Acute purulent mastitis classification. Surgical treatment of acute mastitis. Differential diagnosis of mastitis

Mastitis in the old days they called it a baby. This pathology is an infectious-inflammatory process in the tissues of the mammary gland, which, as a rule, has a tendency to spread, which can lead to purulent destruction of the body of the gland and surrounding tissues, as well as generalization of the infection with the development of sepsis (blood poisoning).

There are lactation (that is, associated with the production of milk by the gland) and non-lactation mastitis.
According to statistics, 90-95% of mastitis cases occur in the postpartum period. Moreover, 80-85% develops in the first month after birth.

Mastitis is the most common purulent-inflammatory complication of the postpartum period. The incidence of lactation mastitis is about 3 to 7% (according to some data up to 20%) of all births and has not had a tendency to decrease over the past few decades.

Mastitis most often develops in nursing women after the birth of their first child. Usually the infectious-inflammatory process affects one gland, usually the right one. The predominance of damage to the right breast is due to the fact that for right-handed people it is more convenient to express the left breast, so stagnation of milk often develops in the right.

Recently, there has been a tendency towards an increase in the number of cases of bilateral mastitis. Today, a bilateral process develops in 10% of mastitis cases.

About 7-9% of lactation mastitis are cases of inflammation of the mammary gland in women who refuse to breastfeed; this disease is relatively rare in pregnant women (up to 1%).

Cases of the development of lactation mastitis in newborn girls have been described, during a period when increased levels of hormones coming from the mother’s blood cause physiological swelling of the mammary glands.

About 5% of mastitis in women is not associated with pregnancy and childbirth. As a rule, non-lactational mastitis develops in women aged 15 to 60 years. In such cases, the disease proceeds less violently, complications in the form of generalization of the process are extremely rare, but there is a tendency to transition to a chronically relapsing form.

Causes of mastitis

Any suppurative process caused by Staphylococcus aureus can be complicated by generalization with the development of septic endocarditis, sepsis or infectious-toxic shock.

Recently, cases of mastitis caused by association of microorganisms have become more frequent. The most common combination is Staphylococcus aureus with gram-negative Escherichia coli (a microorganism common in the environment that normally populates the human intestine).
Lactation mastitis
In cases where we are talking about classic postpartum lactation mastitis, the source of infection most often becomes hidden bacteria carriers from medical personnel, relatives or roommates (according to some data, about 20-40% of people are carriers of Staphylococcus aureus). Infection occurs through contaminated care items, linen, etc.

In addition, a newborn infected with staphylococcus can become a source of infection for mastitis, for example, with pyoderma (pustular skin lesions) or in the case of umbilical sepsis.

However, it should be noted that contact with Staphylococcus aureus on the skin of the mammary gland does not always lead to the development of mastitis. For the occurrence of an infectious-inflammatory process, it is necessary to have favorable conditions - local anatomical and systemic functional ones.

Thus, local anatomical predisposing factors include:

• gross scar changes in the gland left after severe forms of mastitis, operations for benign neoplasms, etc.;
• congenital anatomical defects (retracted flat or lobulated nipple, etc.).

• pregnancy pathology (late pregnancy, premature birth, threatened miscarriage, severe late toxicosis);
• pathology of childbirth (trauma of the birth canal, first birth of a large fetus, manual separation of the placenta, severe blood loss during childbirth);
• puerperal fever;
• exacerbation of concomitant diseases;
• insomnia and other psychological disorders after childbirth.

The causative agent of non-lactation mastitis, as well as mastitis associated with pregnancy and lactation, in most cases is Staphylococcus aureus.

To understand the features of the mechanism of development of lactational and non-lactational mastitis, it is necessary to have a general understanding of the anatomy and physiology of the mammary glands.

Anatomy and physiology of the mammary glands

The mammary gland contains a glandular body surrounded by well-developed subcutaneous fatty tissue. It is the development of the fat capsule that determines the shape and size of the breast.

At the most protruding place of the breast, there is no fat layer - here is the nipple, which, as a rule, has a cone-shaped, less often cylindrical or pear-shaped.

The pigmented areola makes up the base of the nipple. In medicine, it is customary to divide the mammary gland into four areas - quadrants, bounded by conditional mutually perpendicular lines.

This division is widely used in surgery to indicate the localization of the pathological process in the mammary gland.

The glandular body consists of 15-20 radially located lobes, separated from each other by fibrous connective tissue and loose fatty tissue. The bulk of the glandular tissue itself, which produces milk, is located in the posterior parts of the gland, while ducts predominate in the central regions.

From the anterior surface of the gland body, through the superficial fascia that limits the fatty capsule of the gland, dense connective tissue strands are directed to the deep layers of the skin and to the collarbone, representing a continuation of the interlobar connective tissue stroma - the so-called Cooper ligaments.

The main structural unit of the mammary gland is the acinus, consisting of tiny formations of vesicles - alveoli, which open into the alveolar ducts. The inner epithelial lining of the acinus produces milk during lactation.

The acini are united into lobules, from which the milk ducts depart, merging radially towards the nipple, so that the individual lobules unite into one lobe with a common collecting duct. The collecting ducts open at the top of the nipple, forming an expansion - the milk sinus.

Lactation mastitis proceeds less favorably than any other purulent surgical infection, this is due to the following features of the anatomical and functional structure of the gland during lactation:

• lobular structure;
• a large number of natural cavities (alveoli and sinuses);
• developed network of milk and lymphatic ducts;
• abundance of loose fatty tissue.

So, without adequate treatment, the purulent process quickly engulfs the entire gland and often takes a protracted, chronically relapsing course. In severe cases, purulent melting of large areas of the gland and the development of septic complications (infectious-toxic shock, blood poisoning, septic endocarditis, etc.) are possible.

Mechanism of development of the infectious-inflammatory process

Acute lactation mastitis

With regular and complete expression of milk, bacteria that inevitably fall on the surface of the mammary gland are washed away and are not capable of causing inflammation.

In cases where adequate pumping does not occur, a large number of microorganisms accumulate in the ducts, which cause lactic fermentation and milk coagulation, as well as damage to the epithelium of the excretory ducts.

Curdled milk together with particles of desquamated epithelium clog the milk ducts, resulting in the development of lactostasis. Quite quickly, the amount of microflora that multiplies intensively in a confined space reaches a critical level, and infectious inflammation develops. At this stage, secondary stagnation of lymph and venous blood occurs, which further aggravates the condition.

The inflammatory process is accompanied by severe pain, which in turn makes it difficult to express milk and aggravates the state of lactostasis, so that a vicious circle is formed: lactostasis increases inflammation, inflammation increases lactostasis.

