Lactational mastitis is an infectious and inflammatory lesion of the breast that occurred in the postpartum period and is associated with the lactation process. It is manifested by pain and chest compaction, hyperemia of the skin, intoxication reaction with severe hyperthermia, chills, asthenia. Breast ultrasound, blood test, milk bacanalysis, and tissue biopsy are used for diagnosis. Antibiotics, antihistamines and antifungal agents, immunomodulatory and infusion therapy are used in the treatment, which, if necessary, are supplemented by puncture or opening of a purulent focus with its subsequent drainage.
Meaning
Mastitis is one of the most common complications of the lactation period. According to various data, postpartum inflammatory breast diseases occur in 3-20% of maternity patients, especially in first-time mothers over the age of 30. In the structure of all mastitis, the lactation variant is up to 92-95%, while in 81-85% of cases the disease develops during the first month after childbirth. In rare cases, pathology is found in pregnant women and newborn girls with hormonal swelling of the mammary glands. Usually the inflammation is unilateral and affects the right breast, which is associated with the inconvenience of pumping it for right-handed people. In recent years, the frequency of bilateral lactational mastitis, diagnosed in every tenth patient, and resistant forms of the disease has increased.
Causes
The immediate cause of breast inflammation during breastfeeding is the action of an infectious agent. In 79-97% of patients, the disease is caused by a monoculture of Staphylococcus aureus. In other cases, associated microflora is detected – in addition to St. aureus, intestinal and Pseudomonas aeruginosa, proteus, Klebsiella, and bacteroids are sown. The pathogen enters the woman’s body from the environment: from medical personnel, other maternity hospitals, as well as from internal foci of infection. A significant role in infection is played by the presence of one or more predisposing factors, which include:
- Lactostasis. Stagnation of milk in the lobules and ducts of the breast provokes the onset of lactic acid fermentation and local tissue damage with increased permeability. As a result, favorable conditions are created for the reproduction of microorganisms. The causes of lactostasis can be both the features of the structure of the mammary glands (for example, narrowing of the ducts) and insufficient pumping.
- Cracked nipples. Most often, damaged nipple and areola tissues become the entrance gate for the pathogen. They are usually injured due to improper nipple grabbing by a newborn, prolonged feeding and improper care. Prerequisites for damage to the nipple are its anatomical features (flat or retracted shape).
- The presence of a focus of infection. An infectious agent can enter the breast parenchyma from the foci of inflammation in the skin, other organs and tissues. A special role in the development of lactational mastitis is played by chronic infections of the female genital area, complications of pregnancy and childbirth (leakage of amniotic fluid, chorioamnionitis, postpartum endometritis and obstetric peritonitis).
- Decreased immunity. The protective functions of the body may deteriorate as a result of the complicated course of the gestational period and childbirth, improper breastfeeding, fatigue due to increased household loads. During lactation, exacerbation of chronic diseases is also possible, leading to immune disorders.
Violation of the requirements of asepsis and antiseptics. Compliance with sanitary and hygienic requirements in modern medical institutions has improved significantly. However, in some cases, infection of the nursing mother still occurs due to insufficient disinfection of premises, tools, furniture and linen, the presence of carriers of Staphylococcus aureus among the staff.
Pathogenesis
Inflammation of the mammary gland tissues in lactational mastitis goes through a number of successive stages. The first preclinical stage of the process is pathological lactostasis, in which, in addition to milk stagnation, there is an active reproduction of microorganisms that secrete exo- and endotoxins (enzymes, hemolysins, other damage factors). The inflammatory reaction proceeds according to the normal, hyper- or hypoergic type and is represented by two phases – alteration (damage) and regeneration (recovery). With insufficient treatment and impaired reactivity, the surrounding tissues are quickly involved in the inflammatory process. As the local reaction develops, general intoxication of the body appears and increases. The fermentation processes that occur in the pathological focus provoke the coagulation of milk, which further disrupts its outflow and leads to the formation of a pathological vicious circle.
Symptoms
Clinical manifestations of postpartum breast inflammation are represented by pain syndrome, local tissue changes and the general reaction of the body. Lactation function is most often preserved. At the preclinical stage, due to pathological lactostasis, a woman first feels heaviness, swelling and discomfort in the affected breast, which increases somewhat in volume. The disease begins acutely with fever, pain and hyperemia of the skin of the breast. At the stage of serous inflammation, hyperthermia reaches +38.5 ° C, the patient feels weak, chills, may complain of headaches. Parenchymal tissue is somewhat compacted, but not infiltrated.
