Acute Issues of Lactation Mastitis Therapy

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IntroductionThe relevance of one of the most common complications of the postpartum period - lactation mastitis, is difficult to overestimate both because of the high (up to 10%) frequency of development in women in labor, and the factor that causes premature termination of breastfeeding [1]. In the structure of postpartum purulent-inflammatory complications, the frequency of lactation mastitis may vary within 26-67% of cases. The outcome of lactation mastitis is favorable in most cases, but in 7-11% of clinical cases, a lactation abscess is formed, less often-phlegmonous (1-2% of cases) and extremely rarely gangrenous forms (0.7%) of lactation mastitis.Risk factors for the development of lactation mastitis currently include cracked nipples, soft tissue injuries of the breast, abrupt termination of breastfeeding, postpartum complications, the first birth, the presence of concomitant diseases. Until now, in the treatment of patients with lactation abscess, the tactics of performing wide incisions and completing lactation by medication have been adopted. Performing incisions on the mammary gland is associated with a long healing period, the need to perform regular dressings, pain syndrome, difficulties with breastfeeding and unsatisfactory cosmetic results [2].Foreign publications often contain information that the treatment of lactation purulent mastitis with the formation of an abscess is possible in a minimally invasive way - by puncture or drainage of the abscess under ultrasound navigation (mainly with small abscesses, up to 6 cm) [3, 4].The current trend towards the treatment of lactation breast abscess also includes outpatient monitoring by medical specialists (surgeon, mammologist, ultrasound doctor), effective emptying of the breast, the appointment of non-steroidal anti-inflammatory drugs( NSAIDs), the preservation of breastfeeding, [3, 4].The purpose of our work: to form a modern approach to the complex treatment of purulent lactation mastitis.Materials and methodsWe have experience in treating 64 breast abscesses with minimally invasive methods, which were a complication of lactation mastitis in the period 2018-2020. All patients were on outpatient treatment. The average age of the patients was 24.9±4.5 years (from 23 to 44 years). The termination of breastfeeding was carried out only if the mother wanted to complete lactation (only 4 cases). The remaining patients retained lactation.The diagnosis of a breast abscess was established on the basis of examination, local manifestations (compaction in the breast, soreness, redness of the skin, in some cases fluctuation, fever), as well as according to ultrasound examination of the mammary glands (performed in all cases) and puncture (in all cases, pus was obtained with its subsequent bacteriological study).One of the etiological reasons for the development of lactation abscess was galactocele (milk retention cyst). Signs of purulent galactocele are marked by painful formation, hyperemia of the skin with a superficial location, clearer and smoother contours during ultrasound, a level with sediment on ultrasound in the galactocele cavity, often a long history of the disease, the development is more common in women with mature lactation.All surgical interventions for breast abscesses of lactation etiology were performed under local infiltration anesthesia (with a solution of 2% lidocaine or ultracaine).The frequency of abscess formation differed significantly depending on the timing of lactation. In 41% of cases, breast abscesses occurred during lactation up to 1 month, in 34% of patients-the lactation period was in the range from 1 to 3 months. In 16% of clinical cases, an abscess formed during lactation from 3 to 7 months, 7% at a period of 7 to 18 months.The lactation abscess was punctured with a thick needle (18 g “pink"), at the greatest distance from the areola, after pumping /feeding, after the puncture, the abscess cavity was washed with an antiseptic and the appointment of antibiotics compatible with breastfeeding. In all cases, bacteriological sowing and control examination were carried out after 1-2 days.When draining a breast abscess, “passive drainage”was used under the influence of gravity (drainage is installed in the lower part of the abscess), washing the drainage with the size of an antiseptic in order to prevent its obstruction. Drainage of the abscess cavity was carried out for 3-7 days, drainage was fixed to the skin with a single suture.During the formation of lactation abscesses, up to 3-4 cm in size, 18 patients underwent puncture of breast abscesses with aspiration of purulent contents and washing of the abscess