In 15% of women, purulent mastitis develops against the background of cracked nipples. Such damage occurs due to the discrepancy between the sufficiently strong negative pressure in the child’s oral cavity and the weak elasticity of the nipple tissue. Purely hygienic factors can play a significant role in the formation of cracks, such as, for example, prolonged contact of the nipple with the damp fabric of the bra. In such cases, irritation and weeping of the skin often develops.

The occurrence of cracks often forces a woman to give up breastfeeding and careful pumping, which causes lactostasis and the development of purulent mastitis.

To avoid nipple damage when breastfeeding, it is very important to latch your baby to the breast at the same time every day. In such cases, the correct biorhythm of milk production is established, so that the mammary glands are, as it were, prepared for feeding in advance: milk production increases, the milk ducts expand, the lobules of the gland contract - all this contributes to the easy release of milk during feeding.

With irregular feeding, the functional activity of the glands increases already during feeding; as a result, individual lobules of the gland will not be completely emptied and lactostasis will occur in certain areas. In addition, with an “unready” breast, the baby has to expend more effort while sucking, which contributes to the formation of nipple cracks.

Non-lactation mastitis

At non-lactation mastitis the infection, as a rule, penetrates the gland through damaged skin due to an accidental injury, thermal injury (a heating pad, tissue burn in an accident), or mastitis develops as a complication of local pustular skin lesions. In such cases, the infection spreads through the subcutaneous fatty tissue and fatty capsule of the gland, and the glandular tissue itself is damaged again.

(Non-lactation mastitis, which arose as a complication of a breast boil).

Symptoms and signs of mastitis

Serous stage (form) of mastitis

Expressing with lactostasis is painful, but the milk comes out freely. The woman's general condition is not affected and her body temperature remains within normal limits.

As a rule, lactostasis is a temporary phenomenon, so if within 1-2 days the compaction does not decrease in volume and persistent low-grade fever appears (increase in body temperature to 37-38 degrees Celsius), then serous mastitis should be suspected.

In some cases, serous mastitis develops rapidly: the temperature suddenly rises to 38-39 degrees Celsius, and complaints of general weakness and pain in the affected part of the gland appear. Expressing milk is extremely painful and does not bring relief.

At this stage, the tissue of the affected part of the gland is saturated with serous fluid (hence the name of the form of inflammation), into which, a little later, leukocytes (cells that fight foreign agents) enter from the bloodstream.

At the stage of serous inflammation, spontaneous recovery is still possible, when pain in the gland gradually subsides and the lump completely resolves. However, much more often the process moves into the next - infiltrative phase.

Considering the seriousness of the disease, doctors advise that any significant engorgement of the mammary glands, accompanied by an increase in body temperature, should be considered the initial stage of mastitis.

Infiltrative stage (form) of mastitis

Elevated temperature during the serous and infiltrative stages of mastitis is associated with the entry of human milk from foci of lactostasis into the blood through damaged milk ducts. Therefore, with effective treatment of lactostasis and desensitizing therapy, the temperature can be reduced to 37-37.5 degrees Celsius.

In the absence of adequate treatment, the infiltrative stage of mastitis passes into the destructive phase after 4-5 days. In this case, serous inflammation is replaced by purulent inflammation, so that the gland tissue resembles a sponge soaked in pus or a honeycomb.

Destructive forms of mastitis or purulent mastitis

Body temperature rises significantly (38-40 degrees Celsius and above), weakness, headache appear, sleep worsens, and appetite decreases.

The affected breast is enlarged and tense. In this case, the skin over the affected area turns red, the skin veins dilate, and the regional (axillary) lymph nodes often become enlarged and painful.

Abscess mastitis characterized by the formation of cavities filled with pus (abscesses) in the affected gland. In such cases, softening is felt in the area of ​​infiltration; in 99% of patients, the symptom of fluctuation is positive (a feeling of iridescent liquid when palpating the affected area).

(Localization of ulcers in abscess mastitis:
1. - subalveolar (near the nipple);
2. - intramammary (inside the gland);
3. - subcutaneous;
4. - retromammary (behind the gland)

Infiltrative abscess mastitis, as a rule, is more severe than an abscess. This form is characterized by the presence of a dense infiltrate, consisting of many small abscesses of various shapes and sizes. Since the ulcers inside the infiltrate do not reach large sizes, the painful compaction in the affected gland may appear homogeneous (the symptom of fluctuation is positive in only 5% of patients).

In approximately half of the patients, the infiltrate occupies at least two quadrants of the gland and is located intramammary.

Phlegmonous mastitis characterized by total enlargement and severe swelling of the mammary gland. In this case, the skin of the affected breast is tense, intensely red, in places with a cyanotic tint (bluish-red), the nipple is often retracted.

Palpation of the gland is sharply painful; most patients have a pronounced symptom of fluctuation. In 60% of cases, at least 3 quadrants of the gland are involved in the process.

As a rule, disturbances in laboratory blood parameters are more pronounced: in addition to an increase in the number of leukocytes, there is a significant decrease in hemoglobin levels. The indicators of the general urine analysis are significantly impaired.

Gangrenous mastitis develops, as a rule, due to the involvement of blood vessels in the process and the formation of blood clots in them. In such cases, as a result of a gross disruption of the blood supply, necrosis of large areas of the mammary gland occurs.

Clinically, gangrenous mastitis is manifested by an enlargement of the gland and the appearance on its surface of areas of tissue necrosis and blisters filled with hemorrhagic fluid (ichor). All quadrants of the mammary gland are involved in the inflammatory process; the skin of the breast takes on a bluish-purple appearance.

The general condition of patients in such cases is severe; confusion is often observed, the pulse quickens, and blood pressure drops. Many laboratory parameters of blood and urine tests are disrupted.

Diagnosis of mastitis

As a rule, making a diagnosis of mastitis does not cause any particular difficulties. The diagnosis is determined based on the patient’s characteristic complaints and examination of the affected mammary gland.
As a rule, laboratory tests are carried out:

• bacteriological examination of milk from both glands (qualitative and quantitative determination of microbial bodies in 1 ml of milk);
• cytological examination of milk (counting the number of red blood cells in milk as markers of the inflammatory process);
• determination of milk pH, reductase activity, etc.

In controversial cases, which often arise in the case of a chronic process, an X-ray examination of the breast gland (mammography) is prescribed.

In addition, in case of chronic mastitis, differential diagnosis with breast cancer must be carried out, for this purpose a biopsy (sampling of suspicious material) and histological examination are performed.

Treatment of mastitis

The diagnosis of a destructive process can be unambiguously made in the presence of foci of softening in the mammary gland and/or a positive symptom of fluctuation. These signs are usually combined with a violation of the patient’s general condition.

However, erased forms of destructive processes in the mammary gland are often encountered, and, for example, with infiltrative abscess mastitis, it is difficult to detect the presence of foci of softening.

Diagnosis is complicated by the fact that banal lactostasis often occurs with a disturbance in the general condition of the patient and severe pain in the affected breast. Meanwhile, as practice shows, the issue of the need for surgical treatment should be resolved as soon as possible.

