Issue  in  focus  –  LACTATIONAL  BREAST  ABSCESS  

CMI  14:3                                      18     July  2016  

Lactational  Breast  Abscess  Sasank  K.a,  Sumit  Singha,    Anish  Cherianb,    Ebenezer  Ellen  Benjaminc,    aDepartment  of  General  Surgery,  CMC  Vellore,  bDepartment  of  Breast  and  Endocrine  Surgery,  cObstetric  and  Gynecological  Nursing,  CMC  Vellore.    Summary:  •   Lactational breast abscess is defined as a localized collection of pus within the breast during the period of lactation.

It is often a complication of lactational mastitis which is an inflammation of breast tissue secondary to stasis of milk and bacterial colonization (mostly Staphylococcus species).

•   Infection starts in one segment of the breast and presents with a painful, erythematous, tender and fluctuant swelling of the breast. This may be associated with systemic symptoms including fever and malaise.

•   Management of lactational breast abscess includes general supportive measures and specific measures. The two fundamental cornerstones of specific measures include infection control and breast emptying.

•   Surgical options include incision and drainage, needle aspiration and vacuum assisted biopsy. Needle aspiration with concurrent antibiotic therapy is currently recommended as the first line therapy for the treatment of lactational breast abscesses. Incision and drainage is indicated only in large breast abscesses (>5cm), abscesses with thinning or necrosis of overlying skin, failure of needle aspiration therapy and recurrent abscesses.

 

Case  Scenario  A 29 year old lady delivered at term by low forceps delivery. Breast feeding was initiated within one hour of birth and the baby was exclusively breast fed. She started developing engorgement in the right breast on the 14th postnatal day. Manual expression of milk was carried out but she was unable to empty completely. Three days later, she developed redness and swelling of the right breast associated with fever and chills. She found it difficult to feed the baby on the right side. She was managed with breast emptying, antibiotics, analgesics, antipyretic and magnesium sulphate dressing. Ultrasound of the breast showed a multi-loculated collection in lower outer quadrant. Percutaneous needle aspiration of the abscess was done with ultrasound guidance. Approximately 45 ml of pus was drained out. Two days later, the right breast showed persistent induration and tenderness on palpation. A repeat ultrasound showed some residual fluid and she underwent incision and drainage of the abscess. Her postoperative course was uneventful.

Introduction  Lactational breast abscess is defined as a localized collection of pus within the breast during the period of lactation.1, 2 Formation of an abscess may be preceded by a period of generalized inflammation of the breast (mastitis) secondary to stasis of milk in the breast.3 The most common causative organisms are Staphylococcus aureus species and Streptococcus species.1 The risk of infection with Methicillin Resistant Staphylococcus aureus (MRSA) is higher in hospitalized patients.3

Epidemiology  Lactational breast abscess occurs most often in the first 12 weeks of pregnancy and is seen in 0.4 – 11% of all lactating mothers.4 It is more commonly seen among primigravida women more than 30 years of age and in pregnancies more than 41 weeks of gestation.3

Figure 1: Ultrasound of the breast showing a multiloculated breast abscess.

 

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 19 July 2016

Maternal risk factors also include obesity and

smoking.3 About 85% of lactational breast abscesses

occur in either the first month or beyond 6 months after

delivery.

Pathogenesis and clinical features Breast abscess is a common complication of lactational

mastitis (See Box 1). Milk is an ideal culture medium

and an infection develops readily if the engorged breast

is not adequately and frequently emptied.

The usual route of transmission of bacteria is

postulated to be direct contact, with entry of bacteria

via the nipple into the duct system.5The bacteria may

enter via cracked nipples in the first month. Beyond 6

months of age, trauma to the nipple by the baby‟s teeth

has a role to play in the increased risk.3Occasionally, it

may also be haematogenous, with bacterial seeding

from an infection elsewhere in the body.3

Breast abscesses are most commonly seen in the upper

outer quadrant of the breast due to increased amount of

parenchyma in this quadrant.4Infection starts in one

segment of the breast and presents with a painful,

erythematous, tender and fluctuant swelling of the

breast.1 This may be associated with systemic

symptoms including fever and malaise.

Figure 2: Lactational breast abscess with early skin

necrosis and peeling.

