Meghann E. Batten
History of present illness
A 32-year-old gravida 2, para 2 woman presents to an urgent care clinic with complaints of left breast pain, flu-like symp- toms, and fever. She is breast-feeding andfive weeks postpar- tum from an uncomplicated spontaneous vaginal delivery. She reports the pain and fatigue began one day prior. Overnight, she developed fever up to 39.8°C, chills, malaise, and worsening breast pain. She took acetaminophen (Tylenol®) and ibuprofen for comfort, but these did not resolve her symptoms. She states that when she nurses on the left side, the breast is exquisitely painful, the baby is fussy, and her milk production seems decreased. She denies nausea, vomiting, diarrhea, or abdominal pain. She has no other medical problems and is not taking any other medications.
Physical examination
General appearance:Healthy woman who appears uncomfortable and tired
Vital signs:
Temperature: 38.5°C Pulse: 98 beats/min
Blood pressure: 118/76 mmHg Respiratory rate: 18 breaths/min
Chest:Respirations are nonlabored, lungfields are clear Cardiac:Regular rate and rhythm
Breast:Right breast is soft, moderately engorged, with no masses noted. Left breast is tender to palpation,
erythematous and warm to touch in the left outer quadrant. No masses orfluctuance palpated. Nipples intact bilaterally without lesions or skin break down (Fig. 58.1)
Abdomen:Soft, nontender Extremities:Nontender, no edema
How would you manage this patient?
The patient has lactational mastitis, a breast infection that occurs during the postpartum period with breast-feeding. She had classic symptoms and high fever, but no evidence of an abscess, so she was treated as an outpatient. She was prescribed a 14-day course of dicloxacillin (500 mg PO QID). She was also educated on adjuvant therapy, including nonsteroidal anti-inflammatory drugs for pain and fever, rest, hydration, massage and warm compresses of the affected breast, and
frequent nursing or pumping to drain the breast. She was afebrile within 24 hours of initiation of antibiotic therapy and pain free within 72 hours. She continued to breast-feed without disruption or difficulty.
Mastitis
Mastitis (also called lactational mastitis or puerperal mastitis) has been defined by the World Health Organization as an inflammatory condition of the breast, which may or may not be accompanied by infection [1]. It is an acute inflammation of the interlobular connective tissue within the breast and ranges from local inflammation with minimal systemic symptoms to abscess and septicemia [2]. It can occur anytime during lacta- tion, but it is most common during the second and third weeks postpartum, with 75–95% of cases occurring within thefirst 12 weeks postpartum [3]. The reported incidence of mastitis varies widely from 1 to 33% of breast-feeding women. This variance is due to the broad spectrum of methodology for case ascertainment ranging from self-diagnosis to a positive milk culture [1].
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 58.1 Left breast.
Mastitis is thought to be caused by two primary conditions:
milk stasis and infection. Milk stasis can occur as a result of poor breast-feeding latch, incomplete emptying of the breast, over-abundant milk supply, extended periods between feeds, missed feeds, and tight or incorrectly fitting clothing on the breasts. The stagnant milk provides an excellent culture medium for bacterial growth. Infection generally occurs as the result of skin bacteria, though it is not known how the bacteria enters the breast. Because sore nipples are a common finding with mastitis, one theory is that the bacteria enters through a crack orfissure in the nipple [1]. The most common organism involved in mastitis isStaphylococcus aureus. Other organisms such asStreptococcus, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumo- niae,Enterobacter cloacae, Serratia marcescens, andPseudomo- nas pickettiihave been implicated as well [4].
The differential diagnosis for mastitis includes a range of conditions from normal physiologic processes such as lacta- tional fullness, engorgement, galactoceles, and blocked ducts, to infectious processes such as ductal candidiasis and breast abscess, to more chronic pathology such as Raynaud’s phe- nomenon of the nipple, and inflammatory breast cancer [5].