In controversial cases, to determine medical tactics, first of all, carefully express milk from the affected breast, and then after 3-4 hours, re-examine and palpate the infiltrate.

In cases where it was only a question of lactostasis, after expressing the pain subsides, the temperature drops and the general condition of the patient improves. Fine-grained, painless lobules begin to be palpated in the affected area.

If lactostasis was combined with mastitis, then even 4 hours after pumping, a dense painful infiltrate continues to be palpated, the body temperature remains high, and the condition does not improve.

Conservative treatment of mastitis is acceptable in cases where:

• the patient's general condition is relatively satisfactory;
• the duration of the disease does not exceed three days;
• body temperature below 37.5 degrees Celsius;
• there are no local symptoms of purulent inflammation;
• pain in the area of ​​infiltration is moderate, palpable infiltrate occupies no more than one quadrant of the gland;
• General blood test results are normal.

Surgery for mastitis

• when choosing the surgical approach (incision site), the need to preserve the function and aesthetic appearance of the mammary gland is taken into account;
• radical surgical treatment (thorough cleansing of the opened abscess, excision and removal of non-viable tissue);
• postoperative drainage, including the use of a drainage-washing system (long-term drip irrigation of the wound in the postoperative period).

In case of extensive destructive processes in the lower quadrants of the gland, as well as in case of retromammary abscess, the incision is made under the breast.

For subalveolar abscesses located under the nipple, the incision is made parallel to the edge of the nipple.
Radical surgical treatment includes not only removal of pus from the lesion cavity, but also excision of the formed abscess capsule and non-viable tissue. In the case of infiltrative-abscess mastitis, the entire inflammatory infiltrate within the boundaries of healthy tissue is removed.

Phlegmonous and gangrenous forms of mastitis require the maximum volume of surgery, so that in the future plastic surgery of the affected mammary gland may be necessary.

The installation of a drainage and lavage system in the postoperative period is carried out when more than one quadrant of the gland is affected and/or the patient’s general condition is severe.

As a rule, drip irrigation of the wound in the postoperative period is carried out for 5-12 days, until the patient’s general condition improves and components such as pus, fibrin, and necrotic particles disappear from the rinsing water.

In the postoperative period, drug therapy is carried out aimed at removing toxins from the body and correcting general disorders in the body caused by the purulent process.

Antibiotics are mandatory (most often intravenously or intramuscularly). In this case, as a rule, drugs from the group of 1st generation cephalosporins (cefazolin, cephalexin) are used, when staphylococcus is combined with E. coli - 2nd generation (cefoxitin), and in the case of a secondary infection - 3rd-4th generation (ceftriaxone, cefpirome). In extremely severe cases, thienam is prescribed.

With destructive forms of mastitis, as a rule, doctors advise stopping lactation, since feeding a child from an operated breast is impossible, and pumping in the presence of a wound causes pain and is not always effective.
Lactation is stopped with medication, that is, drugs are prescribed that stop the secretion of milk - bromocriptine, etc. Routine methods of stopping lactation (breast bandaging, etc.) are contraindicated.

Treatment of mastitis without surgery

In such cases, women are prescribed conservative therapy.

First of all, you should provide rest to the affected gland. To do this, patients are advised to limit physical activity and wear a bra or bandage that would support but not compress the sore breast.

Since the trigger for the occurrence of mastitis and the most important link in the further development of the pathology is lactostasis, a number of measures are taken to effectively empty the mammary gland.

1. A woman should express milk every 3 hours (8 times a day) - first from a healthy gland, then from a sick one.
2. To improve milk flow, 20 minutes before expressing from the diseased gland, 2.0 ml of the antispasmodic drotaverine (No-shpa) is injected intramuscularly (3 times a day for 3 days at regular intervals), 5 minutes before expressing - 0.5 ml of oxytocin, which improves milk yield.
3. Since expressing milk is difficult due to pain in the affected gland, retromammary novocaine blockades are performed daily, with the anesthetic novocaine administered in combination with broad-spectrum antibiotics in half the daily dose.

Since many of the unpleasant symptoms of the initial stages of mastitis are associated with the penetration of milk into the blood, so-called desensitizing therapy with antihistamines is carried out. In this case, preference is given to drugs of a new generation (loratadine, cetirizine), since drugs of previous generations (suprastin, tavegil) can cause drowsiness in a child.

To increase the body's resistance, vitamin therapy (B vitamins and vitamin C) is prescribed.
If the dynamics are positive, ultrasound and UHF therapy are prescribed every other day, promoting rapid resorption of the inflammatory infiltrate and restoration of the functioning of the mammary gland.

Traditional methods of treating mastitis

In cases where conservative therapy is indicated, traditional medicine is often used in a complex of medical measures.

So, for example, in the initial stages of mastitis, especially in combination with cracked nipples, you can include procedures for washing the affected breast with an infusion of a mixture of chamomile flowers and yarrow herb (in a ratio of 1:4).
To do this, pour 2 tablespoons of raw material into 0.5 liters of boiling water and leave for 20 minutes. This infusion has a disinfectant, anti-inflammatory and mild analgesic effect.

It should be remembered that in the initial stages of mastitis, under no circumstances should you use warm compresses, baths, etc. Warming up can provoke a suppurative process.

Prevention of mastitis

Such prevention includes the following measures:

1. Early attachment of the baby to the breast (in the first half hour after birth).
2. Developing a physiological rhythm (it is advisable to feed the baby at the same time).
3. If there is a tendency to stagnation of milk, it may be advisable to perform a circular shower 20 minutes before feeding.
4. Compliance with the technology of correct milk expression (the manual method is the most effective, in this case special attention must be paid to the outer quadrants of the gland, where stagnation of milk is most often observed).

In addition, wearing a cotton bra helps prevent cracked nipples. In this case, it is necessary that the fabric in contact with the nipples is dry and clean.

Predisposing factors for the occurrence of mastitis include nervous and physical stress, so a nursing woman should monitor her psychological health, get good sleep and eat well.
Prevention of mastitis not associated with breastfeeding consists of observing the rules of personal hygiene and timely adequate treatment of skin lesions of the breast.

Is it possible to breastfeed with mastitis?

There are the following indications for interrupting lactation:

• severe destructive forms of the disease (phlegmonous or gangrenous mastitis, the presence of septic complications);
• prescribing antibacterial agents in the treatment of pathology (when taking which it is recommended to refrain from breastfeeding)
• the presence of any reasons why the woman will not be able to return to breastfeeding in the future;
• the patient's wish.

With serous and infiltrative forms of mastitis, doctors usually advise trying to maintain lactation. In such cases, a woman should express milk every three hours, first from the healthy breast and then from the diseased breast.