Investigations Lactational breast abscess is essentially a diagnosis

made on clinical examination. However, an ultrasound

of the breast may be done in clinically equivocal cases,

to identify possible multiloculated abscesses and to

guide/assess drainage of the abscess cavity.3,4

Management Management of lactational breast abscess includes

general supportive measures and specific measures.

General measures General supportive measures include analgesics for

pain relief, antipyretics and adequate breast support.

Garments for adequate breast support helps in relaxing

the stretched Coopers ligaments, reducing painful

movement of the breast and reducing edema.3Recent

studies exploring the ancient practice of using cold

cabbage leaves for breast abscess have found that

cabbage leaves, cold or not, help in reducing breast

engorgement and hastening recovery.10-13

Specific measures The two fundamental cornerstones of specific measures

include infection control and breast emptying.6

Infection control Antibiotics:Infection control includes administration

of appropriate antibiotics and adequate drainage of pus.

Empiric choice of antibiotics should always be directed

toward Staphylococcal species(Cap. Cloxacillin 500mg

four times daily) as evidence suggests its predominance

in lactational breast abscesses.3 However, the antibiotic

should be tailored based on the culture susceptibility

report and should be continued for a period of 10

days.4,9

Abscess drainage:Various options exist for providing

adequate drainage – incision and drainage, initial

antibiotic therapy with repeated needle aspiration of the

abscess, ultrasound guided vacuum-assisted biopsy.2,7

a) Incision and drainage - In traditional teaching,

incision and drainage of the abscess was

recommended as the primary modality of

treatment. However, recent studies show that this

modality is associated with prolonged recovery

time, a need for repeated dressings, poor cosmetic

outcomes, difficulty in breast feeding and the

possibility of a “milk fistula”.3,7,8

Thus, it is now

indicated only in large breast abscesses (>5cm),

abscesses with thinning or necrosis of overlying

skin, failure of needle aspiration therapy and

recurrent abscesses.1-3,7

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 20 July 2016

b) Needle aspiration with concurrent antibiotic

therapy – This is currently recommended as the

first line therapy for the treatment of lactational

breast abscesses. It is associated with faster time to

healing, better cosmetic outcome and patient

satisfaction. However, it is associated with a failure

rate of up to 15%.14

The risk factors for failure of needle aspiration

for breast abscesses are an abscess larger than 5 cm

in diameter, presence of thick pus, resistant

bacteria, multiloculated abscesses wherein only the

superficial part has been aspirated and rare

etiologies like tuberculosis or inflammatory

carcinoma.3,4,7

c) Ultrasound guided Vacuum assisted

biopsy(VAB) - is an emerging modality of

treatment for lactational breast abscesses. In

comparison to needle aspiration, VAB was found

to have similar outcomes with shorter healing

times. In addition, the VAB needle was found to be

better for large, multiloculated abscesses with thick

pus and abscesses which refill rapidly, owing to its

Box 1:LACTATIONAL MASTITIS

Lactational mastitis is an inflammation of the breast tissue secondary to stasis of milk and bacterial colonisation. It's most common in breastfeeding women, usually within the first three months post partum. The breast becomes swollen, hard and painful and may be associated with systemic symptoms like fever and body ache. Breast abscess is often a complication of mastitis. Hence prevention of mastitis through simple measures is important. Practical tips to prevent mastitis:

Encourage the mother to feed frequently, particularly when the breasts feel overfull. Empty the breast after each feed. Ensure your baby is well attached to the breast during feeds. During every feed the mother must be taught to

look for signs of good attachment such as: the baby’s mouth must be wide open, areola must be inside the baby’s mouth, baby’s lower lip should be turned out and baby’s chin should touch the breast. Good latching is mandatory to prevent and avoid sore nipples and to manage nipple pain. Encourage the mother to reposition the baby correctly on her breast. A comfortable nursing position for both mother and baby helps in good attachment. Currently nursing pillows are available for this purpose.

Allow the baby time to finish the feeds – most babies release the breast when they've finished feeding; try not to remove the baby off the breast unless they're finished.

