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Postpartum Mastitis

In recent years, the frequency of postpartum mastitis has decreased slightly. However, the course of the disease is characterized by a large number of purulent forms, resistance to treatment, extensive breast damage, a tendency to generalization. With mastitis, puerperas often infect newborns.

In the etiology of mastitis, the leading place is occupied by pathogenic staphylococcus.

The clinical picture and diagnosis. A special role in the occurrence of mastitis is played by the so-called pathological lactostasis, which consists in delaying the separation of milk. Lactostasis is accompanied by an increase in body temperature to 38–38.5 ° C, uniform engorgement and tenderness of the mammary glands. The general well-being of the puerpera changes little. These phenomena occur from 2 to 6 days after childbirth. A large number of pathogenic staphylococci are detected in milk.

With lactostasis, it is advisable to use antibiotics - semisynthetic penicillins or cephalosporins; ultraviolet radiation, a warming compress for 3-4 hours; temporarily stop breastfeeding and express milk with a breast pump.

After treatment, the bacteriological examination of milk should be repeated and the issue of resuming breastfeeding should be resolved. With lactostasis, you should not limit fluid intake, and also use diuretics and laxatives.

Lactostasis can be considered as a latent stage of mastitis.

Mastitis Classification:

1. Serous (beginning).

2. Infiltrative.

3. Purulent:

a) infiltrative-purulent: diffuse, nodular;

b) abscessed: areola furunculosis, areola abscess, abscess in the thickness of the gland, an abscess behind the gland (retromammary);

c) phlegmonous, purulent-necrotic;

g) gangrenous.

Mastitis, as a rule, begins acutely. Body temperature rises to 38.5–39 ° C, a febrile state is accompanied by chills or chills, weakness, headaches are noted. Pain appears in the mammary gland, the skin in the affected area is hyperemic, the gland slightly increases in volume. Palpated in the thickness of the gland, densified areas are determined. Serous form of mastitis with insufficient or unsuccessful treatment within 1-3 days becomes infiltrative.

The patient's condition with an infiltrative form of mastitis remains the same: fever continues, sleep disturbance, appetite are disturbed. Changes in the mammary gland are more pronounced: hyperemia is limited to one of its quadrants, a dense, inactive infiltrate is palpated under the changed area of ​​the skin, sometimes an increase in regional axillary lymph nodes is noted. The transition to the purulent stage of mastitis is observed after 5-10 days. Often there is a faster dynamics of the process: suppuration occurs after 4-5 days.

The suppuration stage is characterized by a more severe clinical picture: high body temperature (39 ° C and above), repeated chills, loss of appetite, poor sleep, enlarged and sore axillary lymph nodes.

With phlegmonous mastitis, generalization of the infection with the transition to sepsis is possible. The occurrence of septic shock is especially dangerous, and therefore, early detection of patients with arterial hypotension and the prevention of septic shock are necessary.

Along with the typical course of lactational mastitis, in recent years there have been erased and atypically occurring forms of the disease, characterized by relatively mild clinical symptoms with pronounced anatomical changes. Infiltrative mastitis can occur with subfebrile temperature, without chills. This complicates the diagnosis and determines the lack of therapeutic measures.

Diagnosis of postpartum mastitis is not particularly difficult. The disease begins in the postpartum period, characteristic complaints and clinical manifestations make it possible to make the correct diagnosis. Only in the case of atypically occurring mastitis, the diagnosis is difficult. Of the laboratory research methods, the most informative clinical blood test (leukocytosis, neutrophilia, increased ESR).

Significant help in the diagnosis of mastitis is provided by ultrasound. With serous mastitis, echography reveals the shading of the alveolar tree pattern and lactostasis. For the initial infiltrative stage of mastitis, areas of a homogeneous structure with an area of ​​inflammation around and lactostasis are characteristic. Ultrasound of the mammary gland affected by purulent mastitis most often reveals enlarged ducts and alveoli surrounded by an infiltration zone - “bee honeycombs”. Ultrasound makes it easy to diagnose the abscessed form of mastitis, while revealing a cavity with uneven edges and jumpers, surrounded by an infiltration zone.