Milk expressed from a healthy breast is pasteurized and then fed to the baby from a bottle; such milk cannot be stored for a long time either before or after pasteurization. Milk from a sore breast, where there is a purulent-septic focus, is not recommended for the baby. The reason is that for this form of mastitis, antibiotics are prescribed, during which breastfeeding is prohibited or not recommended (the risks are assessed by the attending physician), and the infection contained in such mastitis can cause severe digestive disorders in the infant and the need for treatment for the child.

Natural feeding can be resumed after all symptoms of inflammation have completely disappeared. To ensure the safety of restoring natural feeding for the child, a bacteriological analysis of the milk is first carried out.

What antibiotics are most often used for mastitis?

Today it is customary to select antibiotics based on the microflora’s sensitivity to them. Material for analysis is obtained during puncture of the abscess or during surgery.

However, at the initial stages, taking material is difficult, and carrying out such an analysis takes time. Therefore, antibiotics are often prescribed before such testing is performed.

In this case, they are guided by the fact that mastitis in the vast majority of cases is caused by Staphylococcus aureus or the association of this microorganism with Escherichia coli.

These bacteria are sensitive to antibiotics from the penicillin and cephalosporin groups. Lactation mastitis is a typical hospital infection, and is therefore most often caused by staphylococcal strains resistant to many antibiotics that secrete penicillinase.

To achieve the effect of antibiotic therapy, penicillinase-resistant antibiotics such as oxacillin, dicloxacillin, etc. are prescribed for mastitis.

As for antibiotics from the cephalosporin group, for mastitis, preference is given to drugs of the first and second generations (cefazolin, cephalexin, cefoxitin), which are most effective against Staphylococcus aureus, including against penicillin-resistant strains.

Is it necessary to apply compresses for mastitis?

Among the folk methods you can use cabbage leaves with honey, grated potatoes, baked onions, burdock leaves. Such compresses can be applied both at night and between feedings.

After removing the compress, you should rinse your breasts with warm water.

However, it should be noted that the opinions of doctors themselves regarding compresses for mastitis are divided. Many surgeons indicate that warm compresses should be avoided as they can aggravate the disease.

Therefore, when the first symptoms of mastitis appear, you should consult a doctor to clarify the stage of the process and decide on treatment tactics for the disease.

What ointments can be used for mastitis?

Compresses with Vishnevsky ointment are used in many maternity hospitals. At the same time, a significant part of surgeons consider the therapeutic effect of ointments for mastitis to be extremely low and indicate the possibility of an adverse effect of the procedure: a more rapid development of the process due to stimulation of bacterial growth by elevated temperature.

Mastitis is a serious disease that can lead to serious consequences. It is untimely and inadequate treatment that leads to the fact that 6-23% of women with mastitis experience relapses of the disease, 5% of patients develop severe septic complications, and 1% of women die.

Inadequate therapy (insufficiently effective relief of lactostasis, irrational prescription of antibiotics, etc.) in the early stages of the disease often contributes to the transition of serous inflammation into a purulent form, when surgery and associated unpleasant moments (scars on the mammary gland, disruption of the lactation process) are already inevitable . Therefore, it is necessary to avoid self-medication and seek help from a specialist.

Which doctor treats mastitis?

Often women confuse the infectious-inflammatory process in the mammary gland with lactostasis, which can also be accompanied by severe pain and increased body temperature.

Lactostasis and initial forms of mastitis are treated on an outpatient basis, while purulent mastitis requires hospitalization and surgery.

For mastitis that is not associated with childbirth and breastfeeding (non-lactation mastitis), contact a surgeon.

Mastitis is a focal inflammatory process in the mammary gland associated with the primary penetration of a purulent infection into its parenchyma and stroma.

Classification: In relation to the functional state of the gland - mastitis of newborns, mastitis of pregnant women, nursing mastitis (lactation), non-lactation mastitis. According to the course of the disease - acute, chronic. According to the localization of the inflammatory process - superficial (subareolar, intramammary), deep (retromammary,

total defeat), according to the clinical phase - serous, acute infiltrative, abscessing, phlegmonous, gangrenous. Along the route of infection spread - hematogenous, lymphogenous, galactogenic. Microorganisms play an important role in the development of mastitis, mainly Staphylococcus aureus, which penetrates c cracked nipple and leads to the development of an inflammatory process. Predisposing factors in the development of mastitis are the presence of cracked nipples, observance of personal hygiene rules, stagnation of milk (lactostasis), weakening of the mother’s immunological reactivity in the first weeks after childbirth. The clinic of mastitis depends on the phase of the process . There are phases - serous (initial), acute infiltrative, abscessive, phlegmonous, gangrenous, chronic infiltrative. The initial stage of mastitis

should be distinguished from lactostasis. The serous phase begins with a sudden increase in temperature to 38.5-39 C. Symptoms of general intoxication appear (fever, chills, weakness). Against the background of lactostasis, bursting pain in the mammary gland. On examination - an enlargement of the gland; on palpation - a moderately painful compaction with unclear boundaries in the thickness or on the surface of the gland. The contours of the gland are preserved, the skin over it is not changed. Expressing milk is painful and does not bring relief; this distinguishes the serous stage of mastitis from lactostasis. The process manifests itself more acutely, reaching full development within 2-3 days. In acute

In the infiltrative phase, the mammary gland sharply enlarges, the skin over the infiltrate is sharply hyperemic. On palpation, there is a sharply painful infiltrate with unclear boundaries without signs of softening and fluctuation. Headaches, insomnia, chills, weakness, fever, leukocytosis, acceleration of ESR to 30-45 mm are noted. h. The axillary l/s increase and become painful. The abscess phase is characterized by an increase in all clinical manifestations. On palpation, a painful limited infiltrate with softening or fluctuation in the center. Depending on the location, abscesses in the mammary gland can be subareolar, intramammary, retromammary, premammary. Temp. The development of stages of acute mastitis is determined by the virulence of the infection, the degree of inhibition

anti-infectious resistance of the body. The diagnosis is based on medical history (nipple cracks and other predisposing factors) and the clinical picture of the disease characteristic of a particular stage. Complications - lymphangitis, lymphadenitis, sepsis, milk fistulas. Treatment of mastitis is based on the stage of inflammation, the rate of development of destruction of the glandular body, the extent of destruction of the glandular body, the form of mastitis. Treatment of serous infiltrative mastitis (conservative) should ensure limitation of exudation and swelling, emptying of the lactation system, rational antibiotic therapy, treatment of cracked nipples for the purpose of closure. Physiotherapeutic treatment includes a HF and UHF magnetic field in a low-thermal dosage, 10-20 minutes daily. Simultaneously with the treatment of mastitis, it is necessary to treat cracked nipples, the entrance gates of infection and prevent new cracks. Delayed or incorrect treatment does not stop mastitis in the initial stages and promotes progression of the process. In the absence of positive dynamics within 2 days of conservative therapy, surgical treatment is indicated. With dense inflammatory infiltrates, one should not wait for the appearance of symptoms of fluctuation. They are subject to early

dissection, because they always contain a central focus of tissue decay and ulcers. Surgery for purulent lactation mastitis should

be performed in a hospital under general anesthesia. During surgical treatment, wide and deep incisions of the mammary gland are necessary, which would allow radical removal of all necrotic tissue and elimination of accumulations of pus. Non-radical operations with small incisions do not stop the spread of the purulent process and the danger of complications and sepsis. Surgical treatment - open the abscess, evacuate the pus, remove necrosis, establish effective drainage. When choosing access to the purulent focus, take into account the localization of the process, the extent of the process, anatomical and functional features of the mammary gland.

