Issue

 in  focus  –  LACTATIONAL  BREAST  ABSCESS  

Lactational  Breast  Abscess  
Sasank  K.a,  Sumit  Singha,    Anish  Cherianb,    Ebenezer  Ellen  Benjaminc,    
a b c
Department  of  General  Surgery,  CMC  Vellore,   Department  of  Breast  and  Endocrine  Surgery,   Obstetric  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
1, 2
lactation. 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
1
aureus species and Streptococcus species. The risk of
infection with Methicillin Resistant Staphylococcus
3
aureus (MRSA) is higher in hospitalized patients.

Epidemiology  
Lactational breast abscess occurs most often in the first
12 weeks of pregnancy and is seen in 0.4 – 11% of all
4
lactating mothers. It is more commonly seen among
primigravida women more than 30 years of age and in
3
pregnancies more than 41 weeks of gestation. Figure 1: Ultrasound of the breast
showing a multiloculated breast
abscess.

 
CMI
 14:3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 18
 
  July
 2016
 
Issue in focus – LACTATIONAL BREAST ABSCESS
Maternal risk factors also include obesity and
3 3,4
smoking. 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
3
from an infection elsewhere in the body.
Breast abscesses are most commonly seen in the upper
outer quadrant of the breast due to increased amount of
4
parenchyma in this quadrant. Infection 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,
CMI 14:3 19
to identify possible multiloculated abscesses and to
guide/assess drainage of the abscess cavity.
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
10-13
engorgement and hastening recovery.
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
July 2016
Issue in focus – LACTATIONAL BREAST ABSCESS
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.

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 to have similar outcomes with shorter healing
biopsy(VAB) - is an emerging modality of times. In addition, the VAB needle was found to be
treatment for lactational breast abscesses. In better for large, multiloculated abscesses with thick
comparison to needle aspiration, VAB was found pus and abscesses which refill rapidly, owing to its
CMI 14:3 20 July 2016
Issue in focus – LACTATIONAL BREAST ABSCESS
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.

Figure 3: Algorithm for management of lactational breast abscess

Clinically diagnosed breast abscess

Overlying skin Overlying skin

normal Necrotic/thinned out

Patient willing Patient unwilling

for repeated for repeated Incision and
aspirations aspirations drainage

Ultrasound scan
&needle aspiration

Repeat scan after

48-96 hours

Repeat aspiration
if residual collection

CMI 14:3 21 July 2016

Issue in focus – LACTATIONAL BREAST ABSCESS
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.
CMI 14:3 22
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
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
July 2016
Issue in focus – LACTATIONAL BREAST ABSCESS
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
3
from an infection elsewhere in the body.
Breast abscesses are most commonly seen in the upper
outer quadrant of the breast due to increased amount of
4
parenchyma in this quadrant. Infection starts in one
segment of the breast and presents with a painful,
erythematous, tender and fluctuant swelling of the
1
breast. 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,
CMI 14:3 19
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
10-13
engorgement and hastening recovery.
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
July 2016
Issue in focus – LACTATIONAL BREAST ABSCESS
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.

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 to have similar outcomes with shorter healing
biopsy(VAB) - is an emerging modality of times. In addition, the VAB needle was found to be
treatment for lactational breast abscesses. In better for large, multiloculated abscesses with thick
comparison to needle aspiration, VAB was found pus and abscesses which refill rapidly, owing to its
CMI 14:3 20 July 2016
Issue in focus – LACTATIONAL BREAST ABSCESS
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.

Figure 3: Algorithm for management of lactational breast abscess

Clinically diagnosed breast abscess

Overlying skin Overlying skin

normal Necrotic/thinned out

Patient willing Patient unwilling

for repeated for repeated Incision and
aspirations aspirations drainage

Ultrasound scan
&needle aspiration

Repeat scan after

48-96 hours

Repeat aspiration
if residual collection

CMI 14:3 21 July 2016

Issue in focus – LACTATIONAL BREAST ABSCESS
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.
CMI 14:3 22
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
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
July 2016