painful swelling in upper inner quadrant of R breast; it occurred once in L breast

  • It usually resolves, but she wants to know why it happens, and what to do


Case Presentation

  • Exam:

    • Afebrile

    • Looks tired but otherwise well

    • Normal nipple and breast; no lumps or indurated areas

    • No skin changes or lymphadenopathy


Case Presentation

  • Exam:

    • Afebrile

    • Looks tired but otherwise well

    • Normal nipple and breast; no lumps or indurated areas

    • No skin changes or lymphadenopathy

  • Dx: Milk stasis or “plugged duct”


Milk stasis

  • Risk factors for milk stasis:

    • Fatigue, stress

    • Infrequent feeding

    • Incomplete emptying of breast

    • Ill-fitting bra

    • Pumps, shields

    • Prior breast trauma or infection


Milk stasis

  • Treatment for milk stasis:

    • Heat application

    • Massage toward nipple

    • Frequent, relaxed nursing

    • Change position to promote emptying

    • Avoid pumps, shields


Case Presentation

  • Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum

  • Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve

  • Now 2 hrs of fever, chills, increased tenderness


Case Presentation

  • Pt calls you Sunday afternoon, 3 PM, now 7 weeks postpartum

  • Had recurrent swelling of upper inner quadrant R breast yesterday, but didn’t resolve

  • Now 2 hrs of fever, chills, increased tenderness

  • Dx: Acute mastitis


Mastitis

  • Incidence: 2 - 3% of lactating women


Mastitis

  • Incidence: 2 - 3% of lactating women

  • More common at 2 - 6 weeks post-partum, but can occur at any time


Mastitis

  • Incidence: 2 - 3% of lactating women

  • More common at 2 - 6 weeks post-partum, but can occur at any time

  • More common in primiparas, but probably due to bias


Mastitis

  • Incidence: 2 - 3% of lactating women

  • More common at 2 - 6 weeks post-partum, but can occur at any time

  • More common in primiparas, but probably due to bias

  • Risk factors: milk stasis, age > 30, stress, fatigue, professional employment of mother or father


Mastitis

Normal breast architecture


Mastitis

  • 1970 Series:

    • 71 cases of acute lactational mastitis

    • Peak incidence at 2-3 weeks postpartum

    • No infants weaned; none became ill

    • 11% developed abscesses; 75% of those required surgical drainage

    • Abscess more likely if antibiotics delayed

    • 8% developed mastitis in a later pg


Mastitis

  • 1975 Series:

    • 65 cases in 2,534 women: 2.5% incidence

    • Average onset 5 weeks postpartum

    • 14% had missed feed or rapidly weaned

    • 12% had nipple fissure beforehand

    • 74% had been nursing normally

    • 5% developed abscesses, all in pts who chose to wean


Mastitis

  • 1978 Series:

    • Similar results to prior studies

    • No abscesses if prompt antibiotic treatment and continued nursing


Mastitis

  • Etiology:

    • 50% or more: S. Aureus

    • Other organisms: E. Coli, S. pyogenes


Mastitis

  • Etiology:

    • 50% or more: S. Aureus

    • Other organisms: E. Coli, S. pyogenes

  • Source: infant nasopharynx (?)


Mastitis

  • Etiology:

    • 50% or more: S. Aureus

    • Other organisms: E. Coli, S. pyogenes

  • Source: infant nasopharynx (?)

  • Mechanism: via milk ducts or nipple fissure


Mastitis

  • Treatment:

    • Prompt antibiotics:

      • PO: Dicloxacillin, cephalexin, erythromycin

      • IV: Nafcillin, cefazolin

    • Continued frequent nursing

    • Heat application

    • Massage toward nipple

    • Antipyretics


Mastitis

  • In non lactating or pregnant women, consider early referral, as cancer is much more common.


Breast Abscess


Breast Abscess

Breast abscess with early skin necrosis


Breast abcess

  • Consider diagnosis in mastitis which fails to respond to antibiotics after 2-3d (may not feel fluctuant)

  • refer to breast surgeon for incisional drainage and biopsy--

  • 10-15% of breast carcinomas in women<40 are found during pregnancy or lactation


Breast Abscess

Inflammatory breast cancer


Neonatal Mastitis


Neonatal Mastitis

  • Occurs up to 5 weeks of age

  • Girls outnumber boys 2 : 1

  • Etiology: 85% S. aureus, also E. coli, group D Streptococcus


Neonatal Mastitis

  • Occurs up to 5 weeks of age

  • Girls outnumber boys 2 : 1

  • Etiology: 85% S. aureus, also E. coli, group D Streptococcus

  • Treatment:

    • Prompt antibiotics (IV?)

    • Careful needle aspiration if abscess


Candida Infection


Candida Infection

  • Burning pain with nursing

  • Mild erythema & pruritis of nipple; findings may be subtle

  • Associated with thrush in the baby

  • May be intraductal


Candida Infection

  • Treat mother and baby with topical antifungals or Gentian violet

  • May be recurrent

  • If no response to topical therapy, may use oral fluconazole 150 mg qd X 5d


Mastitis


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