Table 58.1 includes a comparison of findings for commonly occurring lactational conditions. Diagnosis is based on clinical symptoms including fever, chills, myalgia,flu-like symptoms, breast tenderness and pain, unilateral edema, and erythema in a wedge-shaped area [2]. Milk culture is rarely used because positive cultures can result from normal bacterial colonization and negative cultures do not rule out mastitis. A milk culture may be useful if the infection is severe, unusual, recurrent, or fails to respond to traditional antibiotic therapy [3].
Careful history and physical is crucial to the diagnosis and treatment of mastitis. A detailed breast-feeding history helps identify associated factors including missed feedings, widely spaced feedings, increased stress fatigue, incomplete drainage of the breast, over-abundant milk supply, tight-fitting clothing, and breast pumping [3]. A breast assessment helps to rule out abscess and evaluate for contributing factors such as a crack or
fissure in the nipple. This is especially critical in a patient who has recurrent episodes of mastitis. Breast abscess generally presents as a discrete painful lump with localized heat and erythema and may or may not be associated with fever. If abscess is suspected or mastitis is recurrent, a breast ultra- sound may be beneficial [5]. If nipple tenderness is reported or damage such as cracking or bruising is noted, observation of a breast-feeding session by a healthcare professional or lactation consultant may assist with evaluation of the infant’s latch. Poor attachment to the breast can occur as a result offlat nipples, obesity, poor positioning, tight frenulum, and prema- turity. In this patient, no issues with latch or emptying of the breast were identified. High levels of fatigue and stress, as well as a nursing bra with an underwire were identified as potential contributing factors.
Prompt diagnosis and treatment of mastitis are important in preventing early weaning from breast-feeding. Mastitis has been reported as the third most common reason for weaning with 25% of women citing mastitis as the reason they weaned [6]. Because of the vast benefits of breast-feeding to both mother and infant, the Department of Health and Human Services “Healthy People 2020” and the Surgeon General’s Call to Action have emphasized a critical need to increase breast-feeding initiation and continuation rates, particularly to 6 months of age [7]. Swift symptom resolution and correc- tion of predisposing factors may help to reduce premature cessation of breast-feeding due to mastitis.
The primary goals of treatment are facilitating recovery and preventing complications. There is overwhelming consen- sus that breast-feeding should continue throughout treatment of mastitis. Women should be encouraged to nurse their babies frequently, ideally feeding on the affected sidefirst, with the infant’s chin pointing in the direction of the affected area [5]. If nursing is too painful, pumping with an electric or manual pump may be substituted. If over-supply or incom- plete emptying is identified, pumping after feeds should be instituted to assist in complete drainage of the breast. Hot compresses and massage during feeds may also help to
Table 58.1 Differential diagnosis for common lactational problems
Engorgement Blocked duct Mastitis Abscess
Occurrence during lactation
First-week postpartum Any time Any time Any time
Onset Gradual Gradual Sudden Sudden
Usual location Bilateral Unilateral Unilateral Unilateral
Erythema Bilateral None Unilateral Localized
Heat Generalized warmth Little to none Warm to hot Hot
Pain Generalized Local, mild Unilateral, moderate–severe Localized, severe
Appearance/palpation Firm, enlarged, shiny Localized lumpy area Wedge-shaped area offirmness Swollen discrete lump
Systemic symptoms Feels well Feels well Feels ill May or may not feel well
Fever Afebrile Afebrile Fever>37.5°C May or may not have fever
promote drainage [5]. Supportive therapy to alleviate systemic symptoms includes bed rest, increasedfluids, pain medication, and use of anti-inflammatory agents. If systemic symptoms are mild or noninfective mastitis is suspected, these interventions may be sufficient treatment for mastitis [8].
