Etiology and risk factors
The development of the infectious process is most often triggered by trauma and damage to the integrity of the soft tissues of the birth canal sustained during labor, as well as the physiological decrease in immunity during pregnancy. An important role in epidemiology is played by the uncontrolled use of antibacterial drugs: it leads to the mutation of microflora, causing initially non-pathogenic microorganisms to acquire aggressive properties and provoke inflammation.
Among the pathogens, staphylococci, streptococci, enterococci, Escherichia coli, and anaerobes are in the lead. At the same time, doctors are increasingly facing mixed infections and noting a steady increase in the importance of anaerobic non-spore-forming bacteria in the development of postpartum pathologies.
Classification of diseases
Depending on the scale of the lesion and the involvement of body systems, postpartum infections are divided into two large groups:
- Localized forms: inflammation is limited to a specific focus. These include postpartum mastitis, endomyometritis, as well as wound suppuration (on the perineum or after cesarean section).
- Generalized forms: systemic spread of infection, threatening life. Includes obstetric peritonitis, sepsis, and septic shock.
Lactostasis as a precursor to mastitis
Lactostasis is a delay in the outflow and secretion of milk. Patients complain of uniform engorgement and soreness of the mammary glands, body temperature may rise to 38 °C and above. The key difference from a full-blown infection is that the woman's general well-being is practically unaffected.
The main task in lactostasis is to establish adequate emptying of the glands and restore milk outflow. The following measures are used for this:
- Correcting the breastfeeding technique.
- Using a breast pump for expression after feeding.
- Temporarily restricting fluid intake to reduce milk secretion.
If non-medication methods fail, drugs are prescribed to suppress lactation: bromocriptine (2.5 mg 2 times a day) or cabergoline (250 mcg 2 times a day for 2 days).
Postpartum mastitis: pathogenesis and forms
Mastitis is inflammation of the breast tissue against the background of lactation. The entry gate for the infection is most often nipple cracks, which appear on the 2nd–3rd day after childbirth. The infection penetrates via galactogenic, lymphogenic, or hematogenous routes.
Pathogenesis develops rapidly: due to severe pain during feeding, the woman refuses to apply the baby to the breast and express milk. Lactostasis occurs, and ideal conditions for bacteria multiplication are created in the stagnant milk. The abundance of adipose tissue, a wide network of ducts, and lymphatic pathways contribute to the rapid progression of inflammation.
Clinically, mastitis manifests with an acute onset: temperature shoots up to 38–40 °C, chills, weakness, headache, and poor appetite appear. Locally, the gland turns red, increases in size, and is sharply painful. A complete blood count (CBC) records leukocytosis, neutrophilia, accelerated ESR, and often a decrease in hemoglobin and erythrocyte levels.
The following forms of mastitis are distinguished:
- Serous: palpation determines diffuse tissue edema due to the accumulation of inflammatory exudate.
- Infiltrative: against the background of edema, a dense focus (infiltrate) appears without clear boundaries and areas of softening.
- Infiltrative-purulent: the infiltrate begins to soften, the edema over the focus increases.
- Abscessing: formation of a purulent cavity, sharply painful infiltrate. A positive fluctuation sign is characteristic. The lesion extends beyond one quadrant.
- Phlegmonous: captures 3–4 quadrants. The skin is cyanotic, sharply hyperemic and taut, the "peau d'orange" sign is possible over the infiltrate.
- Gangrenous: total involvement of all quadrants with skin necrosis and purulent melting of the underlying tissues.
Briefly: answers to topical questions
What are the clinical forms of postpartum endomyometritis?
Clinical forms of postpartum endometritis are classified according to the course features, manifestations, and the nature of delivery.
- According to the clinical course — mild form, moderate form, severe form.
- According to the features of clinical manifestations — classical form, erased form.
- According to the nature of delivery — endometritis after spontaneous delivery and after cesarean section.
What are the indications for surgical treatment of lactational mastitis?
Indications for surgical treatment of lactational mastitis are the development of purulent forms of the disease and the inefficiency of conservative measures. The following indications for surgery are distinguished:
- Purulent forms — require mandatory surgical intervention (opening and sanitation of the abscess).
- Lack of effect — inefficiency of the applied minimally invasive treatment methods.
- Relapse — repeated development of the inflammatory disease.
Which antibiotic groups are used for empirical therapy of postpartum mastitis?
Broad-spectrum antibiotics are used for antibacterial therapy of postpartum mastitis. The following groups of drugs are used:
- Penicillins — semisynthetic penicillin preparations.
- Aminoglycosides.
- Cephalosporins.
- Macrolides.
- Sulfonamides — in combination with antibiotics.
For anaerobic pathogens, lincomycin, clindamycin, gentamicin, and rifampicin are used.
To memorize the forms of mastitis in order of severity, use the phrase: Today Intern Says Exclusively Absolute Facts Loudly (Serous, Infiltrative, Purulent, Infiltrative-purulent, Abscessing, Phlegmonous, Gangrenous).
Class and exam questions
How does lactostasis differ from mastitis?
With lactostasis, temperature rises and glands engorge, but the woman's general well-being remains normal. With mastitis, pronounced intoxication, chills, weakness, and local tissue changes join in.
Can breastfeeding be continued while taking antibiotics?
Yes, if broad-spectrum penicillin drugs are prescribed for treatment, breastfeeding can be continued.
Why does lactational mastitis progress so rapidly?
This is facilitated by the anatomical features of the mammary gland: an abundance of adipose tissue, the presence of cavities, as well as a wide network of ducts and lymphatic pathways through which the infection easily spreads.
What else to study on this topic
- Endomyometritis: clinical picture and diagnostic methods
- Suppuration of perineal wounds and cesarean section suture
- Obstetric peritonitis: stages and management tactics
- Sepsis and septic shock in obstetrics
- Surgical treatment of destructive forms of mastitis
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