Postpartum mastitis

Postpartum mastitis is an inflammatory disease of the mammary gland of a bacterial nature that develops after birth and is associated with lactation.

[1], [2], [3], [4], [5], [6]

Epidemiology

Mastitis predominantly occurs in primiparous over 30 years. In 90% of patients one breast is affected.

[7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]

Symptoms of the postpartum mastitis

Patients complain of chilling or chills, weakness, headaches, disturbed sleep, appetite, pain in the mammary gland, an increase in its size. The clinical picture of the disease depends on the stage of the postpartum abscess.

• Pathological lactostasis develops on the 2nd-6th day after birth. General health changes little. Body temperature rises to 38-38.5 ° C. There is a uniform nagrabanie and tenderness of mammary glands at a palpation. Without the stage of lactostasis, mastitis develops rarely, but between lactostasis and the first manifestations of serous mastitis can pass from 8 to 30 days, i.e. Lactostasis - latent stage of mastitis.
• Serous mastitis begins acutely. The general condition of the patient worsens. Developing headache, weakness, cognition or chills; body temperature rises to 38 ° C. There are gradually increasing pains in the mammary gland, especially when feeding. The skin is slightly or moderately hyperemic in the lesion. The mammary gland increases in volume, palpation is determined by compacted areas of oval shape, densely elastic consistency, moderately painful. The duration of this stage is 1-3 days. With inadequate treatment, serous mastitis becomes infiltrative.
• With infiltrative mastitis, the patient remains fever, sleep and appetite are disturbed. In the mammary gland, there are more pronounced changes: under the altered patch of skin of the affected breast, a dense slow-moving infiltrate is palpated, regional axillary lymph nodes increase. The duration of this stage is 4-5 days and if the infiltrate does not resolve, its suppuration takes place.
• Purulent mastitis. The general condition of the patient is severe. There is a chill, a fever of 39 ° C or more, complaints of poor sleep, loss of appetite. The shape of the affected breast changes depending on the location and degree of prevalence of the process, the skin of the gland is sharply hyperemic, its palpation is painful. Axillary lymph nodes increase and become painful when palpated.
  • The predominant form of purulent mastitis is infiltrative-purulent (in 60% of cases). Diffuse form is characterized by purulent impregnation of tissues without obvious abscessing. With the nodular form, an isolated rounded infiltrate is formed without the formation of an abscess.
  • Abscessing mastitis develops less often.
  • Phlegmonous mastitis is a vast diffuse purulent lesion of the mammary gland. It is formed in every 6-7th patient with a purulent mastitis and is characterized by a very severe course. There is a sharp deterioration in the general condition, a repeated chill, an increase in body temperature above 40 ° C. It is possible to generalize the infection with the transition to sepsis.
• Gangrenous mastitis is an extremely rare and very serious form of the disease. Along with local manifestations, signs of severe intoxication are determined (dehydration, hyperthermia, tachycardia, tachypnea).

Currently, mastitis is characterized by a late onset, after the discharge of a woman from the maternity hospital. Often identify subclinical, erased forms of the disease, characterized by the lack of expression or the absence of individual symptoms.

Stages

Postpartum mastitis is classified by stages.

• Pathological lactostasis (latent stage of mastitis).
• Serous mastitis.
• Infiltrative mastitis.
• Purulent mastitis.
  • Infiltrative-purulent (diffuse, nodular).
  • Abscessing (furunculosis areola, absolute areola, abscess in the gland thick, retromammary abscess).
  • Phlegmonous (purulent-necrotic).
• Gangrenous.

[18], [19], [20]

Diagnostics of the postpartum mastitis

• The general analysis of the blood: leukocytosis, the shift of the leukocyte blood formula to the left, the increase in the rate of erythrocyte sedimentation (ESR).
• Bacteriological study of milk with the determination of the sensitivity of the pathogen to antibiotics. The study is desirable to be carried out before the start of antibacterial therapy. Milk for research is taken from the affected and healthy mammary glands. It is necessary to quantify the bacterial contamination of milk, since the diagnostic criterion of mastitis is the presence in milk of 5x10 ² cfu / ml.
• Ultrasound of the mammary glands: serous mastitis is characterized by glossiness of the tissue pattern, lactostasis; for infiltrative mastitis - areas of homogeneous structure, surrounded by an inflammation zone, lactostasis; for suppurative mastitis - dilated ducts and alveoli, with an infiltration zone around ("honeycomb"); for abscessing mastitis - a cavity with uneven edges and bridges, surrounded by an infiltration zone.

