Mastitis of the mammary gland. Symptoms of acute mastitis, causes Symptoms and signs of mastitis

The body of a woman is subject to constant changes. The frequency of menstrual cycles, the restructuring of the body at conception, wearing and after the birth of a child. Various factors can, which a woman usually does not suffer from. Mastitis is common in women who are breastfeeding their babies, although there are cases of occurrence in those representatives who have not given birth recently.

What is it - mastitis?

If you feel chest pains, then perhaps we are talking about mastitis. What it is? This is an inflammation of the mammary gland, which is located in the breast of a woman. It is more common in women during lactation (breastfeeding). However, sometimes it occurs in newborns and even men. Often affects only one mammary gland, although bilateral lesions are not ruled out.

Classification:

1. By forms:
   • Spicy;
   • Chronic.
2. According to the stages of development are divided into types:
   • The initial stage - serous mastitis - the penetration and reproduction of bacteria in the chest;
   • The second stage - infiltrative mastitis - inflammatory foci merge, there is a general swelling of the chest;
   • The third stage - purulent mastitis - purulent contents of the infiltrate. It, in turn, is divided into types:

• Abscessing - limited purulent focus (abscess);
• Phlegmonous - the spread of pus throughout the tissue;
• Gangrenous - massive appearance of necrosis. Often treated by removing the breast.

• They also distinguish pathological lactostasis (or latent, lactational mastitis), which manifests itself in lactating women with stagnation of milk in the breast.

Causes of mastitis of the breast

The main reason for the development of mastitis of the mammary gland is the penetration of infection (bacteria or viruses). This includes:

1. streptococci,
2. mycobacterium tuberculosis,
3. staphylococci,
4. coli.

The infection finds its way through wounds and abrasions on the nipples, as well as through the excretory ducts. It can be carried through the lymph or through the blood from other organs that are affected by the infection.

Without contributing factors, the body can fight off the infection. However, their presence worsens the position of women. What are these factors?

• Breast trauma. Through wounds, the infection penetrates;
• Stagnation of milk, which is a favorable environment for the reproduction of bacteria;
• hypothermia;
• Weakness of immunity;
• Hormonal disruptions that expand the excretory ducts of the mammary gland and open the way for infections.

Symptoms and signs

Common symptoms and signs of mastitis are:

• Deterioration: fever, chills, weakness, headache;
• Pain and breast enlargement;
• Redness of the skin of the chest;
• Palpable induration of tissue in the area of ​​the breast.

Signs of latent mastitis:

1. A slight increase in temperature to 37.5ºС;
2. Painful sensations when pressed;
3. Sealing of mammary glands.

Signs of serous mastitis:

1. Chills;
2. Raising the temperature to 38.5ºС;
3. Drawing pain, aggravated by breastfeeding;
4. Weakness;
5. Headache;
6. redness of the chest;
7. Decreased appetite;
8. Perceived induration of the breast.

Symptoms of infiltrative mastitis:

1. Heat;
2. Sedentary compaction of the breast;
3. severe chest pain;
4. Enlargement of lymph nodes in the armpit with corresponding symptoms, as with lymphadenitis, from the side of the affected chest.

With purulent mastitis, the symptoms intensify:

1. Fever up to 39.5ºС;
2. The skin of the chest is red and hot;
3. Chills;
4. Change in the shape and shape of the mammary gland, swelling;
5. Severe throbbing pains;
6. Axillary lymphadenitis is pronounced.

A non-nursing woman shows the same symptoms and stages of development of mastitis as a nursing woman, only there is no latent stage.

With the formation of an abscess (abscessing mastitis), symptoms appear:

1. Painful swelling that does not go away;
2. Purulent discharge from the nipple;
3. Not falling temperature, despite all the antipyretic drugs taken and measures to eliminate the disease.

Mastitis in children

Although mastitis mostly affects breastfeeding women, it can also occur in newborns. The reason for this is the penetration of infections through the mother. At the same time, the baby's breasts may temporarily swell, regardless of whether it is a boy or a girl. Usually physiological swelling goes away on its own. However, it is better to consult a pediatrician who, if necessary, will prescribe antibiotics, anti-inflammatory drugs that will quickly eliminate the pathology.

Mastitis in adults

Mastitis in adults is manifested mainly in women: more often during breastfeeding, but there are cases in non-nursing women. In men, the disease manifests itself quite rarely due to infection penetration through the lymph, blood or damaged nipples.

Diagnostics

Diagnosis of inflammation of the mammary gland is carried out first with the appeal of a woman with complaints to a doctor (mammologist, surgeon), which aroused suspicions of the development of the disease. How long ago did they appear, what did the woman have before or during this, how clearly do they manifest themselves? The doctor performs a general examination and feels the chest to confirm suspicions of mastitis. Without instrumental and laboratory studies, the diagnosis is not made:

• Blood test;
• Microbiological analysis of secreted contents from the mammary gland;
• Ultrasound of the mammary glands;
• Checking for others inflammatory diseases in other organs.

Treatment

Treatment of mastitis depending on the stage of the disease, since the methods used at each stage differ significantly:

1. At the stage of lactostasis:
   • Expression of milk;
   • More frequent attachment of the baby to the breast;
   • gland massage;
   • Dry heating of the chest (with a heating pad);
   • A bandage or special bra that holds the chest.
2. At the stage of serous and infiltrative manifestation:

• Physiotherapy is prescribed: UHF, microwaves, UVI, ultrasound.
• Medications are prescribed: antibiotics, immunoglobulins, adaptogens, painkillers, vitamins.
• Ibuprofen (pain relief), paracetamol are prescribed.

1. At the stage of purulent manifestation:

• Open the pus surgically and remove the contents;
• The purulent cavity is washed with antiseptic drugs (antiseptics);
• A drain is placed to allow the contents to drain while healing occurs.

Infusion therapy showed itself well - intravenous drip of glucose and saline solutions.

How is a purulent lesion of the entire breast tissue treated? Only by complete removal of the breast - mastectomy. Over time, allowed plastic surgery to restore the shape of the breast.

At home, mastitis is not treated. However, preventive measures are allowed that help in the early stages of development, as well as after recovery:

• Wearing the right bra that does not press or pinch your breasts;
• Compliance with the correct technique of breastfeeding;
• Compliance with personal hygiene;
• Timely pumping of milk that the baby does not drink;
• No hypothermia;
• Treatment for all infectious diseases arising in other parts of the body;
• Consulting a doctor at the first manifestations of mastitis;
• Rest;
• Warm compresses to the chest.

Plasma cell mastitis is treated with X-ray radiation or, if it does not help, excision of the affected area.

Diet during treatment is not prescribed. Since a woman is nursing, her diet is completely dependent on this period. The baby should receive all the nutritious vitamins and substances that help him to be strong and healthy.

life forecast

Mastitis, although it is an infectious disease, does not worsen the prognosis of a woman's life in any way. If you start treatment in a timely manner, then you can avoid any negative consequences. How long do women live with mastitis? It all depends on the complications, if we are talking about the fact that the patient is not treated:

• Destruction of breast tissue.
• Breast deformity.
• Loss of the ability of the mammary gland to produce milk, resulting in an inability to breastfeed.
• Spread of infection to neighboring tissues, for example, provoking lymphadenitis.
• Sepsis is the penetration of pus and infection into the blood, which will spread pathogens throughout the body.

Acute mastitis is an inflammatory and infectious disease of the breast. The pathological process spreads through its glandular tissue, covers the subcutaneous fat. The disease always proceeds with severe clinical manifestations. The code for acute mastitis according to ICD-10 is No. 60-No. 64 (depending on the underlying cause of the condition). When it appears, you need to visit a gynecologist, undergo diagnostics and treatment.

The essence of the disease

The inflammatory process develops as a result of infection of the mammary glands - the entry of Staphylococcus aureus or another pathogen into the paired female organ. Pathology proceeds with severe clinical manifestations, it is not asymptomatic. Left-sided inflammation of the mammary gland is more common, less often right-sided. Bilateral breast damage occurs with a aggravated form of the infectious process. The disease is classified depending on the underlying cause, features of development, severity.

Common causes of development

Regardless of the form of acute mastitis, common causes for the development of the condition are:

1. Hormonal imbalance. It occurs as a result of chronic endocrine disorders, recent abortions, after childbirth, against the background of menopause.
2. The use of contaminated breast pumps, non-compliance with personal hygiene.
3. Using a size smaller than actual bust size.
4. , and feeding.