Avoid suddenly going longer between feeds – if possible, cut down gradually. Care of nipple – Sore nipples and dry, cracked nipples predispose to mastitis. Dryness of the nipple can be

managed by application of expressed breast milk on the nipple to keep the nipple soft and supple. avoid pressure on breasts from tight clothing, including bras. Treatment of mastitis: Mastitis can usually be easily treated and most women make a full recovery very quickly. The main principles of treatment of mastitis are: - 1. Supportive counseling – counseling the mother regarding the prevention of mastitis is helpful, however, this

has to be repeated to be effective. 2. Effective and frequent milk removal - Feed more frequently than usual, express any remaining milk after a

feed and express milk between feeds. Breastfeeding should be continued when you have mastitis, even if you have an infection, won't harm your baby and can help improve your symptoms.

3. Symptomatic treatment – Analgesics, anti-pyretics, dressings that reduce oedema (e.g. Mg So4 dressing) and breast support.

4. Antibiotic therapy – Infected mastitis may benefit from antibiotics especially if the organism is identified. Evidence for its effectiveness is lacking though. A Cochrane review15 showed that there was insufficient evidence to recommend antibiotics in Lactational mastitis. However, antibiotics did lead to a more rapid relief from symptoms.

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 21 July 2016

Figure 3: Algorithm for management of lactational breast abscess

Clinically diagnosed breast abscess

Overlying skin normal

Overlying skin Necrotic/thinned out

Patient willing for repeated aspirations

Patient unwilling for repeated aspirations

Incision and drainage

Ultrasound scan &needle aspiration

Repeat scan after 48-96 hours

Repeat aspiration if residual collection

larger bore and the negative pressure generated by

the machine. 3,7

Breast emptying

Lactational breast abscess occurs due to stasis of milk.

Hence emptying of the breast is an important

component of the management of lactation breast

abscess. This allows for proper drainage of ducto-

lobular system of the breast. Breast emptying may be

done either by suckling of the infant or by manual

expression of breast milk.3,6

Continuing breast feeding does not present any risk to

the baby as mother‟s milk provides immunological

protection by the oral supply of specific antibody and

immunocompetent cells acting against mother‟s

causative microbiologic agent. Suckling may be

difficult following surgical drainage of an abscess due

to pain, presence of a drain or dressing over the

affected site. In these situations, the mother should be

encouraged to feed from the unaffected side and the

affected side should be emptied mechanically.

Recommendations for surgical management – Our practice in CMC

Vellore:(Fig. 3)

If there is necrosis of the overlying skin or if there

is imminent skin rupture, we prefer incision and

drainage as the intervention of choice.

If the abscess has not caused skin necrosis, we

offer the patient ultrasound guided needle

aspiration along with a course of antibiotics. The

patient is advised to review after three to five days

to re-evaluate her symptoms and re-screen the

breast with an ultrasound. Residual collection on

the ultrasound may require a re-aspiration.

A precondition for conservative

treatment with aspiration is a patient who is well-

informed about the problem and who is willing for

regular follow-up and repeated aspirations if

required. If the patient is unlikely to follow up (due

to logistical or any other reasons), the safer option

would be to do an incision and drainage at the first

sepsis.

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 22 July 2016

Conclusions Management of lactational breast abscess

includes general supportive measures and specific

measures. The two fundamental cornerstones of

specific measures include infection control and breast

emptying. Preventive measures and supportive

treatment during a mastitis episode can prevent

progression to an abscess.

If the overlying skin is normal, ultrasound

guided need aspiration is the surgical intervention of

choice. Repeated aspirations may be needed. If the

overlying skin is thinned out or necrotic, incision and

drainage is advisable.

References 1. Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J,

Matthews J, et al. Schwartz‟s Principles of Surgery, 10th

edition. 10 edition. New York: McGraw-Hill Education /

Medical; 2014. 2069 p.

2. Irusen H, Rohwer AC, Steyn DW, Young T. Treatments

for breast abscesses in breastfeeding women. In: Cochrane

Database of Systematic Reviews [Internet]. John Wiley &

Sons, Ltd; 2015 [cited 2016 Apr 17]. Available from:

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010

490.pub2/abstract

3. Kataria K, Srivastava A, Dhar A. Management of

Lactational Mastitis and Breast Abscesses: Review of Current

Knowledge and Practice. Indian J Surg. 2013 Dec;75(6):430–

5.

4. Eryilmaz R, Sahin M, HakanTekelioglu M, Daldal E.

Management of lactational breast abscesses. Breast

EdinbScotl. 2005 Oct;14(5):375–9.