If a woman needs surgery for mastitis, it means her mammary glands are in poor condition. After all, surgical intervention for such a disease is a last resort, because doctors are aware of the aesthetic and physiological importance of the female breast. How is the operation performed, and is it possible to regain femininity and self-confidence after it?

Reasons for the development of mastitis

Mastitis (from the Greek mastos - nipple, breast) is an inflammatory process that develops in the mammary glands. In the old days, the disease was called breastfeeding. Inflammation is caused by pathogenic microflora (usually a staphylococcal infection) and is more common in nursing mothers. If the baby is not placed correctly at the breast, the sucking process will be difficult. And due to strong tension, cracks form on the nipples. Through them, the infection easily enters the mammary glands.

But breast mastitis can also develop in experienced mothers who feed their babies with proper technique. The fact is that breastfeeding women actively open their milk ducts. And if any infection appears in the body (for example, E. coli), then through the network of blood vessels it can reach the chest.

Another possible reason for the development of mastitis is milk stagnation. If the baby does not suckle well, the milk begins to linger in the breast and fester. Firstly, it is dangerous for the baby. Secondly, for the mother herself. Lactostasis creates an ideal environment for the proliferation of bacteria that cause mastitis.

By the way! There is also non-lactation mastitis, which develops in non-lactating women. This may be due to hormonal imbalances and decreased immunity due to other diseases.

How mastitis manifests itself at different stages

The first signs of mastitis begin to appear almost immediately after infection. It is impossible not to feel discomfort or pain in the mammary gland (or both at once). Unpleasant sensations intensify during feeding, when raising hands, or when a woman tries to examine herself by palpation. But mothers often attribute such pain to the regular application of the baby to the breast.

Mastitis is rarely diagnosed at the earliest stage, when mild discomfort is present. The woman begins to feel alarmed when new symptoms appear, which indicate the onset of the next stage of the disease. Each stage is simultaneously considered an independent form of mastitis.

Serous stage

At first, the patient’s general condition is not disturbed: she does not have a temperature, milk comes out freely, but pumping can cause discomfort. A distinctive symptom of the onset of the serous form of mastitis is compaction in the areola area of ​​the nipple. It is painful, but tolerable, with clearly palpable boundaries.

This compaction is caused by stagnation of milk. And if you don’t get rid of it within two days (with the help of a breast pump), inflammation will begin. The temperature will rise, pumping will become sharply painful, and weakness will appear. The breast tissue will begin to become saturated with pathological tissue. The density of the nipple areola will increase.

Treatment of mastitis at this stage is carried out with antibiotics. But many mothers prefer to continue feeding and hope that the disease will subside. This is possible if a woman has a strong immune system: then the high temperature will kill the bacteria and the seal will resolve. But this happens extremely rarely, and after 5-7 days of the serous stage, the next one begins.

Attention! Feeding the child should be stopped at the first signs of mastitis and not resumed until the attending physician gives the go-ahead.

Infiltrative stage

The painful lump spreads throughout the chest and no longer has clear boundaries - an infiltrate forms. The affected mammary gland noticeably increases in size compared to the healthy one.

The infiltrative stage of mastitis lasts approximately 5 days, during which the temperature is maintained at 37-38 degrees, so the woman feels unwell all this time.

Destructive stage

Or purulent mastitis. An advanced process that manifests itself as a sharp deterioration in a woman’s well-being. This is explained by intoxication of the body caused by the release of toxins from the source of infection into the blood. The fever begins, the patient becomes drowsy, but she cannot sleep because of the fever; no appetite.

Redness and local hyperthermia are added to the swelling of the breast: the mammary gland acquires a distinct red or burgundy color, and it is hot to the touch. The nipples may ooze pus or bloody milk. The pain is present all the time, not just when touched. Also, painful spasms sometimes radiate to the armpits, which indicates damage to the lymph nodes.

Today, purulent mastitis is rare, because most women, fearing for the condition of their breasts, consult a doctor at the first signs of inflammation. This allows you to immediately stop the disease and not lead to critical conditions when surgery is required.

Indications for surgery for mastitis

As long as possible, treatment of mastitis is carried out conservatively. The patient is prescribed antibiotics, immunomodulators and anti-inflammatory ointments. Of course, breastfeeding must be stopped during therapy.

Surgery for mastitis is performed in the following cases:

• lack of positive changes from therapeutic treatment;
• rapid deterioration of the patient’s mammary glands;
• diagnosing the destructive form of mastitis (purulent, abscessing, gangrenous);
• chronic mastitis (if the disease develops repeatedly).

Technique of the operation

Surgical treatment of mastitis involves opening and draining the purulent cavity. It is performed under general anesthesia. The technique of performing the operation depends on the location of the accumulation of pus.

Superficial mastitis

The purulent formation is located directly under the skin and is easily palpated. The pus is enclosed in a capsule that is in contact with the lobes of the mammary gland. To access this capsule, the doctor makes two radial incisions (from the areola of the nipple to the edges of the breast). If there are several lesions, then there will be more incisions. The capsules are opened and washed.

Intrathoracic mastitis

Purulent accumulations are located directly between the lobes of the mammary gland. You can also get to them through radial cuts. Then the doctor uses his finger, so as not to injure the lobes, to spread them apart and form a cavity to remove pus. After the contents have drained, the breast cavity is washed with an antiseptic solution and checked for the presence of necrotic tissue to remove them.

Substernal mastitis

If the abscess has developed between the outermost lobe of the breast and the pectoral fascia, it will be more difficult to remove the pus. To get to the depths of the breast, you have to make a Bardenheyer incision - under the mammary gland in its natural fold. Then the mammary gland is pulled upward, almost completely separating it from the fascia of the pectoral muscle. The discovered abscess is opened and washed; necrotic tissue is excised. The breast is returned “to its place.”

Wound drainage

Purulent mastitis will not go away if after surgery you do not install a drainage tube that will drain the pus that accumulates at first to the outside to avoid relapse. Sometimes the drainage system is made through (double or triple) so that the chest cavity can be washed with immediate removal of the solution. In mild cases, surgery without incisions is possible, and then the operation is performed by draining the abscess (if there is only one, and its location is clearly defined).