Unlike other pathologies mammary glands( , ), their inflammation is not associated with hereditary predisposition.

Types of acute mastitis

Depending on the underlying cause of the condition, mastitis is classified into and. They practically do not differ in clinical manifestations and in both cases require treatment.

Lactational mastitis is associated with intra lactiferous ducts.

Non-lactational inflammation is not associated with breastfeeding. Pathogenic microflora enters the chest through skin damage (accidental, sports) of any kind - a cut, burn, abrasion. Also, inflammation of this type occurs due to pustular processes of the skin. The infectious process covers the subcutaneous fat, the breast capsule - a secondary lesion of its glandular tissue occurs.

Stages and symptoms of the disease

In terms of severity, inflammation of the mammary glands is mild, moderate and severe. At the initial stage of the development of the pathological process, the possibility of outpatient treatment is considered. In the middle and severe stages of inflammation, hospitalization in the gynecology department is required.

Forms of mastitis:

1. . It is manifested by heaviness and tension inside the mammary gland. Acute serous mastitis is not always characterized by an increase in body temperature to low numbers. Expressing milk is accompanied by soreness, does not bring relief to well-being. Recovery can happen on its own. But if chest pain persists for 2 days, the condition requires medical intervention.
2. Infiltrative. Acute mastitis of this form is characterized by an increase in body temperature and the formation of seals without clear boundaries. The mammary gland is deformed, significantly enlarged in size.
3. Destructive. It is a continuation of the infiltrative form, not eliminated in a timely manner. At this stage, the destruction of the glandular tissue occurs. Acute is characterized by an increase in body temperature, in 90% of clinical cases it involves surgical intervention.

Purulent mastitis is divided into abscessing, infiltrative-abscessing, phlegmonous and gangrenous type.

Abscessing

Cavities (“pockets”) are formed inside the chest, filled with a large amount of purulent contents. Their location may vary. The accumulation of pathological masses is formed near the nipple, behind the glandular tissue, under the skin, outside the breast. The infiltrate is softened, which is easily determined by palpation (by probing). The patient's condition at acute mastitis This form is characterized by:

• weakness and declining blood pressure;
• pain in the affected mammary gland with the transition to the scapula;
• enlargement of axillary lymph nodes
• an increase in body temperature.

Treatment of inflammation of this form is exclusively surgical. If purulent masses are not removed for a long time, their accumulation leads to the development of sepsis. This condition is characterized by blood poisoning and a dangerously fatal outcome.

Infiltrative-abscessing

It flows much harder than abscessing. The main signs of the patient's condition:

1. Severe pain and throbbing within the area of ​​inflammation.
2. Enlarged lymph nodes (axillary, submandibular).
3. An increase in body temperature to high numbers.
4. General intoxication, which is manifested by weakness, lethargy, decreased performance.

This form of acute mastitis is characterized by the formation of a seal inside mammary gland. The infiltrate consists of several smaller abscesses, differing in shape and size. Multiple inflammatory elements inside the seal do not grow to large volumes. This creates an erroneous feeling of homogeneity of the infiltrate. In about 50% of patients, it is localized inside the mammary gland, its size is 2 square meters. cm.

Phlegmonous acute mastitis

It is characterized by an extensive purulent lesion of the breast. She is edematous, tense, painful. It has a bluish tint, the nipple is retracted, the general body temperature is increased to high numbers. Due to sleep disturbance and general intoxication, the patient has confusion.

Attention! Phlegmonous acute mastitis can develop as a result of self-extrusion of the abscess of the mammary gland.

Treatment of the pathology of this form is mainly surgical (the focus of suppuration must be drained).

Gangrenous acute mastitis

Initially, it proceeds as an inflammatory process, then it joins anaerobic infection and the condition worsens. It develops as a result of involvement in the infectious and inflammatory process of the blood vessels of the mammary gland. Because of this, the blood supply to the tissues is disrupted, and they first take on a purple-bluish, and then black color. Clinical manifestations pathology - severe chest pain, lowering blood pressure, confusion.

Common symptoms of inflammation of the mammary glands are pain, fever, the presence of palpable lumps, intoxication, decreased performance.

Treatment

– conservative or surgical. The operation is not a primary method, which is carried out only in the absence of positive dynamics from drug exposure. Therapy folk remedies at home does not replace standard treatment. The use of decoctions, infusions and alternative options helps to stop the inflammatory process, but subject to the agreement of these funds with the attending physician.

Conservative treatment

Includes medicinal effects, full hygiene, proper expression of milk (during lactation).

Non-surgical therapy is possible only in those clinical cases when:

1. The general condition of the patient is relatively satisfactory.
2. The statute of limitations of the inflammatory process does not exceed 3 days.
3. The level of general body temperature is subfebrile.
4. Pain is easily relieved with standard analgesics.
5. There is no redness of the breast, her skin is moderately swollen, without foci of suppuration.
6. The seal inside the glandular tissue does not exceed 1 sq. cm.
7. Laboratory diagnostics did not reveal a significant increase in the level of leukocytes and ESR.

Conservative treatment involves antibacterial direction. But it can additionally consist of an anti-inflammatory part and vitamin therapy.

Attention! When the patient is shown antibiotic therapy, lactation should be stopped - the drugs saturate the milk and are toxic to the newborn.

A specific antibiotic is prescribed in accordance with the identified pathogen - the microorganism must be sensitive to the recommended drug.

Of the non-steroidal anti-inflammatory drugs for acute mastitis, Voltaren, Diclofenac are used. Vitamin therapy involves the introduction of Ascorbic acid, Thiamine, Riboflavin, Pyridoxine. These drugs are undesirable during lactation and to maintain the health of the child at a full level, breastfeeding is stopped.

The accumulation of pus and its release is accompanied not only by swelling of the tissues, but also by itching. To stop the condition, the patient is prescribed an injection antihistamines- Suprastin, Tavegil, Diazolin.

You need to express milk every 3 hours - to prevent its stagnation inside the milk ducts. Before the procedure, it is necessary (about 20 minutes) to introduce an antispasmodic (No-shpu, Papaverine). Immediately before pumping, an injection of Oxytocin is recommended. It acts on the uterus (contracts its muscles), causes outflow breast milk.

Surgery

The operation is carried out with inefficiency conservative therapy. Surgical intervention is of 2 types - drainage and resection. In the first case, the patient is cut through the inflamed area, the purulent masses are removed. Then a drainage is installed - to prevent the re-accumulation of pathological secretion. In the second case, the operation involves the excision of necrotic tissues. Mastectomy (complete removal of the mammary gland) with mastitis is rarely performed - specialists perform organ-preserving operations.

Before the operation of any of the listed types, the patient is given anesthesia (more often - general). Possible Complications after surgery: scars, inflammation, bleeding.

If mastitis of the gangrenous or phlegmonous form is promptly eliminated, in the future the patient can consider the option of mammoplasty.

Prevention

To avoid development acute inflammation chest, you should follow these recommendations:

1. After feeding, always express any remaining milk.
2. Monitor the cleanliness of the bra, used pads, breast pump.
3. After each feeding, wash the breasts with warm water and neutral soap.
4. Wear a comfortable bra - choose it in accordance with individual body proportions. It should not compress, rub, it is unacceptable to wear an instance in which “bones” periodically protrude on their own. Abandon the idea of ​​using a bra that is smaller than your bust.
5. Correctly apply the child during feeding. If you are inexperienced, you need to be instructed by a specialist (gynecologist, mammologist, neonatologist, pediatrician).

If more than 2 times in a row there were cases of milk stagnation, a contrast shower should be performed. But unlike the standard procedure, alternate warm and cold water. Exposure to high temperatures is contraindicated. It is also necessary to treat minor skin lesions in the decollete area in a timely manner, preventing their suppuration.

Output

Acute mastitis is a disease that can be eliminated both conservatively and surgically. Inflammation of the mammary glands occurs in 75% of women in the early postpartum period, but the development of pathology can be avoided. To do this, it is necessary to carry out feeding and pumping correctly, perform hygiene procedures, and adjust the hormonal background in a timely manner. It is possible to carry out treatment at home, but only if this tactic has been approved by a specialist. Early visit to the doctor allows you to save the mammary gland.

Mastitis is an inflammatory disease of the breast tissue. As a rule, it develops in the postpartum period (approximately in the second or fourth week after discharge from the hospital) in breastfeeding mothers, especially primiparas. However, there are cases of the disease in women outside the lactation period, as well as in men and in children, including newborns.

