Diagnosis and treatment of puerperal mastitis

Diagnosis and treatment of puerperal mastitis

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Diagnosis and treatment of puerperal mastitis

In recent years, the prevalence of postpartum mastitis decreased somewhat. However, the disease characterized by a large number of purulent forms of resistance to the treatment, is characterized by extensive lesions of the breast, the tendency to generalize. The role of mastitis infection in newborns in the process of lactation and postpartum women in contact with newborns.Patients mastitis become a source of infection for healthy women in childbirth.

A special role in the occurrence of mastitis is the so-called pathological lactostasis. The clinical picture of pathological lactostasis characterized by an increase in body temperature up to 38-38,5 ° C, uniform engorgement, and breast tenderness. The general state of health changes little. These phenomena arise from the second to the sixth day after birth. The milk revealed a large number of pathogenic staphylococci. Therefore, only the massive colonization of milk pathogenic staphylococci should be regarded as abnormal and, in conjunction with the corresponding clinical manifestations, be regarded as a pathological lactostasis.

Thus, the detection of the typical picture lactostasis should produce bacteriological analysis of milk. In identifying its massive colonization by Staphylococcus aureus postpartum women must be translated into the 2nd obstetric department. It is necessary to temporarily stop breastfeeding (milk should be expressed and pasteurized) and treat with antibiotics (semi-synthetic penicillins) for three-four days. If pathological lactostasis milk sown Gram-negative flora, gentamicin is used for four or five days. After a course of treatment should be repeated bacteriological examination of milk and resolve the issue of the resumption of breastfeeding. In pathological lactostasis should not limit fluid intake, and use of diuretics and laxatives.

Mastitis without lactostasis stage develops relatively rare. However, between the appearance of symptoms and lactostasis initial manifestations of mastitis (serous mastitis) usually runs from 8-10 to 20-30 days. Thus, pathological lactostasis can be regarded as a latent mastitis step. Taking into account the presence of pathological lactostasis need to conduct more intensive prevention of mastitis.

Based on the clinical course of postpartum mastitis in modern conditions, BL Gurtovoiy (1975) proposed the following classification of mastitis:

  • serous (beginning);
  • infiltrative;
  • purulent:
    infiltrative-purulent – diffuse, nodular;
    abscessed – abrasions nipple, areola abscess, an abscess deep in the breast, an abscess behind the gland (retromammary);
    phlegmonous – necrotic;

Mastitis usually begins acutely. The body temperature rises to 38,5-39 ° C, fever accompanied by chills or chilling, there are weakness, headaches.

In marked breast pain, skin lesions hyperemic in, several iron increases in volume. Palpable sealed sections are defined in the interior of the gland. Serous form of mastitis due to insufficient or unsuccessful treatment within one to three days becomes infiltrative. The patient’s condition remains the same – continued fever, disturbed sleep and appetite. More pronounced changes in the breast: flushing limited to one of the quadrants of the breast, under the modified area of ​​skin is palpated dense infiltrate often marked increase in regional axillary lymph nodes. Go to the stage of purulent mastitis occurs within five to ten days. In modern conditions often observed a faster dynamics of the process. The transition from the serous to purulent mastitis completed within four to five days.

Under festering mastitis is characterized by more severe clinical picture: high body temperature (39 ° C and above), repeated chills, loss of appetite, poor sleep, and increasing morbidity of axillary lymph nodes.

The predominant clinical form of postpartum purulent mastitis is infiltrative-purulent. It can take the form of diffuse or nodular. Diffuse form is characterized by a purulent impregnating fabrics with no apparent abscess formation. When nodular infiltrate round insulated without forming an abscess.

Abscessed mastitis occurs much less frequently. To this form are abrasions and areola abscess, abscess in the thickness of the prostate, including retromammary. Phlegmonous mastitis is an extensive diffuse purulent breast lesion. It occurs every sixth or seventh patient with purulent mastitis, and is characterized by very severe: high body temperature (above 40 ° C), repeated chills, rapid deterioration of general condition. When phlegmonous mastitis possible generalization of infection with the transition to sepsis (pyosepticemia). Especially dangerous is the emergence of septic shock, and therefore need early identification of patients with hypotension and prevention of septic shock.

Extremely rare and very severe form of the disease is a gangrenous mastitis. Local symptoms are accompanied by signs of severe intoxication – dehydration, hyperthermia, tachycardia, tachypnea.

Along with the typical manifestations of lactation mastitis, in recent years more and more common and atypical erased occurring form of the disease characterized by a relatively mild clinical picture with marked anatomical changes when infiltrative mastitis can occur with low grade fever, no chills. It is difficult to diagnose and determine the failure of therapeutic interventions.

A characteristic feature of post-partum mastitis in modern conditions it is a late start, mainly women after discharge from the hospital. Mastitis occurs mainly in nulliparous women in the age group over 30 years. In 90% of patients with mastitis affected one breast. Initially, the inflammatory process often localized in the outer quadrants of the prostate; further it may be limited to initial topography or spread to other areas.