Features of the rehabilitation period

The actions of doctors and the patient herself after mastitis should be aimed not only at healing the wound and preventing infection of the sutures, but also at the rapid restoration of feeding function. To do this, it is necessary to stop lactostasis, which persists after the operation. This will not only prevent recurrent abscess, but will also improve metabolic processes in the breast.

Expressing milk during the postoperative period should be carried out under the supervision of a doctor so as not to damage the sutures. This is a painful process, so at first it is carried out using painkillers.

Possible complications after surgery

Any intervention to open an abscess is associated with the risk of infection of nearby tissues. Therefore, doctors try to work as much as possible with blunt instruments or fingers, for example, to move the lobes of the mammary gland or to bring the capsule out.

The main complications after surgery for mastitis are:

• milk fistula (formation of inflammatory nature);
• phlegmon or gangrene (a developing purulent inflammatory process that spreads over the entire affected surface - without clear boundaries);
• aesthetic defect (scars and scars on the chest);
• risk of relapse.

Even if acute mastitis was cured by surgery, it is possible that the disease will return and become chronic. This can happen either after another birth during lactation, or simply due to hormonal imbalance.

Cosmetic defects in the form of scars can subsequently be eliminated with laser. If an operation was performed with a Bardenheier incision, the scar will be hidden in a natural fold. Also, breasts affected by mastitis may change slightly in size after surgery. This problem can be solved by mammoplasty (if the woman no longer plans to give birth).

Mastitis, or breast (from the Greek mastos - breast), is a focal inflammatory process in the mammary gland associated with the primary penetration of a purulent infection into its parenchyma or stroma, often tending to spread, purulent destruction of the glandular body and fat capsule, retromammary tissue and even to the generalization of infection.
Inflammation of the mammary gland is more often observed in nursing mothers, mainly in first-time mothers, but it occurs in pregnant women in the last weeks before childbirth and much less often in girls or women in menopause.
The highest incidence is observed in the age group from 21 to 25 years (47% of patients). Of the total number of patients with lactation mastitis: primiparous - 65%, after the second birth - 29% and multiparous - 6%.
In 45% of patients, inflammation is localized in the right mammary gland, in 39% - in the left; in 16% the process affects both glands. In 82%, mastitis develops in the first 4 weeks of the postpartum period.
Through fragile skin of the nipple, cracks, scratches, abrasions, excoriation of the epidermis, the infection penetrates through the lymphatic vessels into the interstitial tissue of the gland and leads to the development of the inflammatory process. It can penetrate through the milk ducts into the lobules of the gland and, when the excretory ducts are blocked, lead to the development of mastitis.
The causative agents of mastitis are almost always ordinary pyogenic microbes (staphylococcus, streptococcus, E. coli, etc.). In 90% of patients with mastitis, various types of staphylococci are found in the pus (during culture), in 6-8% - other types of microorganisms.
Often the onset of the disease is stagnation of milk in the gland. It increases in volume, tenses, becomes dense and painful, and microbes that have penetrated into the gland coagulate milk in the excretory ducts of the lobules. Microbial toxins damage the epithelium lining the ducts and lobules, which leads to the breakthrough of microorganisms into the interstitial tissue, the development of inflammation and the formation of ulcers or phlegmon of the mammary gland. When infection penetrates through damage to the skin of the nipple, the process can sometimes be limited to inflammation of the subcutaneous tissue and the formation areolar abscess. In the vast majority of patients, the infection penetrates through the lymphatic vessels into the interstitial tissue of the mammary gland and leads to a reflex dilation of its vessels.

Pathological anatomy

The neurovascular reaction is the first phase of the development of the inflammatory process and determines the entire picture of inflammation with serous tissue infiltration. Stagnation of milk in the lactating gland leads to a significant deterioration of the process. The more virulent the infiltrated infection, the stronger the irritation, the faster it leads to the development of a purulent process in the thickness of the mammary gland itself. In most cases, with mastitis, the formation of one or several, often interconnected, abscesses is observed.
When the abscess is located in lobules on the posterior surface of the gland, it can open into the cellular space behind it and then a rare form is formed - retromammary abscess. Due to the large volume of glandular tissue of the mammary gland, the purulent process in it develops in all its diversity and severity, characteristic of glandular organs.
Features of the purulent process in the glandular organs are their weakly expressed ability to delineate and almost uncontrollable spread with the involvement of more and more glandular tissue in inflammation. This spread often does not stop even after radical opening of the lesion, after which more and more new abscesses form in the parenchyma of the gland.
In some patients, the gland immediately appears to be infiltrated by a large number of small abscesses, i.e. purulent infiltration of the parenchyma of the gland develops, which turns into a sponge filled with pus. This usually quickly leads to necrosis of the affected areas of the gland and the formation of large sequesters, which are gradually delimited from the unaffected segments. The described pathological forms of the process are relatively rare. Even more rarely, putrefactive lesions of the mammary gland are observed, accompanied by a general septic reaction. Such forms can quickly lead to the death of the patient unless early and radical intervention is performed (wide opening or, in especially severe cases, amputation of the gland) and persistent antibiotic therapy.