If the inflammatory reaction cannot be stopped, the disease turns into an infiltrative form in 1-3 days. The temperature rises to +39.0 ° C, the patient’s sleep is disturbed, appetite worsens, chest soreness increases. Redness of the skin, as a rule, is limited to the area of one quadrant, a dense infiltrate is felt in the tissues. Axillary lymph nodes may increase. With unsuccessful therapy, signs of purulent destruction of tissues appear within 5-7 days. The body temperature reaches +39.1 ° C or more. The general condition is severe: the patient is worried about severe chills, there is no appetite at all, confusion may be observed. Sleep is disturbed. Sharply painful seals are felt in the chest, often capturing at least two quadrants of the gland. Fluctuation is noted only in 5% of patients. Axillary lymph nodes on the affected side are enlarged.
As the disease progresses, purulent mastitis can turn into necrotic forms — phlegmonous and gangrenous. With breast phlegmon, 3 quadrants are usually involved in the process, or the entire mammary gland, which increases in size, swells significantly. There is skin tension, intense hyperemia with a bluish tinge, nipple retraction. The gangrenous variant of lactational mastitis is characterized by rapid dehydration of the body, increased breathing and palpitations. Due to the lesion of blood vessels and thrombosis, there is a gross destruction of breast tissue – the skin becomes purplish–cyanotic, necrotizing, blisters with sucrose appear on it. The patient has increasing signs of multiple organ failure, which, in the absence of adequate emergency therapy, can lead to shock and death.
Complications
The most threatening complications of lactational mastitis are infectious-toxic shock and sepsis, which often develop against the background of purulent forms of breast inflammation. In severe clinical cases, there is a spread of infection throughout the body with the involvement of other organs (lungs, kidneys, endocardium), cardiac disorders, renal insufficiency, gross microcirculatory disorders, coma. A complication of surgical treatment may be suppuration of the wound in the postoperative period, which in the future sometimes leads to scarring of the breast and the formation of a lactic fistula. The long-term consequences of mastitis are breast calcifications and an increased risk of neogenesis.
Diagnostics
The association of the disease with the lactation period and the typical clinical picture simplify the diagnosis of postpartum mastitis. However, nowadays there is a tendency to increase the number of late, subclinical, erased forms of pathology with poorly expressed manifestations or the absence of some symptoms. Therefore, the role of laboratory and instrumental research methods is increasing, the most informative of which are:
- Blood test. The study determines the changes characteristic of the acute inflammatory process: an increase in ESR, the number of leukocytes, especially neutrophils with the appearance of their toxic granularity, a shift of the leukocyte formula to the left.
- Ultrasound of the mammary glands. The inflammatory infiltration of tissues is indicated by a decrease in their echogenicity. The expansion of the ducts is noted. The method allows you to identify clusters of pus, having the form of hypoechoic formations, to estimate their number and localization.
- Bacteriological analysis of milk. The study determines the type of pathogen, the number of microbial bodies in 1 ml, the sensitivity of the pathogen to antibiotics. Milk for analysis must be obtained from both mammary glands.
- Puncture biopsy of the breast. Fine needle aspiration biopsy of the lesion is usually prescribed in doubtful cases with differential diagnosis with other processes. The procedure is more often carried out under ultrasound control.
The serous form of lactational mastitis is differentiated from the usual lactostasis, which is also characterized by a pyrogenic reaction. With the erased clinic, suppuration of cysts, atheromas on the background of breast-feeding, the debut of mastitis-like cancer are excluded. In complex diagnostic cases, mammography, CT, MRI, and electroimpedance mammography are additionally performed. Taking into account the peculiarities of the clinical picture, an infectious disease specialist, an oncologist, an anesthesiologist-resuscitator are involved in the examination, if necessary.
Treatment
The choice of therapeutic tactics depends on the stage of development of the disease and involves the solution of the following tasks: preservation or termination of lactation, the fight against the causative agent of the disease, rehabilitation of purulent foci (in case of their formation). Patients with postpartum inflammation of the mammary glands are recommended to temporarily stop breastfeeding the baby. Milk secretion is suppressed only in a small number of patients with certain indications: rapid progression of inflammation with transition to the infiltrative phase within 1-3 days with adequate therapy, recurrence of purulent mastitis after surgery, phlegmonous and gangrenous forms, postoperative resistance to antibiotics, decompensation by other organs and systems.
