37

Mastitis
Wirsma Arif Harahap
Surgical Oncologist
Surgery Department

Mastitis

An acute inflammation of the

interlobular connective tissue within
the mammary gland

Objective

Epidemiology
Presentation
Predisposing factors
Microbiology
Treatment
Complications
Effect on breast milk

Epidemiology
Incidence 2-33%.
Most common worldwide <10%

Most common 2nd-3rd week postpartum

74-95% in first 12 weeks
Can occur anytime in lactation
WHO 2000

Presentation

Systemic illness: Chills, myalgias

Fever of 38.5 0C
Tender, hot, swollen wedge-shaped erythematous area of
breast
Usually one breast

Differential
Diagnosis
Fullness: bilateral, hot, heavy, hard, no redness
Engorgement: bilateral, tender, +/- fever, minimal
diffuse erythema
Blocked Duct: painful lump with overlying erythema,
no fever, feel well, particulate matter in milk
Galactocele: smooth rounded swelling (cyst)
Abscess: tender hard breast mass, +/- fluctuance,
skin erythema, induration, +/- fever
Inflammatory Breast Carcinoma: unilateral, diffuse
and recurrent, erythema, induration

Causes
Milk Stasis
Stagnant milk increases pressure in breast leading
to leakage in surrounding breast tissue
Milk, itself, causes an inflammatory response

+/- Infection
Milk provides medium for bacterial growth

Predisposing factors
Improper nursing technique
Timing of feeds
Poor attachment

Oversupply of milk

Overabundant milk supply

Lactating for multiples
Rapid weaning
Blocked nipple pore or duct

Pressure on Breast
Tight Bra
Car seatbelt (yes, this is actually listed)
Prone sleeping position

Predisposing factors

Damaged nipple (nipple fissure)

Primiparity
Previous history of mastitis
Maternal or neonatal illness
Maternal stress
Work outside the home
Trauma
Genetic

Flat or Inverted
Begin treatment Nipples
late in
pregnancy
Stop if causes uterine
contractions

Breast shells
Wear 1 hour a day and
gradually increase to
several hours
Dry area under nipple
often

Offering Your Breast

to Baby
Fingers underneath,
thumb on top of breast
Fingers well behind
areola

Illustration by Joyce Kopatch, USACHPPM

Microbiology
Detection of pathogens difficult
Usually nasal/skin flora
Difficult to avoid contamination

Milk culture
Encouraged in hospital acquired, recurrent
mastitis, or no response in 2 days

Microbiology
Staph Aureus
Coag neg staph
Also, Group A and B hemolytic Strep, E Coli,
H. flu
MRSA
Fungal infections
TB where endemic 1% of cases

Fungal infections
Based on case reports that anti-fungal cream
improves sx
Case reports of cyptococcal infection
Most common: Candida Albicans
Genital tract Newborn oral colonization

May lead to nipple fissure

Thought to be associated with deep, shooting pains
and nipple discomfort
Most commonly treated with fluconozole to , oral
nystatin to infant

Breast abscess

Treatment
Supportive Therapy
Rest, fluids, pain medication, anti-inflammatory agents,
encouragement

Continue breast feeding

Antibiotics that cover Staph and Strep

Culture results
Severe symptoms
Nipple fissure
No improved sx after 12-24 hours of milk removal

86% of women in the U.S. get treated with Abx

Treatment
Dicloxicillin 500 mg qid
Erythromycin if PCN allergic
If resistant to treatment penicillinaseproducing staph, then vancomycin or
cefotetan until 2 days after infection subsides
Minimum treatment 10-14 days

Complications

(Other bad things related to mastitis)

Abscess

Most common in first 6 weeks

5-11% of mastitis cases
Affect future lactation in 10% of affected
Treatment: I & D, U/S guided needle drainage

Other Complications
Distortion of breast
Chronic inflammation

Granulomatous
Mastitis
Noncaseating granulomas in a lobular distribution
Differential Diagnosis

TB mastitis
Foreign body
Fat necrosis
Autoimmune: sarcoid, erythema nodusum, polyarthritis

Presentation
Unilateral Breast lump
No infection identified at presentation

Granulomatous
Mastitis
Can mimic Breast Ca on clinical, radiological,
and cytological exams
Diagnosis: Histology
Treatment:
Antibiotics not helpful
Corticosteroids
Excision biopsy
Heer 2003, Goldberg 2000

Subclinical Mastitis

No symptoms, usually unilateral

Reduction in milk output
Diagnosis: Increased milk sodium
Causes
Milk stasis, poor nutrition, +/- bacteria

Public Health implication

Poor infant growth
Increased risk of HIV transmission

Natural Hx and clinical implication unclear

Effect on Milk
Immune Factors
IgA is predominant in milk
Increased immune factors from both plasma
and local epithelial cells
No adverse events documented in peds
Poor growth documented likely related to poor
milk production
Contradictory studies showing benefit or harm

Interest in pediatric vaccine development

Increased HIV
transmission risk

Milk VL increases 10-20 fold

Alternating breast/bottle increased risk
Role of free virus vs cell bound virus unclear
If must breast feed, then pump on affected
breast (pasteurize) and feed on unaffected
Subclinical mastitis: Problem -Lab dxs only

Profilaksis

Breast Cancer in
Pregnancy
More progressive
Non Hormonal
Dependence
Young Patient
Worst prognosis
Problem in diagnosis

Therapy
1st trimester : Operative.
Chemotherapy in 2nd trimester
2nd & 3rd trimester : Operative +
Chemotherapy
Radiotherapy : after delivery.
Termination pregnancy : not indicated

Take Home
Mastitis can decrease motivation to
breast feed
OK to Breastfeed (except HIV+)