5. Jr CMT, Beauchamp RD, Evers BM, Mattox KL. Sabiston

Textbook of Surgery: The Biological Basis of Modern

Surgical Practice. 19th edition. Philadelphia, PA: Saunders;

2012. 2152 p.

6. Taylor MD, Way S. Penicillin for Acute Puerperal

Mastitis. Br Med J. 1946 Nov 16;2(4480):731–2.

7. Kang Y-D, Kim YM. Comparison of needle aspiration and

vacuum-assisted biopsy in the ultrasound-guided drainage of

lactational breast abscesses. Ultrason Seoul Korea. 2016

Apr;35(2):148–52.

8. Barker P. Milk fistula: an unusual complication of breast

biopsy. J R CollSurgEdinb. 1988 Apr;33(2):106.

9. Benson EA, Goodman MA. Incision with primary suture in

the treatment of acute puerperal breast abscess. Br J Surg.

1970 Jan 1;57(1):55–8.

10. Arora S, Vatsa M, Dadhwal V. A Comparison of

Cabbage Leaves vs. Hot and Cold Compresses in the

Treatment of Breast Engorgement. Indian J Community Med

Off Publ Indian AssocPrevSoc Med. 2008 Jul;33(3):160–2.

11. Roberts KL, Reiter M, Schuster D. A comparison of

chilled and room temperature cabbage leaves in treating

breast engorgement. J Hum Lact Off J IntLact Consult Assoc.

1995 Sep;11(3):191–4.

12. Nikodem VC, Danziger D, Gebka N, Gulmezoglu AM,

Hofmeyr GJ. Do cabbage leaves prevent breast engorgement?

A randomized, controlled study. Birth Berkeley Calif. 1993

Jun;20(2):61–4.

13. Osterman KL, Rahm VA. Lactation mastitis: bacterial

cultivation of breast milk, symptoms, treatment, and

outcome. J Hum Lact Off J IntLact Consult Assoc. 2000

Nov;16(4):297–302.

14. Gojen Singh, Gojendra Singh, L Ramesh Singh, Rahul

Singh, Sharatchandra Singh, K Lekhachandra Sharma.

Management of breast abscess by repeated aspiration and

antibiotics. J Med Soc2012;26:189-91.

15. ShayestehJahanfa, Chirk Jenn Ng, Cheong LiengTeng.

Antibiotics for mastitis in breastfeeding women.

Cochrane Database of Systematic Reviews. Published

Online: 28 Feb 2013

Box 2: Vacuum assisted biopsy (VAB)

Vacuum-assisted breast biopsy is a relatively new tissue

sampling technique used primarily for obtaining tissue

samples from malignant breast tumours that can be localized

using ultrasound. Increasingly, it is being used for biopsy and

treatment of benign breast lumps and also for the aspiration

of multiloculated breast abscesses.

The technique uses a hollow biopsy probe to remove

samples of breast tissue through a single, small skin incision

under imaging guidance (ultrasound). The lesion is localized

and once the probe has been positioned, a vacuum pulls the

breast tissue through an opening in the side of the probe. A

rotating blade then separates the tissue from the surrounding

breast tissue and places it in a sampling chamber of the

device.

Advantages of VAB

1. VAB allows removal of more tissue through a single

incision when compared to a traditional core biopsy. It is also

a less invasive procedure than an open surgical biopsy.

2. This technique does not have the „forward throw‟ of the

needle (as in a standard core biopsy). This reduces the risk of

touching sensitive structures. It may therefore be used for

lesions close to the nipple, the thoracic wall, the skin, or the

axillary region.

3. There is less epithelial displacement of a malignant tissue

when compared to core biopsy and open biopsy.

Limitation: It is expensive.

Image source: http://medicaldialogues.in

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 19 July 2016

Maternal risk factors also include obesity and

smoking.3 About 85% of lactational breast abscesses

occur in either the first month or beyond 6 months after

delivery.

Pathogenesis and clinical features Breast abscess is a common complication of lactational

mastitis (See Box 1). Milk is an ideal culture medium

and an infection develops readily if the engorged breast

is not adequately and frequently emptied.

