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Deanna J. Attai, M.D., F.A.C.S.Nothing to Disclose

2013 Clinical Congress Presenter Disclosure Slide

Benign Breast Disease:To Operate or Not to OperateAcute Puerperal AbscessDeanna J. Attai, M.D., F.A.C.S.Burbank, CA

Puerperal - DefinitionOf, relating to, or occurring during childbirth or the period immediately following

Latin puerpera woman in childbirth, from puer child + parere to give birth to

Acute Puerperal MastitisIncidence, Pathogenesis, Risk Factors2-10% of lactating women, most within within first 6 weeks of breast feeding or during weaning

Disrupted skin integrity and transfer of pathogenic bacteria from infant, primarily staph, strep speciesMilk stasis nursing technique, plugged lactiferous ductsPrimiparous or no breast feeding with previous pregnancy

Hogg 2004, Cantlie 1988

Acute Puerperal MastitisProgression to AbscessUsually resolve with oral antibiotics if treated within 24-48 hours of onset, continue lactationsharp reduction in incidence of abscess formation when small doses of roentgen therapy were used Hodgkinson and Nelson, JAMA, 1945

3-11% of patients with mastitis progress to abscessDelay in antibiotic therapy, inadequate breast emptying, weaning during episode of mastitis

Acute Puerperal AbscessPresentation and DiagnosisPain, redness, swelling, warmth, indurationDeeper lesions - less typical presentation Fever,adenopathy, leukocytosis variableCentral or peripheral

Primarily staph species, including MRSALess common: strep, coliforms

Acute Puerperal AbscessPresentation and DiagnosisMammography rarely indicated

Variable ultrasound appearanceIrregular hypoechoic to anechoic massInternal debris and septations commonMay have posterior acoustic enhancement, thick echogenic wall

Acute Puerperal AbscessUltrasound Appearance

Acute Puerperal AbscessAntibiotic TherapyTailor antibiotic therapy based on culture resultsCephalosporins, dicloxacillin, clindamycin, erythromycin, TMP-SMX (if baby > 2 months)Doxycycline, ciprofloxacin not indicated in lactating women

IV antibiotic treatment rarely necessary

Acute Puerperal AbscessMechanical TherapyBattle and Bailey 1923 percutaneous aspiration and irrigation with Dakins solutionFlorey 1946 - daily aspiration of small abscess and injection of penicillin

Incision and Drainage: Local or general anesthesia Traditional technique (Haagensen) includes leaving penrose drain for 72 hours (1971) Webster described addition of gauze packing Excision of overlying necrotic skin

Leborgne 2008

Acute Puerperal AbscessMechanical Therapy - Percutaneous Drain Placement1995 Berna 12 patients1997 - 2007 Harish 75 patients2006 Tewari 30 patients2008 Saleem ultrasound-guided drain placement vs. I&D 60 randomized patients - Drain placement = less scarring, shorter time to healing, high resolution rate

Acute Puerperal AbscessMechanical Therapy Aspiration1988 Dixon 6 patients, volume 15-42cc, all treated successfully by serial (3-5) aspiration and oral antibioticsConclusion: breaking down loculations, catheter drainage not necessary

Acute Puerperal AbscessMechanical Therapy - Aspiration1993 Karstrup - 95% success with serial aspiration, irrigation 19 patients1998 Tam - aspiration and instill antibiotics 19/21 patients2003 Leborgne - aspiration, irrigation, antibiotic instillation if >2.5cm 64/67 patients2004 Berna aspiration 3cm 9 patients2005 Christensen - aspiration 3cm 151 total patients, 86/89 puerperal

Acute Puerperal AbscessMechanical Therapy - Aspiration18 gauge needle, lidocaine

Acute Puerperal AbscessAdditional Therapy RecommendationsContinue antibiotics even if no fever / pain as long as purulent fluid is aspiratedNot uncommon to require serial treatments, especially if initial treatment was delayedDuration of therapy dictated by clinical response; tailor antibiotics to culture result

Continue breast feeding if possible, no role for bromocriptineProvide emotional support to patient

Acute Puerperal AbscessConclusionsUltrasound-guided aspiration is preferred technique - no scarring, faster healing, improved cosmesis, less likely to interfere with breast feeding

Surgical treatment still has a role when no response to repeated aspiration and antibiotics, superficial skin necrosis or breakdown

Acute Puerperal AbscessConclusionsIf I&D necessary - small incision, no drain Fistula formation is not commonChronic subareolar abscess may require surgical intervention

If not responding appropriately always consider inflammatory breast cancer; biopsy if indicated

Thank You