Symptoms and signs of mastitis.
This inflammatory disease occurs and proceeds very quickly. The first symptoms appear from several hours to two days and are expressed in the appearance of quite noticeable pain in the mammary gland of a aching nature, while its contours are preserved, and the skin does not undergo any changes. This disease also manifests itself in the form of an increase in body temperature (above 38 degrees), the occurrence of headaches, weakness, discomfort and increasing pain when breastfeeding the baby, chills, enlargement and redness of the chest, loss of appetite, sleep disturbance. In addition, in the axillary region, due to an increase in size, they begin to be felt The lymph nodes in the form of small dense painful formations. It should be noted that mastitis, untreated at an early stage, is fraught with the development of a more serious form of the disease - purulent.

In this option, it is not recommended to self-medicate, because all the means and methods used in this case do not eliminate the source of the inflammatory process, but only relieve its manifestation (symptoms), as a result of which the process progresses. Against the background of the development of the disease, softening appears at the site of compaction in the mammary gland, indicating the appearance of an abscess. The only solution in this situation will be an urgent operation, delay can cause serious complications. To prevent such consequences, early diagnosis and treatment of the disease is important.

Causes of mastitis.
The main cause of the occurrence and development of mastitis are bacteria (mainly staphylococci) that penetrate the breast tissue. And a bacterial infection can get into the tissues through nipple cracks or through the blood if there are foci of infection in the body (pyelonephritis, chronic tonsillitis, etc.).

The appearance of cracks or small defects in the nipples are a kind of gateway for infection. Usually, if bacteria enters the mammary gland, our defense system can cope with them. But since the female body is greatly weakened in the postpartum period, in most cases it is not able to cope with infections on its own. As a rule, immediately after the appearance of cracks in the nipples (which happens in about most women after being discharged from the hospital, especially in primiparas), arching pains appear in the mammary gland, which at the same time swells strongly, thickens, becomes tight, and the skin turns red. All this condition is accompanied by an increase in temperature. There are a lot of reasons for the appearance of cracks in the nipples, but the most common is the non-compliance of the nursing mother with elementary hygiene rules before and after feeding the baby.

Another reason for the development of mastitis may be the so-called lactostasis, which is the stagnation of milk in the ducts of the mammary glands against the background of incomplete or insufficient expression of milk or insufficiently frequent feedings. The presence of milk in the ducts of the mammary gland is considered a favorable environment for the reproduction of bacteria, since it contains a large amount of nutrients. Lactostasis is expressed in painful sensations in the area of ​​​​the mammary gland, the appearance of focal seals (nodules) in it. Usually, with this phenomenon, body temperature does not rise. However, lactostasis that has not been eliminated, within a couple of days, inevitably flows into mastitis, accompanied, first of all, by an increase in temperature. Flat or inverted nipples are one of the causes of lactostasis, because it is very difficult for the baby to suck on the breast, as a result of which it is not emptied enough.

To avoid the development of lactostasis at the first signs of milk stagnation or breast engorgement, it is recommended to express milk more often and apply cold to the mammary gland, it will facilitate its discharge. It is also recommended to carry out daily self-massage of the breast. It must be done according to this scheme: right hand lower the palm down on the head, and at this moment do a massage with the left in the direction from the outskirts to the nipple, while the nipple area itself does not need to be massaged.

Two types of mastitis can be observed: lactational (in lactating mothers) or postpartum and non-lactational, which occurs outside the lactation period. The latter type is quite rare, as a rule, it occurs and develops against the background of trauma to the mammary gland, its compression and due to hormonal disorders in the female body. Against the background of a transitional age or hormonal imbalance, mastitis often occurs in women of reproductive age from 14 to 18, from 19 to 24 and from 30 to 45 years. Cystic and fibrous mastitis are nothing more than cystic fibrous mastopathy.

Stages of development of mastitis.
Mastitis develops in three stages: serous, infiltrative and purulent. The serous stage characterizes the earliest stage in the development of the disease, which occurs two to four days after infection and is manifested by fever, enlargement and slight compaction of the mammary gland, its soreness, which increases with breastfeeding or pumping, and relief after that does not come. A general blood test shows the presence of signs of an inflammatory process. Improper treatment or its absence inevitably leads to the fact that early stage the disease flows in two or three days into an infiltrative one.

Signs of infiltrative and purulent mastitis.
The infiltrative stage of mastitis is characterized by a pronounced inflammatory process and a more severe general condition of the woman. In the process of palpation of the mammary gland, a clear inflammatory thickening (infiltrate) is observed with reddening of the skin above it, which becomes more and more reddening. The high temperature does not subside, there are sharp temperature drops. Fluctuation occurs (in medical terms, fluctuation), indicating the presence of fluid (pus) in the cavity.

With the phlegmanous form of mastitis (when the abscess is not delimited by a capsule from healthy tissues), the body temperature is kept at 40˚, accompanied by chills, weakness. The mammary gland significantly increases in volume, the skin above it becomes edematous, shiny, reddened with a bluish tinge. There is inflammation of nearby lymph nodes.

With the gangrenous form of mastitis (tissue necrosis against the background of circulatory disorders) general state women are characterized as extremely severe: body temperature is 40 - 41˚C, pulse is rapid 120 - 130 per minute, the mammary gland is greatly enlarged, the skin above it is edematous, covered with blisters with bloody contents with areas of tissue necrosis. The swelling affects the surrounding tissues. A blood test shows the presence of severe inflammation.

Chronic purulent mastitis.
The chronic form of breast mastitis is a rather rare phenomenon. It develops against the background of a rather long local treatment injections of penicillin, mainly purulent mastitis. With this form of the disease, the condition of the patients is characterized as satisfactory: the body temperature is normal, or does not rise above 37.5-37.8 C. On palpation, some slightly painful induration is felt, not soldered to the skin. At chronic form disease symptoms are mild. The mammary gland is painful and somewhat enlarged, and in rare cases there is inflammation in the nearby lymph nodes with a small or less often high temperature.

Once again, I note that the treatment of mastitis in the early stages of development is conservative, that is, antibiotics, anti-inflammatory drugs, etc. are prescribed. Purulent forms of the disease are treated only with the help of surgical intervention.

mastitis diagnosis.
At the first sign of mastitis, you should immediately consult a doctor. The diagnosis of mastitis consists in the detection of existing characteristic features revealed during visual examination and palpation of the mammary gland. To clarify the diagnosis, a general blood test is performed, showing the presence of inflammation in the body. In order to determine the type of bacteria and their sensitivity to certain antibiotics, a bacteriological study of milk from an inflamed breast is carried out. Often, an ultrasound of the breast is prescribed to diagnose mastitis.

Mastitis and breastfeeding.
Regardless of the stage and form of mastitis, it is impossible to feed a child, because in milk even from a healthy breast (not to mention a sick one) there can be a huge amount of bacteria that are dangerous for the baby. Moreover, during treatment this disease antibiotics are prescribed, which, entering the mother's milk, can harm the baby. With a temporary cessation of breastfeeding, you should not refuse to express milk, it is simply necessary, while it must be carried out regularly and with great care. Firstly, the complete emptying of the chest during illness significantly speeds up recovery. Secondly, pumping will help maintain lactation so that after recovery, mommy can return to breastfeeding.

Complications of mastitis.
This disease is often complicated by inflammation of the lymphatic vessels (lymphangitis) and lymph nodes (lymphadenitis). In rare cases, especially in phlegmonous and gangrenous forms, the disease is complicated by sepsis (blood poisoning). When an abscess is opened (often spontaneous), lactiferous fistulas (which are channels that connect abscesses to the surface of the body) sometimes form, which close on their own, but this requires a fairly long period of time.

Prevention of mastitis.
The main thing in the prevention of mastitis is the prevention of cracks in the nipples (the main thing is the observance of the rules of personal hygiene, complete pumping after feedings). If cracks appear on the nipples, immediately consult a doctor and do not self-medicate. In preventing the development of the disease, it is important to treat caries and chronic inflammatory diseases (tonsillitis) in a timely manner, since through the blood, microbes can penetrate into the breast tissue from foci of inflammation in other areas.

The female breast is a delicate organ. And with such a load as breastfeeding, the mammary glands become even more sensitive and unprotected.

Therefore, any negative impact leads to the development of diseases of the mammary glands, in particular, to acute mastitis.

In contact with

What is this disease

is an inflammatory process in the mammary gland. It can develop in any condition female body, however, the vast majority of cases are lactational mastitis that occurs during breastfeeding.

