Doctors Revision

Obstetrics

Mastitis / Breast Abscess

Inflammation of the breast tissue (mastitis), which may progress to a localized collection of pus (abscess), usually occurring in breastfeeding women.

Also known as: Breast Infection

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Referral and warning signs

When to refer

Refer to Hospital (HC4/H) if: Suspected abscess, Severe mastitis, Failure to improve on oral antibiotics, Recurrent mastitis.

Red flags

  • Palpable fluctuant mass
  • Signs of sepsis
  • Skin necrosis
  • Failure to respond to antibiotics
  • Suspicion of inflammatory breast cancer

Signs and symptoms

  • Mastitis: Painful, tender, swollen, warm, red area of breast (wedge-shaped). Usually unilateral. Fever, chills, malaise.
  • Breast Abscess: Progression from mastitis. Palpable, tender, fluctuant mass. Skin may be shiny/thin. Persistent fever despite antibiotics.

Risk factors

  • Milk stasis (engorgement, poor emptying, blocked duct).
  • Nipple damage (cracked nipples, poor latch).
  • Previous mastitis.
  • Tight bra.
  • Stress, fatigue.
  • Abrupt weaning.

Diagnosis

Clinical assessment

Mastitis: Localized breast inflammation +/- systemic symptoms. Abscess: Palpable fluctuant mass. Differentiate from engorgement, blocked duct, galactocele, inflammatory breast cancer.

Investigations

  • Clinical diagnosis usually sufficient (mastitis).
  • Breast Ultrasound: Confirm suspected abscess, guide aspiration.
  • Breast Milk Culture: If severe/recurrent/non-responsive.
  • Needle Aspiration of Abscess: Culture + therapeutic.

Diagnostic criteria

Mastitis: Clinical findings. Abscess: Palpable fluctuant mass +/- ultrasound confirmation.

Management

Non-pharmacological management

  • Effective Milk Removal (KEY): Continue Breastfeeding frequently (start on affected side if tolerable) OR Express milk regularly. Correct latch.
  • Supportive: Rest, fluids, Warm compresses BEFORE feeds, Cold compresses AFTER feeds, Supportive bra.
  • Abscess Drainage: Needle Aspiration OR Surgical Incision & Drainage (I&D).

Pharmacological treatment

  • Analgesia: Paracetamol OR Ibuprofen.
  • Antibiotics (Mastitis): If severe/nipple fissure/no improvement after 12-24h milk removal. Cover S. aureus. Cloxacillin 500mg PO QID x 10-14d (First line). Alternatives: Cephalexin, Clindamycin (if MRSA).
  • Antibiotics (Abscess): Required + Drainage. Same choices.

Monitoring

Monitor symptom resolution. Assess milk drainage. Follow up 24-48h. Monitor abscess site post-drainage.

Complications

  • Breast abscess.
  • Recurrent mastitis.
  • Chronic inflammation/scarring.
  • Fistula (rare).
  • Premature weaning.
  • Sepsis (rare).

Prevention

  • Correct breastfeeding technique.
  • Frequent/effective milk removal.
  • Avoid stasis.
  • Treat nipple damage.
  • Good hygiene.

Patient education

  • Importance of CONTINUED milk removal.
  • Antibiotic adherence.
  • Pain relief.
  • Breastfeeding technique support.
  • Signs of worsening/abscess.
  • Hygiene.

Uganda-specific notes

Common. Emphasize continued BF/expression. Cloxacillin standard. Ultrasound access variable. I&D at hospital.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.6.3

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