Clinical picture

In the clinical picture of mastitis, the following phases (development of the pathological process) are distinguished: 1) serous initial phase of mastitis development; 2) acute infiltrative phase; 3) abscess formation phase; 4) phlegmonous phase; 5) gangrenous phase of mastitis development.
Each phase is characterized by a special clinical picture. Rational treatment in most cases manages to interrupt the course of mastitis at the phase of its development with which the patient was hospitalized and at which treatment was started. However, in a certain number of patients this fails, and then the next phase of the process develops.
Patients with the serous phase of lactation mastitis, which is the initial phase, usually remain under the supervision of obstetricians in maternity hospitals or are treated in antenatal clinics and in surgical clinics, so they are almost never admitted to surgical departments.
The clinical picture of different phases of mastitis has its own characteristics. The serous initial phase of mastitis is characterized by the appearance of pain in the mammary gland and an increase in temperature to 39.5-39°. When feeding, the child is less willing to suck on the diseased gland. During the examination, a barely noticeable increase is noted while its contours are completely preserved. The skin has a normal appearance. Only with comparative palpation can one notice a slightly greater elasticity and diffuse pain in the affected gland compared to a healthy one. Patients in this phase of the process are usually not admitted to the hospital. In this phase, milk stagnation is especially dangerous, which leads to venous stagnation and contributes to the rapid transition of mastitis to the second phase.
Stopping feeding or expressing milk from a diseased gland contributes to the rapid development of purulent mastitis. If treatment is delayed or incorrect, the process progresses and enters an acute infiltrative phase. Chills appear, a sharply painful infiltrate with unclear boundaries forms in the gland, the entire gland becomes significantly enlarged, and the skin over it turns red. ESR accelerates to 30-40 mm per hour, leukocytosis increases to 10-12*109/l. The feeling of tension and pain in the affected gland increases, headaches, insomnia, weakness appear, and patients lose their appetite. The axillary lymph nodes become enlarged and painful. With careful but thorough palpation of the infiltrate, it is usually not possible to note areas of its softening or fluctuations.
The abscess phase of mastitis develops in cases where general and local therapy do not stop the process at the infiltrate phase and do not contribute to its reverse development. At the same time, an increase in all clinical phenomena is observed: ESR reaches 50-60 mm/h, leukocytosis rises to 15-16*109/l, chills intensify, temperature rises to 39-40°. There is a sharp reddening of the skin of the mammary gland and expansion of the subcutaneous venous network, regional lymph nodes enlarge and become painful. The infiltrate of the gland is delimited and easily palpated. When suppuration occurs in the area of ​​infiltration, fluctuation is noted.
The phlegmonous phase of mastitis is characterized by a sharp deterioration in general condition, an increase in temperature to 38-40°, repeated chills, often accompanied by septic symptoms, the tongue and lips are dry, patients complain of insomnia, headaches, and lack of appetite. The skin is pale, the mammary gland is enlarged, pasty, the skin on it is hyperemic, shiny, sometimes with a cyanotic tint; when pressed, a pit is formed. There is a sharp expansion of the saphenous veins and often the phenomenon of lymphangitis. The nipple is often retracted. The whole or most of the gland is involved in the process. Palpation reveals pastiness and areas of fluctuation in several places. Leukocytosis increases to 17-20*109/l. ESR accelerates to 60-75 mm per hour. In the leukocyte formula there is a shift to the left with the presence of eosinophilia and lymphopenia. In the urine there are 0.6-0.9 g of protein, 40-50 leukocytes per field of view, 10-15 erythrocytes and single granular and hyaline casts.
The gangrenous phase of mastitis is usually observed in patients who sought medical help late, or as a result of the development of thrombosis and congestion in the vessels of the mammary gland, or during long-term treatment in clinics without taking into account the deterioration of the general condition and the spread of the process. This often leads to the spread of inflammation and the development of the next more severe gangrenous phase of mastitis. Patients are admitted in extremely serious condition. The temperature rises to 40-40.5°. Pulse 110-120 beats per minute, weak filling. The tongue and lips are dry, the skin is pale. Patients complain of general weakness, general malaise and headaches, lack of appetite and poor sleep. The mammary gland is enlarged, swollen, painful, pasty. The skin is pale green and blue-purple, covered in places with blisters, and in some areas there is skin necrosis. The nipple is retracted, there is no milk, and often in a healthy mammary gland. Regional lymph nodes are enlarged and painful. Leukocytosis up to 20-25*109/l, a sharp shift in the leukocyte formula to the left, ESR accelerated to 60-70 mm per hour. Blood pressure decreases. In the urine there is up to 0.9 g of protein, leukocytes, erythrocytes, hyaline and granular casts.
Prevention of mastitis mainly comes down to preventing the formation of cracks and excoriations of the nipples, which usually appear in the first 2-3 weeks of the postpartum period, and treating them if they have formed.
Proper preparation of the breast and nipples for feeding a baby usually prevents the development of nipple trauma and excoriation. The pregnant woman should be warned about this at the antenatal clinic at her first visit. First of all, general hygiene procedures are necessary. It is recommended to wipe the mammary glands daily with water at a temperature of 18-20° with soap and then dry with a towel.
To prevent compression of the mammary glands and stagnation in them, it is necessary, as they increase in size with the development of pregnancy, to increase the size of the bras and to prevent the glands from sagging. From the second half of pregnancy, air baths are indicated: women should lie on the bed with their chest open every day for 15-20 minutes. To improve the general condition of the body and increase its resistance to infection, general irradiation with ultraviolet rays is recommended every 1-2 days in the last 2 months of pregnancy. A balanced diet with plenty of vitamins is very important.
If you have flat and inverted nipples, special preparation is necessary in the form of stretching with cleanly washed hands. First, the midwife, in consultation, teaches this to the pregnant woman, who then performs nipple traction on her own.
For oily skin, it is recommended to wash the mammary gland with baby soap, and for severely dry skin, lubricate the nipple with sterile petroleum jelly.
After childbirth, cracked nipples usually occur due to poor nutrition, vitamin deficiency, non-compliance with general hygiene measures, improper care of the nipples, violation of feeding methods and rough expression of milk by hand.
To prevent cracked nipples when feeding a baby, you should wash your mammary glands daily with water and baby soap and dry them with a special towel. Frequent changes of linen and special punctuality in hand hygiene are very important.
It is important to strictly follow the rules of feeding the child: the mother should sit (from the 5-6th day after birth) with a pillow under her back, the child should grasp not only the entire nipple, but also most of the areola.
When nipple cracks appear, it should be borne in mind that they are always accompanied by a more or less pronounced inflammatory reaction, which is supported by constantly recurring irritation during feeding and bacterial and sometimes yeast infection. If you have cracked nipples, you can use a shield with a wide base when feeding your baby. It is recommended to treat nipples in one of the following ways:
1. Before each feeding, the nipple and areola are wiped with a lump of clean cotton wool or gauze soaked in a 1% solution of ammonia and dried by applying (but not rubbing) dry cotton wool to it; After such preparation, the baby is given breastfeeding. After feeding, the nipple is wiped and dried again, as before feeding; after this, a woman with an open chest takes an air bath while lying down for 15-20 minutes.
2. Before feeding, the nipple is not treated, but after each feeding it is lubricated with a 1% solution of methylene blue in 60° alcohol, then the woman lies with her breast open for 15-20 minutes (air bath).
For yeast dermatitis of the nipples, it is recommended to lubricate the cracks and surrounding skin with a 2% aqueous solution of pyoctanin or gentian violet; in persistent cases, it is necessary to check the balance of vitamins and, if there is a deficiency of one or another of them, prescribe the appropriate drug (especially vitamin C).
For cracked nipples, it is necessary to wear bras - this is one of the important therapeutic and preventive measures.
Maintaining cleanliness of the entire body, frequent changes of underwear and bed linen, short cutting of nails, daily washing of the mammary glands are the most important hygienic measures for cracked nipples.