Before the inflammation turns into a purulent form, the basis of treatment is antibacterial drugs selected taking into account the sensitivity of the infectious agent. In addition to etiotropic therapy, pathogenetic and symptomatic agents are used, which contribute to a faster recovery and prevent complications. Usually in the treatment of the lactation form of mastitis are used:
- Antibiotics. The course of antibiotic therapy is prescribed immediately after the diagnosis and corrected according to the results of the bacteriological study. Synthetic penicillins, cephalosporins, aminoglycosides, combined drugs, nitroimidazole derivatives are used.
- Antifungal agents. Modern broad-spectrum antibacterial drugs, along with pathogenic microorganisms, destroy the natural microflora. Therefore, antifungal drugs are indicated for the prevention of superinfection, dysbiosis and candidiasis.
- Means to improve immunity. Immunomodulators, immunocorrectors, vitamin and mineral complexes are used to stimulate nonspecific protection. To increase specific reactivity, staphylococcal toxoid, anti-staphylococcal plasma and gamma globulin are used.
- Antihistamines. Taking several antibiotics against the background of altered tissue reactivity often provokes allergic reactions, for the prevention of which drugs with an antihistamine effect are prescribed, and in more severe cases — glucocorticoids.
- Infusion therapy. Starting with the infiltrative form of mastitis, the introduction of synthetic colloidal solutions, dextran-based formulations, and protein preparations is shown. Medicines of these groups allow correcting metabolic disorders, maintaining the functions of the main body systems.
Detection of purulent inflammation is a direct indication for surgical rehabilitation of a pathological focus. Taking into account the form of the inflammatory process, an autopsy and drainage of mastitis or puncture of an abscess with subsequent drainage are performed. Properly performed surgical intervention allows you to stop the spread of the inflammatory process, preserve the parenchyma of the breast as much as possible, and ensure optimal cosmetic results. After the operation, the patient is prescribed complex drug therapy.
The scheme of combined treatment of mastitis that occurs during the lactation period provides for the active use of physiotherapy methods. Patients with serous inflammation are shown ultrasound, UV, oil-ointment dressings with camphor or vaseline oil, balsamic liniment, butadiene ointment. During the transition of the disease to the infiltrative stage, thermal loads increase. After the intervention for lactation purulent mastitis, subthermal doses of UHF, suberythemic and low-erythemic doses of UFOs are recommended.
Prognosis and prevention
With adequate timely treatment, the prognosis is favorable. According to experts in the field of mammology, currently purulent-necrotic forms of lactational mastitis are extremely rare, the number of complications of the disease has decreased from 10-12% to 1.5-2.0%. An important role in the prevention of mastitis is played by prenatal preparation of a pregnant woman with the identification and rehabilitation of foci of chronic infection, compliance with the requirements of the sanitary and hygienic regime in obstetric hospitals, regular professional examinations of personnel to identify carriers of hospital infections. After childbirth, it is necessary to observe the rules and techniques of breastfeeding, skin care of the areolar zone.
Literature
- Foxman B., D’Arcy H., Gillespie B., Bobo J.K., Schwartz K. Lactation Mastitis: Occurrence and Medical Management among 946 Breastfeeding Women in the United States // Am. J. Epidemiol. – 2002. – Vol. 155, № 2. -P. 103-114. link
- Infant and young child feeding counselling: an integrated course / World Health Organization. – Geneva: WHO, 2006. – 254 p.
- Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals / World Health Organization. – Geneva: WHO, 2009. -112 p. link
- Jahanfar S., Ng C.J., Teng C.L. Antibiotics for mastitis in breastfeeding women // Cochrane Database of Systematic Reviews. – 2013. – Issue 2. – Art. No.: CD005458 – 3 p.
- Kabir N., Tasnim S. Oketani Lactation Management: A New Method to Augment Breast Milk // J. Bangladesh Coll Phys Surg. – 2009. – № 27. – P. 155-159. link
- Kinlay J.R., O’Connell D.L., Kinlay S. Risk factors for mastitis in breastfeeding women: results of a prospective cohort study [Abstract] // Aust N Z J Public Health. – 2001. -Vol. 25, № 2. – P. 115-120.
- Kvist L.J., Larsson B.W., Hall-Lord M.L, Steen A., Schalént C. The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment // International Breastfeeding Journal. – 2008. – № 3. – P. 3-6.