Diagnosis of puerperal mastitis does not present much difficulty. Onset of the disease in the postpartum period, specific complaints and clinical manifestations allow the correct diagnosis. Only in case of atypical flowing mastitis diagnosis difficult. From laboratory studies the most effective blood count (observed leukocytosis, neutrophilia, increased erythrocyte sedimentation rate). Hematologic changes intensity generally corresponds to the severity of the disease. Essential to determine the adequacy of the therapy and prognosis of the disease is the dynamics of hematological parameters during treatment.

In severe and resistant to therapy, along with the clinical analysis of blood and urine, it is necessary to determine the content of protein and protein fractions, electrolytes, acid-base status and other biochemical parameters of blood. All this allows us to correct the optimum complex therapy.

Bacteriological examination of milk from diseased and healthy breast produce immediately upon receipt of the patient in the hospital (preferably before antibiotic treatment).

In the future, it is repeated in the course of treatment and before discharge from the hospital, to resolve the issue of the resumption of breastfeeding.

When mastitis breastfeeding temporarily stopped. Indications for lactation suppression in patients with mastitis when severe and resistant to therapy are:

  • rapidly progressive process – a transition stage serous infiltrative within one to three days, despite the active complex treatment;
  • purulent mastitis with a tendency to the formation of new lesions after surgery;
  • sluggish, resistant to therapy purulent mastitis (after surgery);
  • phlegmonous and gangrenous mastitis;
  • mastitis, developing on the background of diseases of other organs and systems.

The question of the suppression of lactation should be addressed individually, with the agreement of the patient. In such cases, use the medication that suppresses the production of prolactin (parlodel). Effectively inhibit lactation estrogens, which, however, have a number of side effects, affect endometrial proliferative processes provoke the formation of thrombosis. The combination of estrogen with androgens can significantly reduce the negative effects of estrogen and suppress lactation in the majority of patients effectively. During the suppression of lactation salureticheskim prescribed diuretics.

In contrast to the previously adopted tactics (in the suppression of lactation – not to express milk), now experts recommend careful continue pumping milk. It should be noted that suppression of lactation is performed only on strict conditions in a relatively small number of patients. At the same time it is impossible to prevent relapse of purulent mastitis, is unacceptable to stand idly by severe disease with resistance to combination therapy. In severe cases, lactation suppression to prevent the generalization of the process, is the prevention of sepsis (septicopyemia). Upon termination of lactation usually ceases and mastitis.

If any form of puerperal mastitis (in the absence of indications to the suppression of lactation) more appropriate to separate the child from the breast-feeding with expressed and carry out a healthy prostate and propasterizovannym milk, dairy products for mixed and artificial feeding.

The issue of breastfeeding resuming after suffering mastitis should be addressed individually, depending on the severity of the process and results of bacteriological studies of breast milk.

Treatment for postpartum mastitis should be comprehensive; it should be started as early as possible, at the first signs of the disease. It currently is emphasized, as is often faced with the rapid development of mastitis, accompanied by large destructive breast changes. At the hospital the patient is not always adequate treatment is given on time. The first signs of the disease may occur in the evening or at night, and treatment begins only with the arrival of the physician – in the morning. Timely initiated therapy almost always helps to prevent the development of suppurative process.

The main component of the complex therapy of puerperal mastitis are antibiotics. When purulent mastitis their appointment does not preclude the need for timely surgical intervention. Rational use of antibiotics largely determines the effectiveness of the treatment. Carrying out a course of antibiotics during lactation mastitis should begin immediately after diagnosis. Currently, the primary data of bacteriological research in everyday practice increasingly used for the correction of already ongoing antibiotic therapy. Treatment appropriate to begin with the appointment of a single antibiotic. Drugs of choice should be regarded as semi-synthetic penicillins. They are shown in the serosal disease and infiltrative forms and purulent mastitis, wherein during operation and in the treatment of Staphylococcus aureus detected monoculture. If patients with purulent mastitis after adequately performed the operation revealed resistance to therapy semisynthetic penicillins, can think of a secondary infection nosocomial Gram-negative flora.

When combined antibiotic broad spectrum of antimicrobial action is achieved through the combination of drugs: methicillin or oxacillin with kanamycin; ampicillin or carbenicillin. A broad spectrum antibacterial action have combined preparation ampioks and cephalosporins (tseporin, kefzol).

With a combined antibiotic therapy is provided by a high curative effect, but it increases the likelihood of developing allergic and toxic reactions and side effects associated with the action of each antibiotic (superinfection, candidiasis, the impact on vitamin metabolism, immune status, etc.). The major routes of administration of antibiotics for mastitis are intramuscular and intravenous. Only in mild forms, and to secure the resulting effect may prescriptions inside. Ineffective local application of antibiotics to infiltrate retromammary et al., As well as the use of penicillin. Do not combine benzyl penicillin and streptomycin because of the low efficiency and high toxicity (Oto-and nephrotoxicity). Can not be combined with streptomycin, one of the aminoglycosides (kanamycin, gentamicin, monomitsin) or a combination of two aminoglycoside.