Treatment

Treatment should begin when the first symptoms and complaints of pain in the mammary gland, discomfort, discomfort, swelling of the gland, etc. appear. The lack of objective data in these cases should not lead to refusal of treatment measures.
During the serous phase of mastitis, attention should be paid to preventing stagnation of milk in the gland. Be sure to feed the baby with this breast or express and suction with a breast pump. Venous stagnation in the mammary gland should not be allowed to occur. To do this, in addition to suctioning the milk, it is necessary to give it a horizontal position using a scarf or bra. After this, all symptoms of serous mastitis may disappear. If the temperature rises to 37°C or higher and pain in the mammary gland continues, treatment should be prescribed with sulfonamides (1 g 4-5 times a day), intramuscular penicillin 200,000 units 4 times a day. Penicillin-novocaine blockade has a good effect. Using a syringe and a long needle, 150-200 ml of 0.25% or 0.5% solution of novocaine with penicillin (200,000-300,000 units) is injected into the retromammary space. With timely treatment, the serous phase of mastitis can be eliminated and the inflammatory process undergoes reverse development. If treatment is delayed or incorrect, the process moves into the next phase.
With timely and correct treatment in the acute infiltration phase, it is possible to stop the process and achieve its reverse development in a fairly large percentage of patients. To eliminate the process at this stage, penicillin 200,000 units 4 times a day, physiotherapy (quartz, solux, UHF, etc.), penicillin-novocaine blockade should be used. You should not allow milk to stagnate in the mammary gland and stop feeding from this breast. If there is insufficient release of the mammary gland through feeding, it is necessary to express or suck out the milk with a breast pump.
The vast majority of patients in the abscess phase require surgical treatment. In severe general conditions, surgery should be performed immediately upon admission to the hospital under local anesthesia or IV anesthesia. An incision 7-10 cm long is made at the site of fluctuation or greatest pain in the radial direction, not reaching the areola or 2-3 cm away from the nipple. The skin and subcutaneous tissue are dissected and the abscess cavity is opened. With a finger inserted into the cavity of the abscess, all existing cords and bridges should be separated. If there is an abscess in both the upper and lower quadrants of the mammary gland, an incision should be made in the lower quadrant and through it the abscess located in the upper quadrant should be emptied (Fig. 2). If it is difficult to empty the abscess from one incision, it is necessary to make a second radial incision - a counter-hole. After the pus is cleared, a rubber drainage should be inserted into the cavity.
In the postoperative period, treatment must be carried out in phases: in the hydration phase, dressings with 10% sodium chloride solution are used, in the dehydration phase, ointment dressings (synthomycin emulsion, Vishnevsky ointment, etc.) are used. Along with this, general treatment is necessary (penicillin therapy, intravenous administration of glucose and saline, blood transfusion). Physiotherapeutic methods are also used (quartz, solux, UHF, etc.). When dressings, the bandage on the gland should be applied in such a way as not to create venous stagnation and leave the nipple open for feeding the baby or regular suction with a breast pump.
Treatment of patients with the phlegmonous and gangrenous phase of mastitis consists of urgent surgical intervention immediately upon admission to the hospital as an emergency. We must strive to open the abscess with one or 2 wide incisions 8-10 cm long in the radial direction, as in the purulent phase of mastitis. If phlegmon and gangrene spread to the entire gland, the incision should be made on the lower surface of the gland. If it is not possible to completely free the cavity from pus from one incision, additional incisions can be made and the cavities can be drained. When the process extends to the retromammary space, an oval incision under the gland is rational, for which the latter is lifted upward.
Treatment of patients with phlegmonous and gangrenous phases requires special attention and general measures from the very first days of admission to the hospital: the use of large doses of penicillin, repeated blood transfusions, intravenous infusions of glucose and saline, cardiac medications, plenty of fluids, a high-calorie, easily digestible diet and other measures aimed at to combat toxicosis. Locally on wounds, just as with abscess mastitis, treatment should be applied depending on the phase of the wound process.

Complications

With purulent mastitis, the following complications may develop: 1) bleeding due to erosion of the vessels of the gland by a purulent process, but this occurs rarely, since the vessels of the affected area of ​​the gland become thrombosed; these bleedings are successfully stopped by tamponade of the abscess cavity; 2) sepsis; Previously, it was more common in phlegmonous and gangrenous mastitis; Currently, due to antibiotic therapy and early treatment, this complication is extremely rare; Such patients are treated according to general rules.

Forecast

The prognosis for timely diagnosis of purulent mastitis and timely initiation of treatment with antibiotics, and in the indicated cases, surgical intervention, is favorable, however, after extensive destructive processes in the parenchyma of the gland (extensive abscesses, cellulitis, gangrene), its function suffers significantly.
According to recent data, deaths are observed only with the development of sepsis in patients with phlegmonous and gangrenous forms of mastitis. On average, for all forms of purulent mastitis, mortality ranges from 0.05 to 0.2%.

27. Mastitis

Mastitis is a purulent-inflammatory disease of the breast tissue. The most common microorganisms (causative agents of this process) are staphylococci, streptococci, and Pseudomonas aeruginosa.

Penetration of the infectious agent occurs through cracks in the nipple (most often) or milk ducts. The hematogenous route of infection is extremely rare.

By introducing themselves, microorganisms receive a favorable environment for growth and reproduction, and serous inflammation occurs. It is the initial stage of the process and can be reversible even with conservative treatment.

Subsequently, leukocytes begin to migrate into the lesion, and an increase in vascular permeability leads to the release of the liquid part of the blood into the tissue - exudate. These changes indicate the successive infiltrative and suppurative stages of purulent inflammation of the mammary gland.

Based on localization, suareolar mastitis is distinguished, with the focus of inflammation located around the areola, retromammary - inflammation is localized in the retromammary space, intramammary - the focus of inflammation is located directly in the breast tissue.

The disease develops acutely. The first symptoms are associated with galactostasis and include intense pain of a bursting nature, mainly in one mammary gland. There is a disturbance in the secretion of milk from this gland, it increases in size and becomes denser.

The woman's general health deteriorates.

General complaints appear, including the appearance of fever, chills, most often worsening in the evening, decreased performance, appetite, and sleep disturbance.

In a general blood test, an increase in the erythrocyte sedimentation rate (ESR) and the appearance of leukocytosis with a shift in the leukocyte formula to the left are noted. When examining the patient, an increase in volume of one mammary gland, local redness and hyperemia are noted. When a focus of suppuration appears in the mammary gland, the general condition of the patients worsens significantly, the fever can take on a hectic character, and general complaints are expressed. Upon examination, the presence of a focus of redness is noted in the mammary gland, over which softening (fluctuation) is determined.

Surgical treatment includes opening and draining the lesion. Depending on the location of inflammation, paraareolar, radial incisions and an incision along the transitional fold of the mammary gland are distinguished. The abscess is washed, exudate is removed, all leaks are cleaned, its cavity is sanitized, drainage is installed.

General treatment methods include strictly prohibiting feeding during the disease (but milk must be expressed), and using drugs that suppress lactation.

When the causative agent of the disease is verified, antibiotic therapy is carried out, antibiotics are administered intravenously. Depending on the severity of the disease, detoxification therapy, vitamin therapy, and correction of water and electrolyte metabolism are sometimes indicated.