Antibiotic therapy, a mainstay component of mastitis treat- ment, is controversial. To date, there has been little consensus on which patients require antibiotics, which antibiotic is most appropriate, the timing of treatment, and how long treatment should continue [8]. A Cochrane review of antibiotics in the treatment of mastitis concluded that there is, “Insufficient evidence to confirm or refute the effectiveness of antibiotic therapy for the treatment of lactational mastitis”[8], citing a lack of well-designed, scientific studies such as randomized control trials (RCTs). However, in one study it was found that women who received antibiotic therapy achieved the fastest symptom resolution (2.1 days), as opposed to supportive ther- apy only (4.2 days), or no therapy (6.7 days). Faster resolution of symptoms is likely to avoid disruption or discontinuation of breast-feeding. In addition, 11% of cases with no intervention developed an abscess while there were no cases of abscess in those women who received antibiotic therapy [8]. When pre- scribing antibiotics, there must be careful consideration of antibiotic compatibility with breast-feeding. Dicloxacillin (250–500 mg QID) and cephalexin (500 mg QID) are com- monly used. Generally a 10–14-day course is recommended [3]. Despite the high fever and rapid onset of systemic symp- toms associated with mastitis, patients who undergo appropri- ate treatment have swift resolution as well. Cessation of fever and systemic symptoms generally occurs within one to three days of antibiotic initiation. Breast pain typically resolves within a week.
Complications arising from mastitis include recurrence, breast abscess and sepsis, which can be fatal. Recurrence may result from incomplete treatment, maternal immunoglobulin A (IgA) deficiency, increased stress/fatigue, or undiagnosed abscess. Daily low-dose antibiotic therapy for prevention of recurrence may be required [5]. Abscess has been reported in 5–11% of mastitis cases [2]. Abscess may be diagnosed on physical examination or with ultrasound. It is generally treated with incision and drainage along with antibiotics (potentially parenteral). Needle aspiration of the abscess, repeated every other day until there is no further purulent accumulation has also been suggested [2]. Sepsis, though rare, can result from delayed or inadequate treatment and requires hospital admis- sion and parenteral antibiotics.
Key teaching points
Mastitis is characterized by unilateral breast pain and erythema, accompanied byflu-like symptoms including fever, and myalgia. It is caused by milk stasis
and infection.
Treatment requires evaluation and correction of associated factors such as poor infant latch or incomplete emptying of the breast.
Treatment with antibiotics has been demonstrated to reduce the length of symptoms and the likelihood of abscess. A 10–14 day course is recommended, along with supportive therapy.
Milk culture should be reserved for recurrence or infection that fails standard therapy.
Breast abscess and sepsis can occur if treatment is delayed or inadequate.
References
1. Inch, S, von Xylander, S.Mastitis:
Causes and Management. Geneva, World Health Organization, 2000.
2. Barbosa-Cesnik C, Schwartz K, Foxman B. Lactation mastitis.JAMA2003;
289(13):1609–12.
3. Spencer JP. Management of mastitis in breastfeeding women.Am Fam Physician2008;78(6):727–32.
4. American College of Obstetricians and Gynecologists.ACOG Practice Bulletin,
2006: Compendium of Selected Publications. Washington, DC, ACOG, 2006, pp. 284–5.
5. Betzold, CM. An update on the recognition and management of lactational breast inflammation.
J Midwifery Womens Health2007;
52(6):595–605.
6. Crepinsek MA, Crowe L, Michener K, Smart NA. Interventions for preventing mastitis after childbirth.Cochrane Database Syst Rev2012, Issue 10. Art.
No.: CD007239. DOI: 10.1002/14651858.
7. HealthyPeople.gov. 2020 Topics and objectives: maternal, infant, and child health. Goal 21. Available athttp://
www.healthypeople.gov/2020/
topicsobjectives2020/objectiveslist.
aspx?topicId=26.
8. Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women (review).Cochrane Database Syst Rev 2013, Issue 2. Art. No. CD005458. DOI:
10.1002/14651858.
Case 58: A 32-year-old woman with fever and unilateral breast pain