The main cause of acute mastitis is an infection. There are also predisposing factors that contribute to the penetration of microorganisms into the breast tissue.

It's important to know: develops as a result of stagnation of milk in the ducts of the gland and the attachment of an infectious factor to this process.

Infections that cause acute mastitis are varied. These are mainly staphylococci and streptococci, but there may be some other bacteria - Klebsiella, Proteus, tubercle bacillus. Predisposing factors include the following:

• breastfeeding period;
• stagnation of milk in the thoracic ducts;
• hypothermia;
• contact with an infectious patient;
• injury to the mammary gland;
• injury during breastfeeding of the nipple and areola - cracks, chafing;
• insufficient hygiene of the mammary glands;
• the presence of a chronic focus of infection in the body.

The combination of the underlying cause and predisposing factors leads to the development of acute mastitis.

Classification

Several types of the disease can be distinguished depending on the nature of the inflammatory process in the mammary gland.

At first, mastitis is always catarrhal - this is an incipient inflammation without the addition of microbial flora.

Then there are transparent discharge from the nipple - mastitis becomes serous. After the attachment of an infectious factor, acute purulent mastitis develops.

Clinical picture

The symptoms that make up the picture of acute mastitis are quite specific. First, signs of intoxication of the body appear:

• the temperature rises to 39 * C;
• this temperature is accompanied by profuse sweating and chills;
• general weakness;
• dizziness or headache.

Then the symptoms of mastitis develop directly:

1. The mammary glands - one or both at once - increase in size and become dense.
2. When a woman touches her breast, she feels pain.
3. The skin of the chest becomes red and hot to the touch.
4. The nipple is painful, pathological discharge departs from it.
5. Nearby lymph nodes enlarge and become painful.
6. Breastfeeding becomes impossible due to pain.

Acute mastitis is severe, without treatment, an abscess in the mammary gland or phlegmon may form.

Diagnostics

The diagnosis of acute mastitis is based on the characteristic symptoms. To confirm the diagnosis, some studies are carried out:

1. General blood and urine tests reveal the presence of an inflammatory process.
2. Ultrasound and X-ray examination reveal an inflammatory infiltrate in the breast tissue.
3. To determine the type of pathogen, sowing of the discharge from the nipple is carried out.

Treatment

Acute mastitis needs to be treated. Otherwise, the process will damage the breast tissue so much that it will have to be removed.

The first step is to stop breastfeeding - not only does it hurt the mother, but it can harm the baby. Milk from the breast must be expressed regularly, but it should not be used to feed the baby.

At first, mastitis can be treated conservatively. To do this, the following activities are carried out:

• provides rest to the mammary gland;
• regular expression of milk;
• antibacterial therapy, taking into account the causative agent of the disease;
• symptomatic treatment - painkillers, antipyretic drugs, if necessary, infusion therapy.

Doctor's advice: if within a day of such treatment there is no improvement in the condition of the woman, surgical treatment of mastitis is required. It consists in dissecting the mammary gland, removing pus, washing the cavity with antiseptic solutions, setting up drains and suturing the wound.

The incision can be made in different ways - along the mammary gland from the nipple to the armpit; along the edge of the areola; arcuate at the base of the mammary gland.
Antibacterial and symptomatic treatment continues in the postoperative period.

Prevention

To prevent the development of acute mastitis, a number of measures must be taken:

• do not overcool;
• do not contact with infectious patients;
• do not injure the chest;
• during pregnancy, prepare the mammary glands for the upcoming feeding;
• observe the hygiene of the mammary glands during breastfeeding.

See the following video for doctor's advice on mastitis:

Mastitis (mastitis)- inflammation of the breast tissue, which in the vast majority of cases occurs in women during lactation. According to the figurative expression of one of the founders of Russian purulent surgery V.F. Voyno-Yasenetsky “The breast (as mastitis used to be called in Russia) is as old as the human race; many millions of women suffer from it, and from time immemorial, doctors have excelled in curing it ... ". And today, surgical operations for purulent lactational mastitis are one of the most common interventions performed by a wide range of surgeons.

In different years, the ratio of the number of cases of lactational mastitis to the number of births ranges from 3 to 18%. This disease occupies one of the first places in the structure of postpartum purulent-inflammatory complications. The consequences of transferred purulent mastitis can be significant violations of the function and aesthetic condition of the mammary gland. Violations of lactation, changes in the qualitative composition and contamination of milk with pathogenic microflora during a purulent-inflammatory process in the mammary gland significantly affect the normal development of the child and can lead to serious illnesses. The presence of any defects in the mammary gland, including rough scars after surgery, has a negative impact on the psyche of a woman, and in some cases requires complex plastic surgery.

Classification

Genesis of mastitis.> Lactation (postpartum).

Non-lactating:

Mastitis of pregnant women;

mastitis in newborns.

The nature of the inflammatory process.

Nonpurulent:

Serous;

Infiltrative.

Purulent:

Abscessing;

Infiltrative-abscessing;

Phlegmonous;

Gangrenous. Localization of the abscess:

Subareolar;

Subcutaneous;

Intramammary;

Retromammary.

The prevalence of the process.

Limited (one quadrant of the gland);

Diffuse (two or three quadrants of the gland);

Total (four quadrants of the gland).

Etiology and pathogenesis

Lactational (postpartum) mastitis is an inflammation of the mammary gland that occurs in a woman in the postpartum period against the background of lactation. It accounts for up to 95-99% of all inflammatory lesions of the gland. Lactational mastitis can develop at different times of the postpartum period, but more often at 2-3 weeks after birth. In 75-85% of cases, mastitis occurs in primiparas, much less often after repeated births. This is due to the fact that during repeated births, the mammary gland quickly adapts to the functional changes that occur in it at the end of pregnancy, as well as a certain experience of women in caring for the mammary glands, proper feeding of the child, personal hygiene in the pre- and postpartum periods. In addition, in primiparas with pathology of pregnancy, childbirth or the postpartum period, a decrease in immunological reactivity occurs more often, which leads to increased susceptibility to purulent infection.

The causative agent of purulent mastitis in more than 90% of cases is Staphylococcus aureus as a monoculture or in association with other microflora (Escherichia and Pseudomonas aeruginosa, Proteus, Streptococcus). Less often, mastitis can be caused by opportunistic gram-negative bacteria, the role of which has increased significantly in recent years.

Staphylococcus, which causes purulent mastitis, is characterized by pronounced pathogenicity, polyresistance to many antibacterial drugs.

The immediate source of infection of the mammary gland is the newborn, which transmits the infection to the mother when applied to the breast. The child becomes infected from medical personnel, items of care for him, linen, etc. Cross-infection is also possible: the transfer of pathogenic staphylococci from mother to child and then back to the mother.

The entrance gates of infection in lactational mastitis can be the mouths of the milk ducts, cracks and excoriations of the nipples, various damage to the skin of the mammary gland. According to the entrance gate, the infection spreads by the galactogenic, lymphogenous or hematogenous route. Factors contributing to the occurrence of mastitis are lactostasis, the pathology of pregnancy, childbirth, the postpartum period, and various concomitant diseases.

Lactostasis (milk stasis, breast engorgement, milk fever) precedes mastitis in 85% of cases. Lactostasis and contamination of the mammary glands with pyogenic microflora are the main cause of the onset and progression of mastitis. In this combination, lactostasis plays the role of a "triggering factor" of the disease. With regular and sufficient pumping of breast milk, the microflora is partially excreted with milk from the ducts. Microbes remaining in the ducts in a small amount are not capable of causing inflammation of the gland. But with lactostasis, lactic acid fermentation and intraductal coagulation of milk, damage to the epithelium of the milk ducts occur. The milk passages are obturated with curdled milk, which greatly complicates pumping. The microflora, continuing to develop in the closed space of the milk ducts and alveoli, reaches a “critical level”, an inflammatory process occurs. In most patients, the duration of lactostasis before the development of mastitis is 3-4 days. Edematous tissues, squeezing the milk ducts of neighboring lobules, impede the outflow of milk from them, causing lactostasis in other, adjacent sections of the mammary gland. This is also facilitated by insufficient pumping of breast milk due to pain due to developing inflammation.

Nipple cracks, which are observed in 15% of patients with purulent mastitis, serve as the "entrance gate" of the infection and its reservoir. They significantly disrupt the function of the mammary gland, forcing women to refuse breastfeeding and thorough pumping. The main causes of teat cracks are a mismatch between excessive negative pressure in oral cavity baby, elasticity and extensibility of the nipple tissue. What matters is the prolonged and frequent contact of the nipple with a bra soaked in milk, which causes irritation and maceration of the skin, contributes to the formation and progression of cracks.

