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

Mastitis

Joe Breuner, M.D.


Thanks to

Thanks to

Doug Trotter, who gave this talk 18 months ago


Case presentation

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 presentation1

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 presentation2

Case Presentation

  • Exam:

    • Afebrile

    • Looks tired but otherwise well

    • Normal nipple and breast; no lumps or indurated areas

    • No skin changes or lymphadenopathy


Case presentation3

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

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 stasis1

Milk stasis

  • Treatment for milk stasis:

    • Heat application

    • Massage toward nipple

    • Frequent, relaxed nursing

    • Change position to promote emptying

    • Avoid pumps, shields


Case presentation4

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 presentation5

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


Mastitis1

Mastitis

  • Incidence: 2 - 3% of lactating women


Mastitis2

Mastitis

  • Incidence: 2 - 3% of lactating women

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


Mastitis3

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


Mastitis4

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


Mastitis5

Mastitis

Normal breast architecture


Mastitis6

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


Mastitis7

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


Mastitis8

Mastitis

  • 1978 Series:

    • Similar results to prior studies

    • No abscesses if prompt antibiotic treatment and continued nursing


Mastitis9

Mastitis

  • Etiology:

    • 50% or more: S. Aureus

    • Other organisms: E. Coli, S. pyogenes


Mastitis10

Mastitis

  • Etiology:

    • 50% or more: S. Aureus

    • Other organisms: E. Coli, S. pyogenes

  • Source: infant nasopharynx (?)


Mastitis11

Mastitis

  • Etiology:

    • 50% or more: S. Aureus

    • Other organisms: E. Coli, S. pyogenes

  • Source: infant nasopharynx (?)

  • Mechanism: via milk ducts or nipple fissure


Mastitis12

Mastitis

  • Treatment:

    • Prompt antibiotics:

      • PO: Dicloxacillin, cephalexin, erythromycin

      • IV: Nafcillin, cefazolin

    • Continued frequent nursing

    • Heat application

    • Massage toward nipple

    • Antipyretics


Mastitis13

Mastitis

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


Breast abscess

Breast Abscess


Breast abscess1

Breast Abscess

Breast abscess with early skin necrosis


Breast abcess

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 abscess2

Breast Abscess

Inflammatory breast cancer


Neonatal mastitis

Neonatal Mastitis


Neonatal mastitis1

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 mastitis2

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


Candida infection1

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 infection2

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


Mastitis14

Mastitis


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