With mastitis, breastfeeding is temporarily discontinued.
In severe mastitis, in some cases, one should resort to suppression, less often - to inhibition of lactation. Indications for the suppression of lactation in patients with mastitis in case of its severe course and resistance to the therapy are: a) a rapidly progressing process - the transition of the serous stage to the infiltrative stage within 1-3 days, despite active complex treatment; b) purulent mastitis with a tendency to the formation of new foci after surgery; c) sluggish, therapy-resistant purulent mastitis (after surgical treatment); d) phlegmonous and gangrenous mastitis; e) mastitis in infectious diseases of other organs and systems. In order to suppress lactation, parlodel is used.

Treatment. With postpartum mastitis, treatment should be comprehensive and should be started as soon as possible. The main component of complex therapy are antibiotics.

A wide antimicrobial spectrum of action can be achieved by using a combination of drugs: methicillin or oxacillin with kanamycin, ampicillin or carbenicillin. A wide range of antibacterial effects are possessed by the combined preparation of Ampioks, as well as cephalosporins (zeporin, kefzol). With combined antibiotic therapy, a high therapeutic effect is ensured.

In some cases, pathogens of purulent mastitis may include anaerobes, in particular bacteroids, which are sensitive to lincomycin, clindamycin, erythromycin, rifampicin and chloramphenicol. Most strains are sensitive to metronidazole, some to benzylpenicillin.

The combined use of antibiotics and a polyvalent staphylococcal bacteriophage, which, having fundamentally different mechanisms of action on microorganisms, can complement each other, thereby increasing the therapeutic effect, is advisable. In the first 3-4 days, the dose of the bacteriophage is 20-60 ml, then it is reduced. On average, 150-300 ml of bacteriophage are needed per treatment course.

In the complex treatment of patients with mastitis, an important place is occupied by drugs that increase specific immune reactivity and nonspecific defense of the body. To do this, use a number of tools. Effective anti-staphylococcal gamma globulin 5 ml (100 ME) every other day intramuscularly, per course - 3-5 injections. Apply antistaphylococcal plasma (100-200 ml intravenously), adsorbed staphylococcal toxoid (1 ml with an interval of 3-4 days, for a course of 3 injections). Showing a plasma transfusion of 150-300 ml, the introduction of gamma globulin or polyglobulin 3 ml intramuscularly every other day, for a course of 4-6 injections.

Hydration therapy should be given to all patients with infiltrative and purulent mastitis, with serous - in case of intoxication. For hydration therapy, dextran solutions are used: reopoliglyukin, rheomacrodex, polyfer; synthetic colloidal solutions: hemodesis, polydez; protein preparations: albumin, aminopeptide, hydrolysin, aminokrovin, gelatin. Glucose solutions, isotonic sodium chloride solution, 4% calcium chloride solution, 4-5% sodium bicarbonate solution are also used.

In addition, antihistamines are used: suprastin, diphenhydramine, diprazine; anabolic steroid hormones: nerobol, retabolil. With forms resistant to therapy, as well as with the patient's tendency to hypotension and septic shock, glucocorticoids are indicated. Prednisolone, hydrocortisone is prescribed simultaneously with antibiotics.

Physical methods of treatment should be applied differentially depending on the form of mastitis. With serous mastitis, microwaves of a decimeter or centimeter range, ultrasound, UV rays are used; with infiltrative mastitis - the same physical factors, but with an increase in heat load. With purulent mastitis (after surgery), first use the UHF electric field in a low thermal dose, then UV rays in a sub-erythema, then in a weak erythema dose.

With serous and infiltrative mastitis, it is advisable to apply oil-ointment compresses.

With purulent mastitis, surgical treatment is indicated. Timely and correct execution of the operation helps prevent the spread of the process to other areas of the mammary gland, significantly contributes to the preservation of glandular tissue and the achievement of a favorable cosmetic result.
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Postpartum Mastitis

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