Of great importance in the pathogenesis of lactational mastitis is a violation of reactivity immune system, as well as sensitization of the body of women to various medicines, staphylococcus and autoimmune reactions to organ-specific antigens: milk and breast tissues. With a perverted immune response to these antigens, the inflammatory process in the mammary gland proceeds more severely, up to the development of severe sepsis.

Inflammation in the gland due to its lobular structure of a large number of natural cavities (alveoli, sinuses, etc.), a wide network of milk and lymphatic ducts, an abundance of fatty tissue is poorly delineated and tends to spread to neighboring areas of the mammary gland.

The course of lactational mastitis is characterized by the rapid dynamics of the inflammatory process, i.e. a rapid transition of its serous and infiltrative forms to purulent with simultaneous damage to more and more new areas of breast tissue. The purulent-inflammatory process is often located intramammary, often has a protracted course with frequent relapses of the disease and damage to two or more quadrants of the gland. In recent years, the number of patients with bilateral mastitis has increased, and the incidence of septic complications has increased. Among the purulent forms of acute lactational mastitis, infiltrative-abscessing and phlegmonous are more common.

Clinical manifestations

Serous mastitis

Serous mastitis is characterized by the formation of inflammatory exudate in the tissues of the gland without any focal changes, accumulations of leukocytes are noted around the blood vessels. The disease begins acutely with the appearance of pain and a feeling of heaviness in the mammary gland, chills and fever up to 38 ° C and above. Women also complain of weakness, headache. The mammary gland increases in volume, there is a slight hyperemia of the skin in the area of ​​inflammation. Expression of breast milk from the mammary gland and palpation in the area of ​​skin hyperemia are painful. The amount of milk expressed is reduced. There is a slight increase in the number of blood leukocytes and ESR.

Infiltrative form of mastitis

With the infiltrative form of mastitis, all the above symptoms persist, but a painful infiltrate is determined in the tissues of the gland without clear boundaries, areas of softening and fluctuation.

High body temperature and chills initial stages mastitis (serous and infiltrative forms) are explained, first of all, by lactostasis, in which milk, which has a pyrogenic effect, is absorbed into the blood through damaged milk ducts. When conducting desensitizing therapy and measures that stop lactostasis, in most patients, the body temperature drops to 37.2-37.5 ° C.

In the absence of treatment or with inadequate therapy, serous and infiltrative forms of mastitis pass into purulent within 3-4 days.

Abscess mastitis

Abscessing mastitis is manifested by a deterioration in the well-being of patients, an aggravation of all general and local symptoms of the disease, and an increase in intoxication. More than a third of patients have a body temperature above 38 °C. Hyperemia of the skin increases, its swelling appears (Fig. 42-1). A sharply painful infiltrate is palpated in the mammary gland, which has a cavity (abscess) with a pyogenic capsule and in 50% of patients it occupies more than one quadrant. In 60% of cases, the abscess is located intramammary, less often - under the areola or subcutaneously. Often in the center of the infiltrate softening is determined, and in its zone - a symptom of fluctuation. In many patients, leukocytosis is more than 1010 9 /l.

Rice. 42-1. 0sharp left-sided purulent lactational mastitis.

Infiltrative-abscess mastitis

Infiltrative-abscessed mastitis is more severe than the abscessing form of the disease. However, the severity of skin hyperemia, tissue edema of independent and palpable pain corresponds to abscessed mastitis. the infiltrative-abscessing form of mastitis is characterized by the presence of a dense infiltrate in the tissues of the mammary gland, consisting of many small abscesses of various sizes, like "honeycombs". That is why, with this form of abscess, the symptom of fluctuation is rarely determined. In half of the patients, the infiltrate occupies at least two quadrants of the mammary gland.

Phlegmonous mastitis

In the phlegmonous form of inflammation, a sign of intoxication is expressed, the state of health and the general condition of patients deteriorate significantly. Pain in the mammary gland intensifies and headache increases, weakness increases, appetite decreases, pallor of the skin is noted. in 80% of patients, the body temperature is above 38 "C, and in a third more than 39 0 C. The mammary gland is sharply enlarged in volume, its tissues are swollen; the skin is intensely hyperemic, tense, in places with a cyanotic tint. - The nipple of the gland is often retracted. On palpation, a sharp soreness and pastosity of tissues. 60% cases, three or four quadrants of the mammary gland are involved in the purulent-inflammatory process. At in all patients, the number of blood leukocytes exceeds 10. 10 9 /l in many cases (90%) the content of hemoglobin in the blood decreases there are significant changes in indicators general analysis urine

Gangrenous form of mastitis

The gangrenous form of mastitis is characterized by a very serious condition of patients and extensive necrosis of the skin and deep tissues. The process proceeds malignantly, with rapid purulent fusion of tissues and spread to the cellular spaces of the chest, accompanied by a pronounced systemic inflammatory reaction. In most patients, body temperature rises above 39 ° C. All the above general and local symptoms of the disease are pronounced. All quadrants of the mammary gland are involved in the inflammatory process. Her skin with areas of bluish-purple color and exfoliated epidermis with the formation of blisters filled with hemorrhagic fluid, there are foci of necrosis. In all patients, the number of blood leukocytes was significantly increased and the hemoglobin content was reduced to 80-90 g/l. In the general analysis of the urine of all patients, there are protein and increased amount erythrocytes, and in 75% of cases - hyaline and granular cylinders.

In some cases, gangrene of the mammary gland is a local manifestation of autosensitization of the body to organ-specific antigens: milk and inflamed breast tissue.

Diagnostics

Expressed local and general symptoms purulent inflammation of the mammary gland (hyperemia and swelling of the skin, palpable sharply painful infiltrate with a site of fluctuation, high body temperature and severe intoxication) leave no doubt about the diagnosis of the disease. The need for surgical treatment in such cases is beyond doubt. In cases long-term treatment patients with antibiotics in the clinic or antenatal clinic possibly erased (latent) course of a purulent inflammatory process. It is characterized by a discrepancy between the clinical manifestations of the disease and the true severity of the pathological process in the tissues of the gland, i.e. some local signs of inflammation may be absent: fluctuation or softening of the infiltrate, skin hyperemia and tissue swelling, as well as fever and leukocytosis. At the same time, even in such patients, independent pains in the mammary gland always persist, and a dense painful infiltrate is determined in its tissues. Often there is a variant when some purulent foci of inflammation in the mammary gland proceed latently against the background of others that have a pronounced inflammatory reaction.

The leading symptom of abscessing mastitis is fluctuation, which is determined in 99% of cases. Valuable diagnostic value is the puncture of the infiltrate with a needle with a wide lumen and ultrasound.

With an infiltrative-abscessing form of mastitis, due to the small volume of abscesses, in the vast majority of cases (95%), the fluctuation symptom is negative, it is determined only when a larger cavity is formed. For the same reason, the diagnostic value of a puncture of a purulent focus is low. In such cases, ultrasound plays a leading role.

Differential Diagnosis

Mastitis should be distinguished from lactostasis. With lactostasis, body temperature also rises, the mammary gland increases in volume, palpation determines pain in all its departments, but there is never swelling and hyperemia of the skin. The question of the need for surgical treatment in these cases, it is advisable to resolve within 3-4 hours after careful decantation of breast milk from the mammary gland. If there is only lactostasis, then after emptying the gland, the pain in it subsides, begins to be palpated small size painless lobules with clear contours and a fine-grained structure, body temperature decreases. With a duration of lactostasis of more than 3 days, as a rule, mastitis develops. If lactostasis is combined with purulent mastitis, then after decanting, a dense painful infiltrate continues to be determined in the tissues of the gland, the fine-grained structure of the milk lobules is not determined, the body temperature remains high, and the patients' well-being does not improve.

Non-purulent forms of lactational mastitis are treated conservatively, with purulent forms, surgical treatment is indicated. Treatment of lactostasis does not differ from the treatment of non-purulent forms of mastitis.

The scheme of treatment of lactostasis and non-purulent forms of mastitis

1. Expression of milk from both mammary glands every 3 hours (8 times a day). First of all, milk is expressed from a healthy gland, then from a sick one.

2. Intramuscular injection of 2.0 ml of drotaverine for 3 days at regular intervals: 3 times a day 20 minutes before expressing milk from a diseased mammary gland, and 0.5 ml of oxytocin 5 minutes before, which improves milk flow.

