What is the recommended management for a pregnant woman with a breast abscess?

Management of Breast Abscess During Pregnancy

Breast abscesses during pregnancy should be managed with ultrasound-guided needle aspiration as first-line treatment, combined with appropriate antibiotics, reserving incision and drainage only for cases that fail to respond to repeated aspiration. 1, 2, 3

Initial Diagnostic Approach

• Perform ultrasound imaging immediately to confirm the presence of a fluid collection and differentiate true abscess from inflammatory mastitis without focal pus collection 2
• Obtain pus for culture and sensitivity testing, though empiric antibiotic therapy should be initiated immediately without waiting for results 1
• Look specifically for predisposing factors including lactation status, recent breast trauma or biopsy, diabetes, or signs of systemic infection 3

First-Line Treatment: Aspiration-Based Management

Ultrasound-guided needle aspiration is the preferred initial intervention, even for large abscesses (up to 10 cm have been successfully managed this way) 1, 2, 3:

• Aspirate all pus under ultrasound guidance to ensure complete drainage 2
• Repeat aspiration in the outpatient setting is often necessary and should be planned rather than proceeding directly to surgical drainage 2, 3
• This approach avoids prolonged healing time, eliminates the need for regular dressings, prevents milk fistula formation, and provides better cosmetic outcomes compared to incision and drainage 1

Antibiotic Selection

Initiate empiric antibiotics immediately after aspiration, as Staphylococcus aureus is the predominant pathogen allowing rational antibiotic choice 1:

• First-line options safe in pregnancy include penicillinase-resistant penicillins, cephalosporins, or erythromycin 1
• These antibiotics are secreted in breast milk but are considered safe for the infant 1
• Adjust therapy based on culture results if the organism differs from expected S. aureus 1

Special Considerations for Pregnancy-Associated Abscesses

• Pregnancy and lactation-associated abscesses respond particularly well to aspiration alone, even when large (>3 cm) 3
• In one series, 11 of 22 abscesses managed successfully with aspiration alone were lactational, with mean size of 4.3 cm 3
• Continue breastfeeding or pumping from the affected breast unless there is purulent drainage directly into the infant's mouth 4

Indications for Surgical Incision and Drainage

Proceed to incision and drainage only when 2, 3:

• Lack of improvement or recurrence after 2-3 aspiration attempts (most common reason) 3
• Presence of a fistula tract 3
• Spontaneous discharge before intervention may occur and does not necessarily require surgical drainage 2
• Chronic or recurrent subareolar abscesses may require definitive surgical management 3

Important Clinical Pitfalls

• Do not assume all breast masses in pregnancy are simple abscesses—granulomatous mastitis can mimic abscess and requires biopsy if the mass fails to resolve with standard therapy 5
• Inflammatory masses without focal pus collection on ultrasound should be treated with antibiotics alone without aspiration 2
• In 18 of 53 suspected abscesses in one series, ultrasound revealed inflammation without pus, which resolved with antibiotics alone in all but two cases 2
• Rare causes like Salmonella typhi should be considered if there are no typical predisposing factors or if the patient has concurrent systemic symptoms suggesting enteric fever 6

Follow-Up Protocol

• Repeat ultrasound and clinical assessment within 48-72 hours after initial aspiration 2
• Plan for repeat aspiration in the outpatient clinic if fluid reaccumulates 2
• Most abscesses resolve with 1-2 aspirations; three or more failed aspirations warrant surgical consultation 3