O91.112 Abscess of breast associated with pregnancy, second trimester

Name of the Condition

• Abscess of Breast Associated with Pregnancy, Second Trimester (O91.112)

Summary

This condition involves a localized collection of pus within the breast tissue, occurring specifically during the second trimester of pregnancy. It typically results from a bacterial infection and may present as a painful, swollen mass. Prompt medical evaluation is necessary to prevent complications and guide appropriate treatment.

Causes

Abscesses usually develop when bacteria, such as Staphylococcus aureus, enter the breast tissue through a break in the skin or milk ducts. This can occur due to hormonal changes during pregnancy, which may alter breast tissue and increase susceptibility to infection. Blocked ducts or minor trauma to the breast may also contribute to abscess formation.

Risk Factors

• Hormonal changes during the second trimester.
• Previous breast infections or abscesses.
• Poor hygiene practices.
• Weakened immune system.
• Trauma or injury to the breast.

Symptoms

• Localized breast pain, swelling, or redness.
• Palpable, tender lump with fluctuance.
• Fever or chills.
• Skin warmth or discoloration over the affected area.
• Nipple discharge or pus (if present).

Diagnosis

Diagnosis is based on clinical evaluation, including physical examination for signs of abscess formation. Ultrasound may be used to confirm the presence of a fluid collection and assess its size. Cultures of any discharge may be taken to identify the causative organism.

Treatment Options

Treatment typically involves antibiotics to address the underlying infection. For larger or persistent abscesses, drainage may be necessary, either through needle aspiration or surgical incision. Pain management and supportive care, such as warm compresses, may also be recommended.

Prognosis and Follow-Up

With prompt treatment, most abscesses resolve without long-term complications. Follow-up care may include monitoring for recurrence or signs of worsening infection. Patients should be advised to seek care if symptoms persist or worsen.

Complications

• Spread of infection to surrounding tissue.
• Recurrent abscess formation.
• Mastitis (inflammation of breast tissue).
• Systemic infection if left untreated.

Lifestyle & Prevention

• Maintain good breast hygiene during pregnancy.
• Avoid tight or restrictive clothing that may irritate the breast.
• Monitor for any changes in breast tissue and report symptoms early.
• Follow prenatal care guidelines to support overall health.

When to Seek Professional Help

Seek medical attention if you experience persistent breast pain, swelling, fever, or notice a lump. Early evaluation can prevent complications and ensure appropriate treatment.

Tips for Medical Coders

Document the trimester (second trimester) and confirm the presence of an abscess. Ensure clinical notes support the diagnosis and any interventions performed. Code O91.112 is specific to abscesses in the second trimester; verify no other trimester or condition is documented that would require a different code.