The usual route of transmission of bacteria is

postulated to be direct contact, with entry of bacteria

via the nipple into the duct system.5The bacteria may

enter via cracked nipples in the first month. Beyond 6

months of age, trauma to the nipple by the baby‟s teeth

has a role to play in the increased risk.3

Occasionally, it

may also be haematogenous, with bacterial seeding

from an infection elsewhere in the body.3

Breast abscesses are most commonly seen in the upper

outer quadrant of the breast due to increased amount of

parenchyma in this quadrant.4Infection starts in one

segment of the breast and presents with a painful,

erythematous, tender and fluctuant swelling of the

breast.1 This may be associated with systemic

symptoms including fever and malaise.

Figure 2: Lactational breast abscess with early skin

necrosis and peeling.

Investigations Lactational breast abscess is essentially a diagnosis

made on clinical examination. However, an ultrasound

of the breast may be done in clinically equivocal cases,

to identify possible multiloculated abscesses and to

guide/assess drainage of the abscess cavity.3,4

Management Management of lactational breast abscess includes

general supportive measures and specific measures.

General measures General supportive measures include analgesics for

pain relief, antipyretics and adequate breast support.

Garments for adequate breast support helps in relaxing

the stretched Coopers ligaments, reducing painful

movement of the breast and reducing edema.3Recent

studies exploring the ancient practice of using cold

cabbage leaves for breast abscess have found that

cabbage leaves, cold or not, help in reducing breast

engorgement and hastening recovery.10-13

Specific measures The two fundamental cornerstones of specific measures

include infection control and breast emptying.6

Infection control Antibiotics: Infection control includes administration

of appropriate antibiotics and adequate drainage of pus.

Empiric choice of antibiotics should always be directed

toward Staphylococcal species (Cap. Cloxacillin

500mg four times daily) as evidence suggests its

predominance in lactational breast abscesses.3

However, the antibiotic should be tailored based on the

culture susceptibility report and should be continued

for a period of 10 days.4,9

Abscess drainage: Various options exist for providing

adequate drainage – incision and drainage, initial

antibiotic therapy with repeated needle aspiration of the

abscess, ultrasound guided vacuum-assisted biopsy.2,7

a) Incision and drainage - In traditional teaching,

incision and drainage of the abscess was

recommended as the primary modality of

treatment. However, recent studies show that this

modality is associated with prolonged recovery

time, a need for repeated dressings, poor cosmetic

outcomes, difficulty in breast feeding and the

possibility of a “milk fistula”.3,7,8

Thus, it is now

indicated only in large breast abscesses (>5cm),

abscesses with thinning or necrosis of overlying

skin, failure of needle aspiration therapy and

recurrent abscesses.1-3,7

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 20 July 2016

b) Needle aspiration with concurrent antibiotic

therapy – This is currently recommended as the

first line therapy for the treatment of lactational

breast abscesses. It is associated with faster time to

healing, better cosmetic outcome and patient

satisfaction. However, it is associated with a failure

rate of up to 15%.14

The risk factors for failure of needle aspiration

for breast abscesses are an abscess larger than 5 cm

in diameter, presence of thick pus, resistant

bacteria, multiloculated abscesses wherein only the

superficial part has been aspirated and rare

etiologies like tuberculosis or inflammatory

carcinoma.3,4,7

c) Ultrasound guided Vacuum assisted

biopsy(VAB) - is an emerging modality of

treatment for lactational breast abscesses. In

comparison to needle aspiration, VAB was found

to have similar outcomes with shorter healing

times. In addition, the VAB needle was found to be

better for large, multiloculated abscesses with thick

pus and abscesses which refill rapidly, owing to its

Box 1: LACTATIONAL MASTITIS

Lactational mastitis is an inflammation of the breast tissue secondary to stasis of milk and bacterial colonisation. It's most common in breastfeeding women, usually within the first three months post partum. The breast becomes swollen, hard and painful and may be associated with systemic symptoms like fever and body ache. Breast abscess is often a complication of mastitis. Hence prevention of mastitis through simple measures is important. Practical tips to prevent mastitis:

Encourage the mother to feed frequently, particularly when the breasts feel overfull. Empty the breast after each feed. Ensure your baby is well attached to the breast during feeds. During every feed the mother must be taught to

look for signs of good attachment such as: the baby’s mouth must be wide open, areola must be inside the baby’s mouth, baby’s lower lip should be turned out and baby’s chin should touch the breast. Good latching is mandatory to prevent and avoid sore nipples and to manage nipple pain. Encourage the mother to reposition the baby correctly on her breast. A comfortable nursing position for both mother and baby helps in good attachment. Currently nursing pillows are available for this purpose.

