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Breast- Painful Breast > Lactational Mastitis > Flashcards

Lactational Mastitis Flashcards

1
Q

What is mastitis?

A

• Mastitis means inflammation of the breast and may be non-infectious or infectious in origin.

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2
Q

What is the main cause of mastitis in lactating women?

A

• In lactating women, it is essentially caused by an accumulation of milk.

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3
Q

How does infectious mastitis occur in lactating women?

A
  • Infectious mastitis occurs when accumulated milk allows bacteria to grow. The usual infecting organism is Staphylococcus aureus, although it may also be Staphylococcus albus and streptococci.
  • Methicillin-resistant Staphylococcus aureus (MRSA) infection is increasing and may be more common in women who have had a caesarean section.
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4
Q

What are you worried about with infectious mastitis?

A

• Infectious mastitis may lead to a breast abscess, which occurs when a localised collection of pus develops.

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5
Q

Pathophysiology of mastitis in lactating women

A

• In lactating women, milk stasis is usually the primary cause of mastitis.

o The accumulated milk causes an inflammatory response which may or may not progress to infection.

o The most common organism associated with infectious mastitis in breastfeeding women is Staphylococcus aureus, including strains of Methicillin-resistant S. aureus (MRSA) if the infection was hospital-acquired.

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6
Q

What is the main cause of mastitis in non-lactating women?

A

• In non-lactating women, mastitis is usually accompanied by infection

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7
Q

What is the classification of infection in non-lactating women?

A
  • Central/ subareolar

- Peripheral

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8
Q

Cause of central/subareolar infection?

A

Usually caused by periductal mastitis or duct ectasia

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9
Q

What is periductal mastitis?

A

a condition where the subareolar ducts are damaged and become infected.

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10
Q

What is duct ectasia?

A
  • This is a harmless-age related breast change.
  • Duct ectasia of the breast, mammary duct ectasia or plasma cell mastitis is a condition in which occurs when a milk duct beneath the nipple widens, the duct walls thicken and the duct fills with fluid. This is the most common cause of greenish discharge.
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11
Q

What causes peripheral non-lactating mastitis?

A

Peripheral non-lactating infection (less common) has been associated with diabetes mellitus, rheumatoid arthritis, trauma, corticosteroid treatment, and granulomatous lobular mastitis (GLM), but often there is no underlying cause.

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12
Q

What is granulomatous lobular mastitis (GLM)?

A

GLM is a rare inflammatory disease of the breast which is thought to be an autoimmune reaction to substances secreted from the mammary ducts. It can be idiopathic or occur in people with certain risk factors, although it is not exactly clear how it develops.

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13
Q

What are the common organisms that are associated with infectious mastitis in non-lactating women?

A

o The most common organisms associated with infectious mastitis in non-lactating women are S. aureus, enterococci, and anaerobic bacteria (such as Bacteroides spp and anaerobic streptococci)

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14
Q

What are the risk factors for mastitis?

A
  • Problems with attachment of infant to breast during feeding, due to problems with technique or anatomical anomalies such as tongue-tie or cleft lip.
  • Reduced number of feeds, or duration of feeds, leading to milk accumulation.
  • Pressure on the breast - due to tight clothing, seat belt, sleeping in the prone position.
  • Nipple fissures, cracks and sores.
  • Trauma to breasts.
  • Blocked milk ducts.
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15
Q

What can cause reduced number of feeds in lactating women?

A

o Partial bottle feeding.
o Changes in regime (due to infant starting to sleep through the whole night for example).
o Rapid weaning.
o Painful breasts.
o Preferred breast, leading to milk accumulation in the other.

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16
Q

How can periductal mastitis present?

A

• Periductal mastitis may present with peri areolar inflammation (with or without an associated mass), an established abscess, nipple retraction at the site of the diseased duct, central breast pain, and/or greenish discharge from the nipple.

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17
Q

How does GLM?

A

• GLM may present with breast distortion, ulceration, or a large area (or areas) of infection with multiple simultaneous peripheral abscesses.

18
Q

What are the symptoms of mastitis?

A

The area affected is painful, tender, red and hot.

o Systemic symptoms include fever, rigors, muscle pain, lethargy, depression, nausea and headache.

19
Q

How does lactating mastitis present?

A

o This normally presents ≥1 week postpartum usually in only one breast. The area affected is painful, tender, red and hot.
o Systemic symptoms include fever, rigors, muscle pain, lethargy, depression, nausea and headache.
o It should be distinguished from congestive mastitis (breast engorgement) which usually presents on the second or third day of breast-feeding. The complaint in this case is of swollen and tender breasts bilaterally, without fever or erythema.

20
Q

What are the signs of mastitis?

