O91.119 Abscess of breast associated with pregnancy, unspecified trimester

Name of the Condition

• Abscess of Breast Associated with Pregnancy, Unspecified Trimester (O91.119)

Summary

This condition involves the formation of a localized collection of pus within breast tissue during pregnancy, without specification of the trimester. It typically results from a bacterial infection and may present as a painful, swollen area. Prompt medical evaluation is necessary to manage symptoms and prevent complications.

Causes

Abscesses often develop when bacteria, such as Staphylococcus aureus, enter the breast tissue through a break in the skin or milk ducts. Hormonal changes during pregnancy can increase susceptibility, and inadequate milk drainage or engorgement may contribute to infection progression.

Risk Factors

• Cracked or damaged nipples.
• Previous breast infections.
• Inadequate milk removal or engorgement.
• Poor hygiene practices.
• Weakened immune system.

Symptoms

• Breast pain, swelling, or redness.
• Fever or chills.
• Palpable, tender lump with fluctuance.
• Nipple discharge or pus.
• Skin warmth or discoloration over the affected area.

Diagnosis

Diagnosis is based on clinical evaluation, including physical examination for signs of abscess formation. Ultrasound may be used to confirm the presence and extent of the abscess. Cultures of discharge or aspirated fluid may identify the causative organism.

Treatment Options

Treatment typically involves drainage of the abscess, either through needle aspiration or surgical incision, combined with antibiotic therapy to target the underlying infection. Pain management and supportive care, such as warm compresses, may also be recommended.

Prognosis and Follow-Up

With appropriate treatment, most abscesses resolve without long-term complications. Follow-up care ensures complete healing and monitors for recurrence. Breastfeeding may continue with guidance to prevent further infection.

Complications

• Spread of infection to surrounding tissue.
• Recurrent abscesses.
• Mastitis or sepsis in severe cases.
• Temporary disruption of breastfeeding.

Lifestyle & Prevention

• Maintain good breast hygiene, especially after feeding.
• Ensure proper milk drainage to prevent engorgement.
• Treat cracked nipples promptly to avoid bacterial entry.
• Wear well-fitting, supportive bras to reduce friction.

When to Seek Professional Help

Seek medical attention if symptoms worsen, fever persists, or the abscess does not improve with initial care. Immediate evaluation is necessary for signs of systemic infection, such as high fever or chills.

Tips for Medical Coders

Document the trimester when known, but use O91.119 when unspecified. Include details of clinical presentation, diagnostic methods, and treatment to support code assignment. Ensure alignment with ICD-10-CM guidelines for obstetric conditions.