PANCE Blueprint Reproductive System (7%)

Mastitis (Lecture)

Patient will infectious mastitis present as → a breastfeeding woman 3 weeks postpartum complaining of a painful area of the breast that is reddened and warm. The patient feels very fatigued with a fever of 101.5 ° F and chills.   She reports a burning pain present constantly or at times only while breastfeeding. On exam, the patient appears ill.  Breast examination shows an erythematous right breast with a palpable mass, induration, erythema, and tenderness to palpation.

Patient with congestive mastitis presents as → a primigravida with bilateral, painful breast engorgement.

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Mastitis is a condition in which bacteria enter the breast tissue through a milk duct or a fissure in the skin, caused by breastfeeding. Mastitis usually occurs within the first few weeks of breastfeeding but may occur later

  • Mastitis occurs mainly in breastfeeding women. Rarely, this condition occurs in women who are not breastfeeding
  • Infectious vs. congestive mastitis (unilateral vs. bilateral)
    • Infectious (unilateral) - Unilateral, fever, chills, and color change
    • Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas

***Inflammatory breast cancer presents with breast tenderness and color change, but fever and chills are not usually present

Breast examination shows an erythematous right breast with a palpable mass, induration, erythema, and tenderness to palpation

Diagnosis is clinical – if an abscess is suspected and ultrasound may be warranted

  • Culture of the breast milk can be useful to guide selection of antibiotics
  • Blood cultures are warranted in the setting of severe infection

Treat with dicloxacillin 250 mg QID x 10 days for staphylococcus

  • Patients should be encouraged to continue breastfeeding and apply warm/cold compresses to the infected area along with oral NSAIDs

Question 1
A 28-year-old primigravida develops an erythematous skin discoloration in the upper outer quadrant of the left breast. She has achy, influenza-like symptoms and temperature of 101 ° F. You suspect bacterial mastitis. At this time, what would you do?
stop breast-feeding and have the mother express her breast milk until the infection is cleared
continue breast-feeding and treat the mother with hot compresses and antibiotics
continue breast-feeding and treat both the mother and the infant with antibiotics
discontinue breast-feeding for now and provide antibiotics to the mother
discontinue any further breast-feeding and perform an incision and drainage immediately
Question 1 Explanation: 
Unless exceptional circumstances dictate otherwise, the recommended course of action with maternal mastitis is to continue breast-feeding and to treat the mother with symptomatic treatments, such as hot compresses, and antibiotics effective against Staphylococcus aureus (including coagulase-positive staphylococcus). The antibiotic of choice in this case is cloxacillin or dicloxacillin. Erythromycin or first-generation cephalosporins may be used for penicillin-allergic patients.
Question 2
What is (are) likely cause( s) of recurrent mastitis you should explore?
Check latch-on and determine if the baby is positioned properly
Encourage the use of different breastfeeding positions to massage different milk ducts
Make sure the patient is getting adequate rest and hydration and is not waiting too long between feeds (or pumping)
Check nipples for cracks, fissures, or signs of fungal infection
All of the above
Question 2 Explanation: 
Causes of recurrent mastitis are multiple. Check the latch-on and make sure the baby’s nose is pointing toward the nipple and the mouth has most of the areola encircled. The mother should change positions so the infant’s mouth massages different ducts. Teaching a woman to watch for clogged milk ducts before the development of mastitis, to use massage with a motion toward the nipple, and to use warm, moist packs can often resolve the plugged duct before development of mastitis. Advice to “go to bed with baby” is important so the mother can relax, allow time for feeding, and prevent milk duct stasis. Frequent emptying of the breast— often difficult with some of the less expensive, less effective pumps— is especially important for the working mother. The electric double-pumping system (Medela and Hollister are commonly used brands) is generally more effective than hand or battery-operated pumps. An undiagnosed fungal infection of the nipple that may be due to infant thrush (or vice versa) should be treated to prevent fissuring and cracks. If a nipple has a sore or crack, the infant should begin feeding on the least sore side. Pure lanolin may be used, but otherwise breast milk may be used to soothe the crack. Other ointments and nipple shields should not be used. Generally sore, cracked nipples are due to improper positioning or prolonged suckling that is non-nutritive.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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