A

o Breast examination reveals unilateral oedema, erythema in a wedge-shaped area, and tenderness. The affected area feels firm and hot.
o There may be fever.
o It is not possible to distinguish clinically between infectious and non-infectious mastitis.
o If a breast abscess has developed, there will be a fluctuant tender lump, with overlying erythema.
o Axillary lymphadenopathy may be palpable.

21
Q

What should you do if an abscess is suspected?

A

• If an abscess is suspected, early referral is required. Ultrasound will show whether there is a collection of pus and should also be considered when infection does not settle after one course of antibiotic.

22
Q

What are the differentials of mastitis?

A
  • Galactocele
  • Blocked duct
  • Breast cancer
  • Cellulitis
  • Non-lactational breast abscesses may occur in smokers, diabetic patients and those who are immunocompromised.
  • However, an important diagnosis not to miss is inflammatory breast cancer.
23
Q

What is inflammatory breast cancer?

A

This is a rare form of breast cancer in which cancer cells grow along the lymph vessels causing the breast to become inflamed and swollen. It can mimic mastitis and breast abscess.

24
Q

What is the first line management of mastitis?

A

o Reassurance. Mastitis is painful, but should not interfere with ability to breast-feed, or affect the long-term appearance of the breast.
o Encourage the woman to continue breast-feeding. Explain that to do so will not cause any harm to the baby. If it is too painful, consider feeding via expressing until symptoms improve.
o Improve milk removal.
o Analgesia. Paracetamol or ibuprofen may be used for pain and inflammation where appropriate.
o Advise not wearing a bra at night.
o Be aware that many women may require emotional support.
o Antibiotics

25
Q

How does milk removal improve?

A

This may involve:
Assessment of breast-feeding technique by an appropriately trained, skilled person who can assess feeding pattern, positioning, attachment, sucking behaviour and breast fullness

Manual expression of milk to empty the breast after feeding.

Self-massage of the breast before feeding or expression, or application of heat by warm compresses, shower or heat packs.

Increasing feeding frequency.

Feeding on the affected side first while symptoms persist so this breast is emptied most effectively.

26
Q

Which antibiotics are used for mastitis?

A

First-line measures for 24 hours before starting antibiotics unless the woman is acutely unwell or has an infected nipple injury.

Antibiotics, usually flucloxacillin or erythromycin, should be prescribed. Treatment should be in accordance with local prescribing guidelines.

Co-amoxiclav in women with non-lactational mastitis, if allergic to penicillin then erythromycin.

27
Q

What is the surgical management of breast abscesses?

A

Surgical management is indicated for breast abscesses. Incision and drainage of abscess with cavity packed open with gauze is recommended if the overlying skin is thin or necrotic.

Parenteral antibiotics should be administered at the same time, with added coverage for anaerobic bacteria. Fluid from the abscess should be cultured, and results used to determine ongoing antibiotic treatment.

Needle aspiration of the abscess, repeated every other day until the pus no longer accumulates, has been suggested as an alternative to open drainage.

In some cases, breast-feeding may have to cease until the abscess is successfully treated, but can usually resume later.

Any persisting mass will need further investigation to exclude sinister causes.

28
Q

What is the preferred method of draining abscesses?

A

Ultrasound-guided drainage of the abscess is preferred over surgical incision and drainage as this can be done in the breast unit under local anaesthetic, there is less scarring, patient recovery is quicker, and mother and baby are not separated.

This is performed under local anaesthetic.

29
Q

What are the complications of mastitis?

A
  • Cessation of breast-feeding is the most common complication of mastitis. This may lead to emotional distress in women who had planned to continue breast-feeding.
  • Serious complications occur in cases where treatment is delayed, incorrect or ineffective. These include breast abscess and sepsis.
  • Breast abscesses occur in around 3-7% of women with puerperal mastitis. Stopping breast-feeding suddenly in mastitis increases the risk of developing an abscess. Other risk factors include obesity and smoking.
30
Q

What are the physiological changes to the breast during pregnancy?

A
  • During pregnancy, increasing oestrogen levels stimulate growth and branching of the ductal system.
  • Alveolar cells develop secretory capability under the influence of progesterone, and both hormones act synergistically to contribute to ductal and lobular growth.
  • Small amounts of colostrum are secreted in the last few days of pregnancy, but milk production begins after childbirth under the influence of prolactin.
  • Lactation is sustained by each breastfeeding episode via oxytocin which mediates prolactin secretion.
  • Clinically the breasts will feel larger, firmer and more nodular.
  • There may be increased alveolar and nipple pigmentation and Montgomery’s tubercles may become more prominent.
31
Q

What are the changes to imaging of the breast of a pregnant woman?

