Postnatal (lactational) mastitis
The postnatal mastitis is one of the most frequent complications of a puerperal period. Last years, according to domestic and foreign authors, frequency of mastites fluctuates over a wide range - from 1 % to 16 %, averaging 3-5 %. Among feeding women its frequency has no tendency to depression.
Classification
All milk fevers share on three forms which, as a matter of fact are consecutive stages of acute inflammatory process:
- A serous (beginning) mastitis
- An infiltrative mastitis
- A purulent mastitis
- Infiltrative-purulent
- Abscessing
- an areola furunculosis
- an areola abscess
- an abscess in a gland depth
- an abscess behind glands (retromammary)
- Phlegmonous/
- Gangrenous
Etiology and pathogenesis
In modern conditions the basic originator of a milk fever is the golden staphilococcus which is characterised by high virulence and fastness to many antibacterial preparations.
Penetration of the originator into mammary gland tissues descends lymphogenous by through nipple cracks and galactopoietic by - through milk courses. Was extremely rarely the inflammatory locus in iron is formed again, at generalisation of the postnatal infection contamination localised in the sexual apparatus.
To development of inflammatory process in a mammary gland promotes lactostasis, bound to an occlusion of the ducts deducing milk, therefore the mastitis in 80-85 % of cases arises at the primapara.
The important role in a milk fever pathogenesis belongs to a condition of an organism of the woman in childbirth, features of its protective forces. These causes it is possible to explain augmentation of number of diseases at women is more senior 30 years, more often with a somatic pathology.
Clinic and diagnostics
For the typical clinical form of a serous mastitis the acute beginning usually on 2-4 week of a puerperal period is characteristic. The body temperature quickly raises till 38-39, is quite often accompanied by a fever. The general delicacy, weakness, a headache educe. There is a pain in a mammary gland. However there can be such variants of clinical flow of mastites at which the general phenomena precede the aboriginal. At inadequate therapy the beginning mastitis within 2-3 days passes in the infiltrative form. In a mammary gland start to palpate dense enough painful infiltrate. The skin over an infiltrate - is always hyperemic.
Mastitis transition in the purulent form descends within 2-4 days. The temperature raises to 39, there are cold fits, intoxication signs accrue: slackness, delicacy, bad appetite, a headache. Aboriginal signs of inflammatory process accrue: an edema and morbidity in the lesion locus, fields of a ramollissement in the field of the infiltrative-purulent form of a mastitis meeting approximately at half sick purulent mastitis.
At 20 % of patients the purulent mastitis shows in the form of the abscessing form. Thus prevailing variants are the furunculosis and an abscess auras, meet the intramammary and retromammary abscesses representing purulent lumens, circumscribed to a connective-woven capsule less often.
At 10-15 % of patients the purulent mastitis proceeds as the phlegmonous form. Process grasps the most part of a gland with fusion of its tissue and transition to surrounding fat and a skin. The general condition of the woman in childbirth in such cases - serious. The temperature reaches 40, observe the tremendous cold fits, the expressed intoxication. The mammary gland is sharply enlarged in volume, its skin hydropic, hyperemic with a cyanotic shade, a gland palpation - sharply painful. The gathered breast can be accompanied by a septic shock.
The sharp gangrenous form of a mastitis has extremely serious flow with sharply expressed intoxication and a mammary gland necrosis. The outcome of a gangrenous mastitis is unfavorable.
Trearment
Main principles of therapy of a beginning (serous) mastitis
The major component of complex therapy of milk fevers is complex application of antibiotics. Before the beginning of antibacterial therapy effect sowing of milk from the struck and healthy mammary glands on flora. Now the golden staphilococcus finds the greatest sensitivity to semisynthetic Penicillinums (Methicillinum, Oxacillinum, a dicloxacillin), to a lincomycin to Fusidinum and aminoglycosides (gentamycin, Kanamycinum). At conservation of thoracal feeding the choice of antibiotics is bound to possibility of their unfavorable influence on the newborn. At initial stages of a milk fever antibiotics, as a rule, introduce intramusculary.
At use of semisynthetic Penicillinums course of treatment is continued by 7-10 days. Oxacillinum sodium salt 4 times a day intramusculary, ampicillin introduce on 100 mg sodium salt - on 750 mg 4 times a day intramusculary.
Besides antibacterial therapy, the important place in treatment of beginning mastites belongs to the actions referred on reduction lactostasis in struck gland. Parlodelum prescribed inside on 2,5 mg of 2 times a day within 3 days is most effective in this respect. A highly effective component of complex treatment of a beginning mastitis is application of physical factors of influence.
At the expressed phenomena of an intoxication infusional therapy is shown. At average mass of a body sick (60-70 kg) within days intravenously introduce 2000-2500 ml of fluid.
Main principles of therapy of a purulent mastitis
Treatment of patients with purulent forms of milk fevers spend in specialised surgical hospitals or units for, at conservation of a principle of integrated approach, the surgical method becomes the basic method of treatment. Timely dissecting of an abscess prevents diffusion of process and its generalisation. In parallel with a surgical intervention continue the complex therapy which intensity depends on the clinical form of a mastitis, character of an infection contamination and condition of the patient.
Extremely big attention at treatment of patients with milk fevers the questions, concerning possibilities of thoracal feeding and necessity of depressing of a lactemia deserve.
High virulence and polyresistance to antibiotics, characteristic for an infection contamination causing development of mastites in modern conditions, force to answer unequivocally a question on applying of the newborn to a breast. At any form of a mastitis in interests of the child thoracal feeding should be stopped. In modern obstetrics as the indication for lactemia depressing at mastites serve:
- Promptly progressing process, despite a spent intensive care
- A multifocal infiltrative-purulent and abscessing mastitis
- Phlegmonous and gangrenous forms of mastites
- Any form of a mastitis at relapsing flow
- Torpently current mastitis which is not giving in to complex therapy, including surgical dissecting of the locus
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