Laboratory markers of the inflammatory process
To objectively assess the severity of the patient's condition in the postpartum period, a comprehensive set of laboratory tests is used.
- Complete blood count: reflects a systemic inflammatory response. It is characterized by a significant acceleration of the erythrocyte sedimentation rate (ESR reaches 50 mm/h) and pronounced leukocytosis (up to $20 \times 10^9$/L). An important diagnostic sign is a left shift in the leukocyte differential, which is manifested by the appearance of band neutrophils.
- Urinalysis: allows for the detection of signs of toxic effects on the kidneys. Protein (proteinuria) and red blood cells (hematuria) are determined in the sediment. The appearance of hyaline and granular casts is also diagnosed.
- Bacteriological examination of breast milk: is performed to select adequate etiotropic antibacterial therapy. A key diagnostic criterion for the development of mastitis is the detection of pathogenic bacteria in milk at a concentration exceeding $5 \times 10^2$ colony-forming units (CFU) per 1 milliliter.
Ultrasound examination (US)
Ultrasound examination plays a crucial role in establishing an accurate diagnosis and allows for the clear differentiation of the stages of the inflammatory process. The sonographic picture directly depends on the form of the disease:
- Serous stage: ultrasound visualizes a general blurring of the structural pattern of the tissues, accompanied by signs of milk stasis (lactostasis).
- Initial infiltrative stage: characterized by the appearance of areas with a homogeneous echostructure. A pronounced zone of inflammation is determined around these areas, and lactostasis persists.
- Purulent stage: the sonographic picture acquires a specific "honeycomb" appearance. Expanded milk ducts and alveoli are visualized, densely surrounded by a zone of inflammatory infiltration.
- Abscess formation: a pathological cavity is clearly defined on the monitor. Its distinctive features are irregular contours and the presence of internal septa. The cavity is surrounded by a pronounced zone of infiltration.
Principles of medical and surgical treatment
Therapeutic tactics must be strictly comprehensive and depend on the stage of the pathological process. Serous and infiltrative forms are subject to conservative management, whereas purulent forms require immediate surgical intervention.
- Surgical treatment: begins in purulent forms and consists of a wide opening of the focus using a radial incision. The surgeon bluntly destroys the connective tissue septa between the affected lobules, completely evacuates the purulent contents, and excises necrotic tissues. The operation concludes with mandatory drainage placement.
- Antibacterial therapy: broad-spectrum antibiotics form the basis. If the presence of anaerobic pathogens is confirmed, the drugs of choice are lincomycin, clindamycin, gentamicin, rifampicin, and metronidazole.
- Concomitant pharmacotherapy: infusion therapy with crystalloid solutions is performed to combat intoxication in purulent forms. Antihistamines are prescribed as desensitizing treatment. Additionally, immunotherapy with immunity-boosting agents is used.
Physiotherapy and lactation management
Physical treatment methods are applied in a strictly differentiated manner. For serous inflammation, decimeter- or centimeter-wave microwaves, ultrasound therapy, and ultraviolet irradiation (UVI) are prescribed. When transitioning to the infiltrative stage, the same physical factors are used, however, the thermal load on the tissues is increased.
Lactation management: Upon successful relief of inflammatory clinical symptoms, breastfeeding may be resumed. However, in non-purulent forms, medical cessation of milk production using bromocriptine or cabergoline may be required.
There are strict indications for the complete cessation of lactation in patients with a severe and resistant course of the disease:
- Rapid transition of the serous stage to the infiltrative stage (within 1–3 days), despite ongoing active complex therapy.
- Tendency to form new purulent foci after surgical intervention has already been performed.
- Indolent purulent process demonstrating treatment resistance in the postoperative period.
- Development of extremely severe forms: phlegmonous or gangrenous.
- Presence of concomitant infectious diseases of other organs and body systems.
Briefly: answers to topical questions
What changes in the complete blood count are characteristic of a postpartum ulcer?