2. Daily retromammary novocaine blockades (100-150 ml of 0.25% procaine solution) with the addition of broad-spectrum antibiotics in half daily dose. The blockade is performed as follows: the mammary gland is pulled forward by hand, at its outer base, prescribing a solution of procaine, a long needle is inserted parallel to the chest under the posterior fascia of the mammary gland into fatty tissue to the areola projection zone. Then a solution of procaine with antibiotics is administered. Immediately after the blockade, the pain stops, the milk ducts expand, which facilitates pumping, and a high concentration of the antibiotic is created in the mammary gland. The milk is expressed from the gland 20-30 minutes after the blockade.

3. Prescription of antibiotics.

4. Desensitizing therapy ( intramuscular injection antihistamines 2-3 times a day).

5. Vitamin therapy (C and group B).

6. Semi-alcohol dressings on the mammary gland (do not use any ointment warming compresses).

7. Ultrasound or ultrahigh-frequency therapy (with positive dynamics of the disease one day after the start of conservative therapy).

Conducting conservative therapy is possible with a satisfactory condition of the patient, body temperature up to 37.5 ° C, normal indicators of the general blood test, the duration of the disease is less than 3 days, the presence of an infiltrate that occupies no more than one quadrant of the gland, and the absence of other local symptoms of purulent inflammation. If there is no positive dynamics within 2 days of treatment, surgical treatment is indicated.

Surgical treatment of purulent mastitis

The operation should be performed in a hospital under general anesthesia. The main principles of surgical treatment of acute purulent lactational mastitis at the present stage are as follows.

1. The choice of rational access to the purulent focus, taking into account the need to maximize the preservation of the function and aesthetics of the mammary gland.

2. Radical surgical treatment of a purulent focus.

3. Adequate drainage of the purulent focus, including with the use of a drainage-flushing system.

4. Closure of the wound with a primary suture, and in case of contraindications - the imposition of secondary sutures and the use of skin plastics.

5. Prolonged drip washing of the wound through the drainage-washing system in the postoperative period with antiseptic solutions.

The choice of access to the purulent focus should take into account the localization and prevalence of the purulent process, the anatomical features of the structure of the mammary gland (Fig. 42-2). When localizing a purulent focus under the areola, the paraareolar approach is the most rational: the incision is made parallel and 1-2 mm away from the edge of the areola. When the inflammatory process is localized in the lower quadrants of the mammary gland (or one of them), the best access is the incision, which is performed 1-2 cm above and parallel to the lower transitional fold of the mammary gland. The total defeat of the mammary gland or the retromammary location of the abscess makes it necessary to make an incision along the lower transitional

breast folds.

Rice. 42-2. Incisions for purulent mastitis: 1 - external-lateral; 2 - radial; 3 - paraareolar; 4 - along the lower transitional fold of the mammary gland.

To open a purulent focus located on the border of the outer quadrants or occupying both outer quadrants, an arcuate incision is made along the outer base of the mammary gland. With a deep and narrow intermamammary fold, an arcuate incision along the outer base of the mammary gland is preferable to open the abscess in the inner quadrants.

The incisions described above do not violate the aesthetic state of the mammary gland, allow you to widely open and examine the purulent cavity, and completely excise non-viable tissues. In case of skin necrosis, it should be excised with two semi-oval incisions and surgical treatment of the purulent focus should be performed from this access.

The radial incision is universal and is used for any localization of the purulent focus, except for its subareolar location. However, scars after radial incisions in the upper quadrants are difficult to hide with clothing, and in the lower quadrants often lead to severe deformity of the mammary gland, so their use should be limited.

After the incision is made, all non-viable purulent-necrotic tissues are excised, which accelerates the relief of the inflammatory process. Surgical treatment of a purulent focus is the most responsible and difficult stage of the operation. The non-viable tissue remaining after surgical treatment causes a recurrence of the disease. At the same time, excessive radicalism and excision of viable tissue can lead to dysfunction and appearance mammary gland. Since the abscessing form of mastitis is characterized by the presence of a clear boundary between the purulent focus and the rest of the breast tissue, the complete excision of the pyogenic membrane and fibrous capsule guarantees the radicalness of surgical treatment. With an infiltrative-abscess form of mastitis, it is necessary to excise the entire palpable infiltrate to healthy tissues. It is a dense, whitish-colored tissue with small abscesses, less often it is formed by a loose, bluish-colored tissue. The usefulness of the performed surgical treatment is controlled by palpation of the mammary gland both from the side of the wound and from the side of the skin. With phlegmon of the mammary gland, tissue impregnated with pus should be considered unviable. It is always loose and edematous, has a dull gray appearance, does not bleed. Bleeding from a separate large vessel passing through tissues saturated with pus is not a sign of the viability of this area of ​​\u200b\u200bthe mammary gland. The criterion for a fully performed necrectomy is the appearance of capillary bleeding from healthy tissue. In the gangrenous form of mastitis, after excision of necrosis, extensive skin defects may form, requiring further closure by one of the methods of autodermoplasty.

Surgical treatment of a purulent focus is supplemented by washing the wound with antiseptic solutions using an electric suction, which reduces its microbial contamination. The stage of radical non-crectomy is completed with the change of gloves, instruments, barrier material and re-treatment of the surgical field. Perform a thorough, but not rough expression of milk from the mammary gland. This must be done, since full pumping of milk before the operation and in the first hours of the postoperative period is not feasible due to the sharp pain in the mammary gland. In addition, when decanting milk before opening and sanitizing the abscess, there is a real danger of the penetration of microbial flora into the milk ducts damaged by the inflammatory process and spreading it to other areas of the mammary gland.

Of great importance in the surgical treatment of acute purulent mastitis is adequate drainage of the purulent cavity by imposing a drainage-flushing system consisting of separate polyvinyl chloride tubes of various sizes with holes on the side surfaces (Fig. 42-3). Drainage of the abscess cavity and its prolonged washing in the postoperative period with antiseptic solutions provide mechanical removal of microbial flora and small necrotic areas of breast tissue. At the same time, solutions antibacterial drugs and proteolytic

Rice. 42-3. Drainage and flushing system.

cal enzymes have a direct effect on the microflora and necrotic tissues. All this contributes to the rapid cleansing of the wound and accelerates the relief of the inflammatory process.

Radical surgical treatment of the purulent focus, followed by constant washing of the cavity with antiseptic solutions through the drainage-flushing system, allows closing the wound with a primary suture (Fig. 42-4) and thus reducing its healing time, improving the functional and aesthetic results of treatment.

Rice. 42-4. Intramammary abscess mastitis: but- drainage-but-flushing system and primary seams are imposed; b- localization of the abscess and a variant of the drainage-flushing system.

Sutures are applied only to the subcutaneous tissue and skin. As a result, a closed cavity (non-sutured inner part of the wound) is formed in place of the existing purulent focus, which communicates with the external space through drains. Granulation tissue, filling the cavity, preserves the volume of the mammary gland, which is very important in terms of aesthetics. Contraindications to the imposition of primary sutures on the wound are an anaerobic component of the infection and an extensive skin defect, which is why it is not possible to bring the edges of the wound together without tension. In the postoperative period, the cavities are constantly drip-washed through both ends of the irrigator aqueous solution chlorhexidine with an intensity of 10-15 drops per minute. The introduction of an antiseptic solution into both ends of the irrigator helps to fill its lumen with liquid throughout, due to which purulent

the cavity is evenly irrigated through all holes with a tube. In total, no more than 3 liters of solution are required per day. More significant is the duration of washing the cavity, and not the rate of administration of antiseptic solutions.

During the first 5 days after the operation, daily dressings are performed to control the course of the wound process and the ““phenomenon of purulent wound complications. In the future, as the “* scorching phenomena in the mammary gland subside, dressings can be done in 1-2 days. During them, the cavity is washed through ^ ™ * ^ ™ with hydrogen peroxide and chlorhexidine, with ^ th pay attention to its volume, the functioning of the drainage-wash system and the nature of the discharge. The drainage-washing system is removed within 5 to 12 days after the operation. The indication for this is the complete relief of the inflammatory process and the presence of a residual cavity with a volume of not more than 5 ml. In the wounds remaining after the removal of the tubes, a rubber strip is inserted on the 1st-2nd day. In an uncomplicated course of the postoperative period, the sutures are removed on the 8th-9th day after the operation.