A
  • Mammographically, the main features are increased breast size and density. It may help to ask the patient to breastfeed or express milk before a mammogram is performed to decrease the density of the engorged breast.
  • On ultrasound, the combination of glandular enlargement and engorgement of breast tissue results in increased echogenicity of the breast parenchyma. Duct dilatation and hypervascularity of the breast tissue may also be observed.
  • At the histological level, there is progressive enlargement of the lobules with increasing luminal distension in the later stages of pregnancy.
32
Q

How do you assess breast feeding problems?

A

Breastfeeding history
Breast and nipple pain history
Maternal history
Infant history

33
Q

Which questions do you ask relating to breastfeeding history?

A

o Previous breastfeeding experiences, problems, pain.

o Any breast or nipple sensitivity before pregnancy.

o Milk supply issues (engorgement, low or oversupply).

o Pattern of breastfeeding (frequency, duration, night feeds, one or both breasts offered).

o Expressing of milk (frequency, hand or pump used).

o Maternal beliefs, ideas, concerns, and expectations about breastfeeding.

o Other fluids or foods given (when
started, quantity, and frequency).

o Use of nipple shields or breast shells.

34
Q

Which questions will you ask in terms of breast pain and nipple pain?

A

o Onset post-partum.

o Any nipple trauma (abrasions, fissures, bleeding).

o Timing (with attachment, during breastfeeds, between breastfeeds, with expressing of milk) and whether intermittent or constant.

o Location (unilateral or bilateral, nipple and/or breast, superficial or deep).

o Character and severity (burning, itching, sharp, dull).

o Any associated signs and symptoms (fever, breast skin changes, nipple colour changes, nipple shape or appearance after feeds).

o Any exacerbating or relieving factors (cold, heat, massage or touch).
o Previous treatments (analgesia, topical or oral drugs including antibiotics).

35
Q

Which questions do you ask in terms of maternal history?

A

o Any complications during pregnancy, labour, or post-partum.

o Known medical conditions, such as thyroid disorders, Raynaud’s phenomenon, eczema or psoriasis, recent Candida or bacterial infection, chronic pain syndromes, family history of ankyloglossia (tongue-tie).

o Previous breast surgery and indication.

o Medications and allergies.

o Alcohol and smoking history.

o Associated insomnia, stress, anxiety, or depression.

36
Q

Which questions do you ask in terms of infant history?

A

o Birth gestation, any birth trauma or known medical conditions or congenital abnormalities.

o Birth weight, weight gain, general health and behaviour (settled or crying).

o Behaviour at the breast (pulling, biting, coughing, breathlessness, sleepiness) which may be a consequence of nasal congestion, teething, or an overactive milk ejection reflex.

o Gastrointestinal symptoms which may suggest oversupply of milk, gastro-oesophageal reflux disease
, or cows’ milk protein allergy.

o Known ankyloglossia or cleft lip and/or palate; any treatments to date.

o Use of a dummy or pacifier.

37
Q

Examination for assessment of breast feeding

A 
o Woman's nipples:
Flat or inverted nipples.
Skin integrity.
Sensitivity to palpation.
Nipple discharge.
Skin discolouration, lesions, or rashes

o Woman’s breasts:
Any breast lumps, such as a galactocele.
Tenderness to light or deep palpation.
Skin discoloration, lesions, or rashes.

o Infant:
Signs of dehydration.
Head and neck symmetry and facial features.
Oral anatomy (ankyloglossia, palate, jaw, and lips) or oral Candida infection that may affect sucking and swallowing.
Any nasal congestion.
Muscle tone, neurological maturity, behaviour.

38
Q

What are the problems with attachment and positioning?

A

o Breastfeeding:
Maternal and infant positioning.
Attachment (mouth wide-open with lips everted).
Pattern of sucking.
Shape and colour of nipples after feeding.

o Expressing milk:
Hand and/or breast pump expressing technique.
Breast shield/flange fit.
Nipple or breast trauma due to breast pump use (for example caused by improper flange fit, excessive high-pressure suction, or prolonged duration of use).

39
Q

What are the symptoms of inflammatory breast cancer?

A 
• Symptoms often develop quite suddenly.
• The breast may become:
o Red and inflamed
o Firm
o Swollen
o Tender​
• Breast pain
• Nipple discharge
• Breast lump
• Peau d’orange (pitted skin)
• Symptoms are similar to that of mastitis.
40
Q

How do you diagnose inflammatory breast cancer?

A
  • Triple assessment
  • Inflammatory breast cancer can spread more quickly than other types of breast cancer so treatment should be started as soon as possible.
41
Q

What is the management of inflammatory breast cancer?

A
  • Same as breast cancer but neo-adjuvant treatment is indicated in inflammatory breast cancer.
  • Most women have mastectomy and breast reconstruction doesn’t happen at the same time as a mastectomy as radiotherapy is usually given as well.

Breast- Painful Breast (2 decks)

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