Indications for consultation of other specialists

Consultation of the surgeon and anesthesiologist is shown in connection with the need for surgical treatment of purulent and phlegmonous mastitis.

[21]

Differential diagnosis

Rarely postpartum mastitis must be differentiated with mastopathy and breast cancer, which, as a rule, have a long history, in contrast to lactational mastitis that occurs immediately after birth.

[22], [23], [24], [25], [26]

Treatment of the postpartum mastitis

Purpose of treatment:

• Eradication of the pathogen, relief of the symptoms of the disease, normalization of laboratory indicators and functional disorders.
• Prevention of complications of the disease.

Indications for hospitalization

Appearance of clinical and laboratory signs of mastitis.

Non-pharmacological treatment of postpartum mastitis

During the disease, regardless of the clinical form, the infant is not allowed to breastfeed as a sick or healthy breast.

It is necessary to use a bandage that hangs the mammary gland and dry heat on the affected area. Physiotherapy

• Serous mastitis uses microwaves of the decimeter or centimeter range, ultrasound, UV rays; With the infiltrative mast, the same physical factors are shown, but with an increase in the heat load.
• When purulent mastitis after surgical treatment, first use the electric field of UHF in a low-heat dose, then UV rays in suberythmic and low-erythematous doses.

Drug therapy

• It is necessary to inhibit or suppress lactation with the help of drugs.
  • With serous and infiltrative mastitis resorted to inhibition of lactation, and in the absence of the effect of therapy for 2-3 days suppress it. To suppress lactemia, it is necessary to obtain the consent of the puerpera.
  • When purulent mastitis, lactation should always be suppressed.
  • Depending on the severity of the clinical picture of the disease and the severity of lactation, cabergoline is used at a dose of 0.25 mg every 12 hours for 2 days or bromocriptine 2.5 mg 2-3 times a day for 2-14 days.
• Antibacterial therapy.
  • Drugs of choice - penicillins (for example, oxacillin in a dose of 4 g / day IV, in / m or inside).
  • Effective cephalosporins I-III generations.
    • Cephalothin in a dose of 4-6 g / day IV or in / m.
    • Cefazolin in a dose of 4-6 g / day IV or in / m.
    • Cefuroxime in a dose of 4-6 g / day iv or in / m.
    • Cefotaxime in a dose of 4-6 g / day IV or IM.
    • Cephalexin in a dose of 2 g / day iv or in / m.
  • When allergic to penicillins and cephalosporins, lincomycin is used at a dose of 1.8 g / day IV, in / m.
  • Effective aminoglycosides: gentamycin at a dose of 0.12-0.24 g / day IM, amikacin 0.9 g / day iv or IM, sizomycin at a dose of 3 mg / kg body weight per day in / in or in / m, tobramycin at a dose of 3 mg / kg body weight per day IV or IM.
• Medicines that increase specific immune reactivity and nonspecific defense of the body.
  • Antistaphylococcal human immunoglobulin for 100 IU every other day IM, course of 3-5 injections.
  • Staphylococcal anatoxin for 1 ml with an interval of 3-4 days, for a course of 3 injections.
  • Immunoglobulin human normal at a dose of 0.4-1 g / kg body weight IV drip daily for 1-4 days.

[27], [28], [29], [30], [31],

Surgical treatment of postpartum mastitis

With purulent mastitis operative treatment is shown: it is necessary to make a wide opening of the purulent focus with minimal traumatization of the milk ducts. Apply a radial incision from the border of the nipple to the periphery. In a blunt way, they destroy the lintels between the affected lobules, evacuate the pus, and remove the necrotic tissues. Drainage is introduced into the wound. With phlegmonous and gangrenous mastitis, necrotic tissues are excised and removed.

Training patient

It is necessary to teach the mother-in-law the proper care of the breasts, the decantation of milk, the technique of feeding the baby.

Further management of the patient

The question of the resumption of breastfeeding after the transferred mastitis should be solved individually, depending on the severity of the process and the results of bacteriological study of breast milk.

Prevention

Proper care of the breasts should be carried out and the technique of feeding the baby should be monitored. Timely recognition and treatment of nipple and lactostasis cracks is necessary.

[32], [33], [34], [35], [36]

Forecast

The course of the disease is characterized by a large number of purulent forms, resistance to treatment, the vastness of the lesion of the mammary glands. With phlegmonous mastitis it is possible to generalize the infection with the transition to sepsis.

[37], [38], [39]