If the wound was not closed with primary sutures, then dressings are done using various local funds in the area from the phase of the wound process. In the phase of milk inflammation, water-soluble ointments are used (chloramphenicol + methyluracil, chloramphenicol + methyluracil + sulfadimethoxine + trimecaine hydroxymethylquinoxylindioxide + trimecaine + methyluracil), in the regeneration phase - drugs that stimulate healing processes (methyluracil ointment, vinylin, etc.). After stopping the signs of acute inflammation, secondary sutures are applied. In the general therapy of purulent lactational mastitis, tibacterial and immunocorrective drugs. In case of a severe course of the disease, metabolic and hemodynamic disorders are corrected, detoxification therapy is carried out (see the principles of sepsis treatment, Chapter 3).

One of the important tasks of the postoperative period is the cupping of lactostasis, which always accompanies purulent mastitis; it is necessary to express milk from both small glands every 3 hours: first from a healthy one, then from a patient, as rarely as possible, pumping is decided individually, but not before inflammation subsides. Before expressing milk from a diseased gland for 3-4 days 3 times a day prom horrors of time intramuscularly injected with drotaverine and oxytocin. With a longer use of these drugs, lactation may increase, which is inappropriate for lactostasis and mastitis.

With mastitis, you should refrain from applying the child to the diseased and healthy mammary glands. Natural feeding can be continued only after relief of inflammation and with a negative result. bacteriological research milk. Milk expressed from a diseased gland is disposed of, and from a healthy one, after pasteurization, it is suitable for feeding a baby from a bottle through a nipple. It should be borne in mind that milk before and after pasteurization cannot be stored.

Indications for interruption of lactation: 1) severe course of the inflammatory process in the mammary gland (gangrenous or total phlegmonous mastitis, sepsis), 2) bilateral mastitis, 3) recurrence of the disease, 4) the presence of any reasons why it is impossible to feed the child with mother's milk after her recovery, 5) mother's request. Lactation can be interrupted only after the relief of lactostasis.

Interruption of lactation by tight bandaging of the mammary glands is extremely dangerous, since milk production still continues for some time and lactostasis always occurs, and circulatory disorders in the mammary gland contribute to the development of severe forms of purulent mastitis. Most effective way interruption of lactation is the appointment of drugs that inhibit the secretion of prolactin (cabergoline, bromocriptine).

Complications and prognosis

Acute purulent lactational mastitis can be complicated by sepsis and the spread of the purulent process to chest with the development of phlegmon. The consequences of purulent mastitis can be the formation of a milk fistula, deformation of the mammary gland and a decrease in its volume, a significant decrease or cessation of lactation.

Prevention

Prevention of mastitis involves the fulfillment of a number of conditions. First, compliance with a strict sanitary and hygienic regime in the maternity hospital. Secondly, an increase in the immunological reactivity of the woman's body. Thirdly, personal hygiene during pregnancy and in the postpartum period. Fourth, proper care of the mammary glands, prevention of the appearance and timely treatment of nipple cracks and lactostasis. A promising solution to the problem is the organization of boxed wards for women and newborns, in which they are at all stages of their stay in the maternity hospital from hospitalization to discharge. This creates the possibility of preventing contacts between pregnant women, women in labor and childbirth with each other and with a wide range of medical personnel, as well as between newborns. After the woman and the newborn are discharged, the boxed ward is completely disinfected, which significantly reduces the level of nosocomial infection.

The risk group for developing lactational mastitis includes women:

Having a pathology of pregnancy, childbirth and the immediate postpartum period;

Having a history of purulent-septic diseases;

Patients with mastopathy;

Having anomalies in the development of the mammary gland and nipple;

Previously undergone a trauma of the mammary gland or surgery on it;

Prone to the formation of cracks in the skin and mucous membranes;

With pathological premenstrual syndrome, accompanied by diffuse enlargement and soreness of the mammary glands in the second phase menstrual cycle.

Favorable psycho-emotional state of a woman in the family, rest, walks in the fresh air - important factors mastitis prevention. Smoking and drinking alcohol are incompatible with pregnancy and the postpartum period.

The mammary glands require special care. During pregnancy, it is recommended to additionally wash them with water at room temperature, followed by rubbing with a clean terry towel. This helps to harden the mammary glands and increase the resistance of the nipples to mechanical damage that may occur when feeding the baby. From the second half of pregnancy and in the postpartum period, daily air baths for the mammary glands for 15-20 minutes are useful, in summer - under direct sunlight at an open window, in winter - in combination with small doses of ultraviolet radiation. During this period of pregnancy and after childbirth, women should also be advised to perform a light massage of the nipples and mammary glands.

Of great importance for the prevention of lactostasis and lactation disorders is wearing a bra, which must be made of cotton or cotton fabric, since synthetic underwear irritates and injures the nipples and can lead to cracking. In addition, a synthetic bra cannot be ironed with a hot iron. The bra should support well, but not squeeze the mammary gland. It should be washed daily separately from other laundry and put on after ironing with a hot iron.

To prevent the occurrence of nipple cracks, it is necessary to carefully observe the feeding technique and not keep the baby at the breast for a long time. If the baby suckles the breast sluggishly and slowly, then it is advisable to periodically take short breaks. After each feeding, the mammary glands must be washed with warm water, dried with a clean towel and left open for 10-15 minutes. In this case, you should not use soap and strongly rub the mammary glands with a hard towel. Between the bra and the areola of the gland, a sterile gauze napkin or a folded piece of a sterile bandage is laid, which is changed when soaked with milk. When caring for the mammary glands and skin of other parts of the body, it is not recommended to use lotions, creams and other scented products, as the child will be reluctant to breastfeed or refuse to feed in the future.

For successful treatment of cracks, it is necessary, first of all, to temporarily stop breastfeeding the child, to ensure that there is no prolonged contact of milk with the crack. Milk is expressed by hand into a sterile dish, the baby is fed from a bottle through a nipple with a very small hole. With a large hole in the nipple, the child may refuse to take the breast in the future. A good result is the treatment of a crack by applying a sterile gauze pad with sea buckthorn or rosehip oil to the nipples.

To establish normal lactation and prevention of lactostasis, successful and prolonged breastfeeding, it is necessary to take into account the physiological mechanisms that stimulate the separation of milk. This is facilitated by the early attachment of the newborn to the breast (within 30 minutes after birth), which activates the release of prolactin into the mother's blood, which stimulates milk production. A positive effect on lactation has a frequent attachment of the child to the breast - approximately every 2 hours. At the same time, there is a constant emptying of the mammary gland, which is the prevention of lactostasis and increases the release of prolactin. With established lactation, after each feeding of the child, it is recommended to express the remaining milk. This is due to the fact that milk during feeding primarily flows from the milk lobules, which have wide and straight milk passages. Slices with convoluted and thin tubules are not emptied enough, milk stagnation may occur in them and, as a result, an inflammatory process. You can empty them with additional pumping. The manual pumping method is the most effective in terms of preventing lactostasis. It is very important to observe the correct technique of feeding and expressing milk. For a more complete return of milk, a warm circular shower on the mammary gland 20 minutes before feeding can be recommended. If a woman is prone to the development of lactostasis, then each feeding should be carried out from both mammary glands.

Features of the diagnosis and treatment of non-lactational mastitis

Non-lactational mastitis is much less common than lactational mastitis. The infection, most commonly Staphylococcus aureus, enters the breast tissue through the milk ducts or broken skin. The disease can occur at any age and is not associated with lactation.

A purulent inflammatory process in non-lactational mastitis in adults usually proceeds less severely, more often in the form of an abscess, is prone to delimitation, and stops faster. Immunological reactivity in non-lactational mastitis is rarely reduced, there are no problems associated with the functional activity of the mammary gland. The principles of surgical treatment of non-lactational mastitis are the same as for lactational mastitis. Be sure to perform a histological examination of the excised tissue to exclude breast tuberculosis and decaying cancer, complicated by suppuration.

Mastitis of pregnant women

Mastitis of pregnant women is very rare, it develops against the background of the restructuring of the mammary glands during pregnancy.

mastitis in newborns

Mastitis of newborns occurs during the first 2-3 weeks of life, both in girls and boys, against the background of physiological engorgement of the glands, which develops as a result of the mother's estrogen entering the blood of the newborn. In the tissue of the gland, the infection penetrates through damaged skin or hematogenously. Often the disease is preceded by diaper rash, various purulent-inflammatory processes in the skin and deeper tissues. The disease begins acutely, the inflammatory process progresses rapidly and at the end of the 1st - the beginning of the 2nd day becomes purulent. The child behaves uneasily, refuses to eat. Body temperature reaches 38-39 "C. Hyperemia of the skin and swelling of tissues are visible in the region of the gland, a symptom of fluctuation is determined. The disease can be complicated by the development of phlegmon of the anterior chest wall, severe sepsis.