Due to the low efficiency should not be used macrolides and tetracyclines. It proved toxic to newborn coming from mother’s milk preparations of tetracycline and chloramphenicol.

For prophylaxis to prevent the development of dysbiosis and candidiasis shows the use of antifungal antibiotics (nystatin, Levorinum).

Thus, in the initial stages of the disease (serous and infiltrative mastitis) should be used antistaphylococcal antibiotics (oxacillin, methicillin, dicloxacillin, fuzidin-, lincomycin). When purulent mastitis, these drugs can be used, if at the time of surgery in the treatment of Staphylococcus aureus found monoculture. Due to the frequent secondary infection operational RAS opportunistic gram-negative bacteria, the antibiotic of choice should be considered as gentamicin. In this case, a cephalosporin, a combination of semi-synthetic antibiotics kanamycin combination semisynthetic penicillins, particularly ampioks.

In some forms of purulent mastitis not excluded part anaerobic microflora, particularly Bacteroides. Last sensitive to lincomycin, clindamycin, erythromycin, rifampicin and chloramphenicol. Most strains are sensitive to metronidazole, some – to benzylpenicillin.

Consequently, when a stubborn resistance to treatment with purulent mastitis can assume the possibility of participation of anaerobic microflora and apply treatment with metronidazole, or the above-named antibiotics. Appropriate to combine the use of antibiotics and the polyvalent staphylococcal bacteriophage, which have fundamentally different mechanism of action on microbes and can complement each other, thus increasing the therapeutic effect. Bacteriophage are used with purulent mastitis topically to a wound tamponade.

In the treatment of mastitis important are tools that enhance specific immune reactivity and non-specific defense of the body. Effective antistaphylococcal g-globulin antistaphylococcal plasma adsorbed staphylococcal toxoid.

Infusion therapy should be carried out in all patients with infiltrative and purulent mastitis, with serous – in the presence of intoxication. For infusion therapy using solutions based on dextran – reopoligljukin, polyglukin, reomakrodeks, Polifer; synthetic colloids – gemodez, polidez; protein preparations – albumin, aminopeptid, gidrolizina, aminokrovin, zhelatinol.

In the treatment of mastitis using antihistamines – suprastin, diphenhydramine, promethazine; Anabolic steroids – nerabol, retabolil. In therapy-resistant forms, as well as a tendency to hypotension and septic shock are shown glucocorticoids. Prednisolone, hydrocortisone administered simultaneously with treatment with antibiotics.

Physical treatment to be applied differentially depending on the form of mastitis. When serous mastitis using microwaves decimeter and centimeter range, ultrasound, ultra-violet rays; in infiltrative mastitis – the same physical factors, but with an increase in the thermal load. Purulent mastitis (after surgery) first prescribed electric field in the UHF slaboteplovaya dose further UV rays suberythermal, then – in slaboeritemnoy dose.

When serous and infiltrative mastitis using oil-ointment compresses. For this purpose, apply vaseline oil, camphor oil for external use, butadiene ointment, Liniment balsamic.

When purulent mastitis operative treatment. Timely and correct operation is generated to prevent the spread of the process on the other breast areas, contributes significantly to the preservation of glandular tissue and achieve a favorable cosmetic result. Surgery for purulent mastitis should be regarded as serious interference and performed in the operating room in a hospital by an experienced doctor. At the same time produce a wide opening purulent focus, seeking to injure the minimum milk ducts. The most commonly used radial section from the border of the areola to the periphery. Blunt by destroying the bridges between the affected segments, evacuate the pus, necrotic tissue is removed, the wound is administered swab or drainage. When phlegmonous and gangrenous mastitis dissected and necrotic tissue is removed.

Prevention of postpartum mastitis should be carried out in three directions: the strict observance of sanitary-hygienic and sanitary-epidemiological norms maternity hospital; systematic measures to prevent staphylococcal infections; implementing targeted measures of general and local character to prevent mastitis.

In the postpartum period in the maternity hospital, the following activities: a daily hygienic shower and change of clothes; carrying out physical exercise on special complexes for women in childbirth; early ambulation in the absence of contraindications; daily, at least twice (morning and evening), washing hands before feeding, wash the breast with warm running water and mild soap; receiving air baths for 10-15 minutes after each feeding; wearing a bra lifts, but not squeezing breasts. It should be particularly alert to the possibility of postpartum mastitis in postpartum women “high risk” groups; Women need familiarization with the rules and techniques of breastfeeding, prevention, early detection and rational treatment of nipple cracks and lactostasis.

Preventive measures in relation to lactation mastitis is not effective enough, and therefore takes on a special role of its early diagnosis and comprehensive treatment.