In the complete blood count: ESR reaches 50 mm/h, leukocytosis is 20 × 10^9/L, and a left shift of the leukocyte differential with the appearance of band neutrophils is noted.
What is detected in the urinalysis in postpartum ulcer?
Urinalysis reveals protein (proteinuria), red blood cells (hematuria), hyaline and granular casts.
What bacteriological criterion is used to diagnose mastitis?
To diagnose mastitis, a quantitative assessment of the bacterial contamination of breast milk is used. The diagnostic criterion for the disease is the presence of bacteria in milk in an amount of more than $5 \times 10^2$ CFU (colony-forming units) per 1 ml. This bacteriological study is carried out for the purpose of subsequent prescription of etiotropic antibacterial therapy.
What are the sonographic signs of the serous stage of inflammation on ultrasound?
In serous mastitis, ultrasound reveals blurring of the pattern and lactostasis.
What does the purulent stage of inflammation look like according to ultrasound data?
In purulent mastitis, ultrasound reveals expanded ducts and alveoli surrounded by a zone of infiltration; a "honeycomb" pattern is determined.
What are the distinctive features of the abscess form on ultrasound?
In the abscess form, ultrasound visualizes a cavity with irregular edges and septa, surrounded by a zone of infiltration.
Which antibiotics are used when anaerobic flora is confirmed?
If the presence of anaerobic microflora is confirmed as part of complex antibacterial therapy, broad-spectrum drugs are prescribed. The etiotropic treatment regimen includes the following antibiotics:
- Lincomycin
- Clindamycin
- Gentamicin
- Rifampicin
- Metronidazole
What drugs are used for the medical cessation of milk production?
Bromocriptine or cabergoline are used for the medical cessation of lactation in non-purulent mastitis.
What are the strict indications for complete cessation of lactation?
Strict indications for complete cessation of lactation in patients with severe and resistant mastitis are:
- Transition of the serous stage to the infiltrative stage within 1–3 days against the background of active treatment.
- Tendency to form new purulent foci after surgery.
- Indolent, therapy-resistant purulent mastitis after surgical intervention.
- Phlegmonous and gangrenous forms of mastitis.
- Development of mastitis against the background of infectious diseases of other organs and systems.
How is surgical intervention performed for purulent forms?
In purulent forms, a wide opening of the purulent focus is performed using a radial incision. The septa between the affected lobules are bluntly destroyed, pus is evacuated, necrotic tissues are removed, and a drain is inserted.
For quick memorization of inflammation stages on ultrasound, use the mnemonic SIGA: Serous (shadowing/blurring), Infiltrative (homogeneous areas), purulent (Gnoinaya — "honeycomb" pattern), Abscessing (cavity with septa).
Class and exam questions
What changes in the complete urinalysis are characteristic of this condition?
Protein (proteinuria) and red blood cells (hematuria) are detected in the urine. The appearance of hyaline and granular casts is also a diagnostic sign.
What does the surgical treatment of purulent forms involve?
A wide opening of the purulent focus is performed using a radial incision. The surgeon bluntly breaks down the septa between the lobules, evacuates pus, removes necrotic tissue, and inserts a drain.
Which antibiotics are prescribed when anaerobic flora is detected?
In such cases, broad-spectrum drugs are indicated: metronidazole, lincomycin, clindamycin, gentamicin, or rifampicin.
When is it necessary to completely stop lactation?
Lactation is suppressed in severe cases: rapid transition to infiltration (within 1–3 days), appearance of new abscesses, phlegmonous and gangrenous forms, as well as concurrent infections of other organs.
What else to study on this topic
- Mechanism of action of bromocriptine and cabergoline in lactation suppression
- Technique for performing a radial incision on the breast
- Differential diagnostics of serous and infiltrative stages by ultrasound
- Features of infusion therapy with crystalloids in purulent processes
- Effect of physical therapy (microwaves, UV, ultrasound) on breast tissue
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