Treatment of purulent mastitis in newborns is surgical.

Chapter 43 DISHORMONAL

DISEASES

BREAST GLANDS

In clinical practice, in relation to benign diseases of the mammary glands, the term fibrocystic mastopathy is usually used, which unites a large group of dyshormonal hyperplasia of different morphological structure, the frequency of malignancy of which is quite high. Therefore, knowledge of the features of their occurrence and clinical manifestations is necessary for the practitioner.

The main features of the pathology

There are various forms of hormonal imbalance that contribute to the occurrence of hyperplasia in this organ. This idea is confirmed by a wide variety of pathomorphological and clinical forms of fibroadenomatosis, the structural organization of which, apparently, is due to a different hormonal background. Fibrocystic disease, according to the WHO definition, is a complex of processes characterized by a wide range of proliferative and regressive changes in mammary gland tissues with the formation of abnormal ratios of epithelial and connective tissue components and the formation of fibrous, cystic and proliferative changes in the mammary gland, which are often, but not surely coexist. There are non-proliferative and proliferative forms of fibrocystic disease. The risk of malignancy in a non-proliferative form does not exceed 1%, with moderate proliferation - no more than 2.5%, and with a pronounced proliferation it increases to 30%.

Clinical and morphological characteristics of dishormonal hyperplasia. Among the various forms of dyshormonal hyperplasia of the mammary gland, clinicians distinguish diffuse (small- or large-focal), nodular (local) and mixed, when against the background diffuse changes nodes more or less expressed in size are determined. Fibroadenomatosis of the mammary gland is the most common type of diffuse dysplasia. The main classification criterion may be the presence or absence of proliferation.

The diffuse form is the earliest stage in the development of mastopathy. At histological examination reveal hyperplastic and atrophic lobules, dilated ducts and acini, small cysts, growth and coarsening connective tissue, collagenosis and areas of the normal structure of the mammary gland.

The nodular form of mastopathy is characterized by a variety of morphological patterns of dyshormonal hyperplasia. It can be dominated by the processes of hyperplasia of glandular lobules, cyst formation, fibrosis, proliferation of cellular elements lining cysts and ducts. Detection of epithelial proliferates in the lumen of the glandular cavities in the preparations of the removed, pathologically altered part of the mammary gland gives reason to regard the disease as a localized mastopathy with proliferation. The detection of single atypical cells in these proliferations serves as a reason for the diagnosis of localized mastopathy with proliferation and atypia and classifying these forms as precancerous conditions.

Fibroadenomas of the mammary gland are also referred to as local benign tumors. Histologically, several forms of fibroadenomas are distinguished.

1. Intracanalicular - with a predominance of growing epithelium, among which are squeezed ducts in the form of glandular branched strands.

2. Pericanalicular - with a parallel growth of the connective tissue of the epithelium, forming glandular tubules; at the same time, dilated ducts and cysts are revealed, as in mastopathy.

3. Foliate, or phylloidal - grows rapidly, reaching large, even gigantic sizes. The section reveals a layered structure resembling the sheets of a folded book. Histological examination reveals proliferation of connective tissue rich in cellular elements, glandular passages and cysts lined with proliferating epithelium are noted.

4. Intraductal papilloma (bleeding mammary gland, Mintz's disease) is localized in large ducts, often near the nipple and behind the areola. Papilloma is a growth of the epithelium inside the enlarged excretory duct of the mammary gland, easily injured when squeezed or bruised, followed by spotting from the nipple. The main clinical symptom is the discharge of greenish-yellow or bloody contents from the nipple.

Adenoma is characterized by excessive growth of glandular passages (acini) with the formation of microadenomas from closely spaced hyperplastic glandular elements. As the proliferation of the epitherium of the acinus increases, third-degree dysplasia develops, which passes into carcinoma in situ and then into invasive cancer. These tumors of the mammary gland are poor in stroma, they are dominated by the growth of glandular epithelium. They are characterized by less clear contours, they are softer than fibroadenomas. At present, there is no doubt that dyshormonal dysplasia (mastopathy), especially with atypical proliferation of the epithelium, in a certain percentage of cases can be a precursor of breast cancer. The risk of breast cancer increases with lobular and ductal hyperplasia, multiple large cysts. Early detection of cancer appears to be an important strategy for reducing mortality from this disease and is the goal of screening programs conducted in a number of countries. In our country, unfortunately, in 90% of cases, pathological formations in the mammary glands are detected by women themselves, and only in 10% by doctors during preventive examinations.

Etiology

The physiology of the mammary glands in women is such that they are in a state of constant change in the processes of proliferation and involution associated with the phases of the menstrual cycle. The processes of proliferation of the epithelium of the mammary glands are influenced by estrogens and progesterone produced by the ovaries, as well as gonadotropic hormones of the anterior pituitary gland. In women with fibrocystic mastopathy reveal various violations of the hormonal status: 1) gestagenic insufficiency; 2) hyperestrogenism; 3) a decrease or increase in the level of gonadotropins, a change in the ratio of follicle-stimulating and luteinizing hormones.

The activity of the endocrine glands, on which the processes of physiological proliferation of the mammary gland epithelium depend, is regulated by the diencephalic region and the cerebral cortex. A variety of influences disrupt neurohumoral regulation (abortions, inflammatory diseases of the genital organs, damage to nervous system etc.), lead to the development of dishormonal disorders. Disturbances in hormonal balance cause a restructuring of the mammary glands, which underlies a variety of pathological processes. Under the influence of hormonal changes, the processes of physiological evolution and involution of the mammary glands are disrupted, and foci of pathological proliferation of the epithelium develop.

The influence of the functional activity of the thyroid gland on the luteinizing function of the pituitary gland is known. In a number of patients with mastopathy, a change in the state of the thyrotropic function of the pituitary gland can cause inhibition of the secretion of luteinizing hormone and disorders of the ovarian cycle, which contribute to the occurrence of pathological processes in the mammary glands. Functional and morphological changes in the liver may underlie changes in the mammary glands, since they disrupt estrogen inactivation.

The above data allow us to conclude that hyperplastic processes in the mammary gland can occur at very different hormonal levels. Both a high concentration of estrogens in the body, and a high concentration of progesterone with a lack of estrogen, and relative estrogenization with a lack of androgens and progesterone, and various disorders of the pituitary gland, as well as qualitative changes in the formation and metabolism of steroid hormones, a violation of functional rhythms in reproductive system.

Classification

Diffuse mastopathy:

Simple;

With moderate intraductal proliferation of the epithelium;

With moderately expressed atypia of an epithelium.

Nodular mastopathy:

With proliferation;

with proliferation and atypia.

Fibroadenoma of the breast:

Intracanalicular;

Pericanalicular;

Leaf-shaped (phylloidal);

Intraductal papilloma (bleeding mammary gland,
Mintz's disease).

Adenoma.

Clinical manifestations and diagnosis

Patients with dyshormonal breast hyperplasia have a causal relationship between mental and hormonal factors. Often women are drowsy during the day, and at night they suffer from insomnia, are hypochondriacal, prone to conflicts, irritable, complain of headaches, induration in the mammary gland; they are often troubled by pain, a feeling of fullness, swelling in the mammary glands, especially before menstruation.

Medical history

When collecting an anamnesis of the disease, it is necessary to trace the dynamics of the development of the disease from the moment of its first manifestations. From the anamnesis of the patient's life, the doctor should be aware of past and concomitant diseases (especially of the genital organs, liver, thyroid gland), gynecological and sexual history, social and living conditions of the patient, her character and temperament; the presence of signs of neurasthenia, hereditary diseases especially on the side of the father and mother.

Objective examination of the patient

On examination, attention should be paid to the development of the mammary glands, their symmetry, size, relative position of the nipples, their deformation, vascular pattern, skin color. Palpation should be carried out very carefully, starting from the upper inner quadrant of the breast and moving from the periphery to the nipple. Palpation of the mammary glands is carried out in several positions: in the supine position, standing and in the position on the right or left side with a hand placed under the head on the side of palpation. At the same time, attention is paid to soreness, temperature of the skin over the tumor, its contours, and mobility. It is necessary to check the discharge from the nipples, palpate the regional lymph nodes (see Fig. 44-3-44-6).