Allow the baby time to finish the feeds – most babies release the breast when they've finished feeding; try not to remove the baby off the breast unless they're finished.

Avoid suddenly going longer between feeds – if possible, cut down gradually. Care of nipple – Sore nipples and dry, cracked nipples predispose to mastitis. Dryness of the nipple can be

managed by application of expressed breast milk on the nipple to keep the nipple soft and supple. avoid pressure on breasts from tight clothing, including bras. Treatment of mastitis: Mastitis can usually be easily treated and most women make a full recovery very quickly. The main principles of treatment of mastitis are: - 1. Supportive counseling – counseling the mother regarding the prevention of mastitis is helpful, however, this

has to be repeated to be effective. 2. Effective and frequent milk removal - Feed more frequently than usual, express any remaining milk after a

feed and express milk between feeds. Breastfeeding should be continued when you have mastitis, even if you have an infection, won't harm your baby and can help improve your symptoms.

3. Symptomatic treatment – Analgesics, anti-pyretics, dressings that reduce oedema (e.g. Mg So4 dressing) and breast support.

4. Antibiotic therapy – Infected mastitis may benefit from antibiotics especially if the organism is identified. Evidence for its effectiveness is lacking though. A Cochrane review15 showed that there was insufficient evidence to recommend antibiotics in Lactational mastitis. However, antibiotics did lead to a more rapid relief from symptoms.

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 21 July 2016

Figure 3: Algorithm for management of lactational breast abscess

Clinically diagnosed breast abscess

Overlying skin normal

Overlying skin Necrotic/thinned out

Patient willing for repeated aspirations

Patient unwilling for repeated aspirations

Incision and drainage

Ultrasound scan &needle aspiration

Repeat scan after 48-96 hours

Repeat aspiration if residual collection

larger bore and the negative pressure generated by

the machine. 3,7

Breast emptying

Lactational breast abscess occurs due to stasis of milk.

Hence emptying of the breast is an important

component of the management of lactation breast

abscess. This allows for proper drainage of ducto-

lobular system of the breast. Breast emptying may be

done either by suckling of the infant or by manual

expression of breast milk.3,6

Continuing breast feeding does not present any risk to

the baby as mother‟s milk provides immunological

protection by the oral supply of specific antibody and

immunocompetent cells acting against mother‟s

causative microbiologic agent. Suckling may be

difficult following surgical drainage of an abscess due

to pain, presence of a drain or dressing over the

affected site. In these situations, the mother should be

encouraged to feed from the unaffected side and the

affected side should be emptied mechanically.

Recommendations for surgical management – Our practice in CMC Vellore:

(Fig. 3)

If there is necrosis of the overlying skin or if there

is imminent skin rupture, we prefer incision and

drainage as the intervention of choice.

If the abscess has not caused skin necrosis, we

offer the patient ultrasound guided needle

aspiration along with a course of antibiotics. The

patient is advised to review after three to five days

to re-evaluate her symptoms and re-screen the

breast with an ultrasound. Residual collection on

the ultrasound may require a re-aspiration.

A precondition for conservative

treatment with aspiration is a patient who is well-

informed about the problem and who is willing for

regular follow-up and repeated aspirations if

required. If the patient is unlikely to follow up (due

to logistical or any other reasons), the safer option

would be to do an incision and drainage at the first

sepsis.

Issue in focus – LACTATIONAL BREAST ABSCESS

CMI 14:3 22 July 2016

Conclusions Management of lactational breast abscess

includes general supportive measures and specific

measures. The two fundamental cornerstones of

specific measures include infection control and breast

emptying. Preventive measures and supportive

treatment during a mastitis episode can prevent

progression to an abscess.

If the overlying skin is normal, ultrasound

guided need aspiration is the surgical intervention of

choice. Repeated aspirations may be needed. If the

overlying skin is thinned out or necrotic, incision and

drainage is advisable.

References 1. Brunicardi F, Andersen D, Billiar T, Dunn D, Hunter J,

Matthews J, et al. Schwartz‟s Principles of Surgery, 10th

edition. 10 edition. New York: McGraw-Hill Education /

Medical; 2014. 2069 p.

2. Irusen H, Rohwer AC, Steyn DW, Young T. Treatments

for breast abscesses in breastfeeding women. In: Cochrane

Database of Systematic Reviews [Internet]. John Wiley &

Sons, Ltd; 2015 [cited 2016 Apr 17]. Available from:

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010

490.pub2/abstract

3. Kataria K, Srivastava A, Dhar A. Management of

Lactational Mastitis and Breast Abscesses: Review of Current

Knowledge and Practice. Indian J Surg. 2013 Dec;75(6):430–

5.

4. Eryilmaz R, Sahin M, HakanTekelioglu M, Daldal E.

Management of lactational breast abscesses. Breast

EdinbScotl. 2005 Oct;14(5):375–9.

5. Jr CMT, Beauchamp RD, Evers BM, Mattox KL. Sabiston

Textbook of Surgery: The Biological Basis of Modern

Surgical Practice. 19th edition. Philadelphia, PA: Saunders;

2012. 2152 p.

6. Taylor MD, Way S. Penicillin for Acute Puerperal

Mastitis. Br Med J. 1946 Nov 16;2(4480):731–2.

7. Kang Y-D, Kim YM. Comparison of needle aspiration and

vacuum-assisted biopsy in the ultrasound-guided drainage of

lactational breast abscesses. Ultrason Seoul Korea. 2016

Apr;35(2):148–52.

8. Barker P. Milk fistula: an unusual complication of breast

biopsy. J R CollSurgEdinb. 1988 Apr;33(2):106.

9. Benson EA, Goodman MA. Incision with primary suture in

the treatment of acute puerperal breast abscess. Br J Surg.

1970 Jan 1;57(1):55–8.

10. Arora S, Vatsa M, Dadhwal V. A Comparison of

Cabbage Leaves vs. Hot and Cold Compresses in the

Treatment of Breast Engorgement. Indian J Community Med

Off Publ Indian AssocPrevSoc Med. 2008 Jul;33(3):160–2.

11. Roberts KL, Reiter M, Schuster D. A comparison of

chilled and room temperature cabbage leaves in treating

breast engorgement. J Hum Lact Off J IntLact Consult Assoc.

1995 Sep;11(3):191–4.

12. Nikodem VC, Danziger D, Gebka N, Gulmezoglu AM,

Hofmeyr GJ. Do cabbage leaves prevent breast engorgement?

A randomized, controlled study. Birth Berkeley Calif. 1993

Jun;20(2):61–4.

13. Osterman KL, Rahm VA. Lactation mastitis: bacterial

cultivation of breast milk, symptoms, treatment, and

outcome. J Hum Lact Off J IntLact Consult Assoc. 2000

Nov;16(4):297–302.

14. Gojen Singh, Gojendra Singh, L Ramesh Singh, Rahul

Singh, Sharatchandra Singh, K Lekhachandra Sharma.

Management of breast abscess by repeated aspiration and

antibiotics. J Med Soc2012;26:189-91.

15. ShayestehJahanfa, Chirk Jenn Ng, Cheong LiengTeng.

Antibiotics for mastitis in breastfeeding women.

Cochrane Database of Systematic Reviews. Published

Online: 28 Feb 2013

Box 2: Vacuum assisted biopsy (VAB)

Vacuum-assisted breast biopsy is a relatively new tissue

sampling technique used primarily for obtaining tissue

samples from malignant breast tumours that can be localized

using ultrasound. Increasingly, it is being used for biopsy and

treatment of benign breast lumps and also for the aspiration

of multiloculated breast abscesses.

The technique uses a hollow biopsy probe to remove

samples of breast tissue through a single, small skin incision

under imaging guidance (ultrasound). The lesion is localized

and once the probe has been positioned, a vacuum pulls the

breast tissue through an opening in the side of the probe. A

rotating blade then separates the tissue from the surrounding

breast tissue and places it in a sampling chamber of the

device.

Advantages of VAB

1. VAB allows removal of more tissue through a single

incision when compared to a traditional core biopsy. It is also

a less invasive procedure than an open surgical biopsy.

2. This technique does not have the „forward throw‟ of the

needle (as in a standard core biopsy). This reduces the risk of

touching sensitive structures. It may therefore be used for

lesions close to the nipple, the thoracic wall, the skin, or the

axillary region.

3. There is less epithelial displacement of a malignant tissue

when compared to core biopsy and open biopsy.

Limitation: It is expensive.

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