cavity with an antiseptic solution (group 1). In 6 cases, the puncture was performed once, 2 punctures were performed in 8 patients, 3 or more punctures were performed in 4 patients to achieve the rehabilitation of the abscess.46 patients with breast abscesses due to purulent lactation mastitis underwent drainage of abscesses with drains of different diameters (group 2). No vacuum aspiration systems were used. The sizes of abscesses in this group of patients were from 4 to 7 cm in the largest dimension. Drainage was established under ultrasound control according to the Seldinger method in 22 cases and in 24 cases with a clamp followed by a PCV catheter through the resulting wound channel. After the drainage was installed, the abscess cavity was washed with an antiseptic solution. The drainage was attached to the skin with a separate seam. Drainage was extended by a plastic container, 1-2 times a day, drainage was washed with an antiseptic solution to prevent occlusion by pus and blood clots.The average drainage time was from 3 to 7 days. Drainage was removed in the case when the abscess cavity ceased to be visualized by ultrasound or decreased to 1-2 cm and breast milk without pathological impurities was separated by drainage. Breastfeeding was encouraged for all patients.Empirically, all patients were prescribed antibiotic therapy. In 4 cases, the patients categorically refused to use antibacterial drugs. With severe pain and fever, patients used non-steroidal anti-inflammatory drugs for 1-2 days. Also, all patients were prescribed probiotic therapy.All patients were trained in the methods of properly organized breastfeeding and the prevention of further stagnation and mastitis. Feeding from the affected breast was recommended 24 hours after the drainage operation, during this period, the emptying of the breast was carried out by pumping (using a breast pump and/or manually). An adequate drinking regime (without limiting the volume of liquid) and adequate rest were also recommended.The blood test was performed 1-2 days after the surgical treatment. Ultrasound of the mammary glands was performed every 2-3 days for a week, followed by monitoring 7 days after drainage removal.The pain scale was evaluated using the numerical NRS rating scale on the day of surgery, 1, 3 and 7 days after surgery (where 0 is the absence of pain, and 10 is the highest severity of pain).Satisfaction with the cosmetic result was assessed by phone 8 weeks after the operation. The distribution of the score is made as follows: 0 - for an unsatisfactory result, 1 - for a moderately satisfactory result, 2 - for a satisfactory result and 3 for expressed satisfaction.The duration of breastfeeding was studied at 3 days, 3 weeks and 12 weeks after surgery by phone or at an outpatient appointment.Statistical processing of the results of the study was carried out using the programs "Microsoft Excel", "Statistica 6.0". The required sample size was calculated using the Lopez-Jimenez F formula. Statistical characteristics of the studied parameters and a test for the normality of the distribution (Kolmogorov-Smirnov criteria, Shapiro-Wilk W-test) are determined. The differences between the groups were also determined using nonparametric methods (the Mann-Whitney test).Results and discussion75% of the patients were 2-6 weeks after delivery at the time of diagnosis. In 23% of cases, cracks of the nipples on the side of the affected breast were verified. In 86% of patients before the occurrence of the abscess, lactostasis of the affected breast was previously formed before the appearance of mastitis symptoms. The duration of symptoms (thickening, pain, fever, hyperemia of the skin) was 3-4 days. The presence of infiltration persisted for an average of 9.8±7.8 days. During the initial examination, only 16% of patients had fever. In 64 cases, abscesses were unilateral (in the right breast 61%, in the left 38%), in 2 cases, abscesses were in both mammary glands. The average diameter of abscesses in the first group (puncture only) was 24±8 mm, in the second group 53±9 mm.On average, 5 ml of pus was obtained during aspiration in 1 group and 24 ml of pus in the second group. All operations were performed under local anesthesia. There was no postoperative bleeding, hematoma or wound infection in any case.The average assessment of the severity of the pain syndrome was 4.4±1.2 points on the day of surgery, 1 day after surgery, the intensity of the pain syndrome was 2.3±0.8, on the 3rd day after surgery – 1.3±0.5. The average time of hyperthermia was 1.8±0.8 days, the average time of skin hyperemia was 1.3±0.6 days. The average duration of antibiotic therapy was 5.8±1.3 days.The results of a bacteriological study did not reveal any growth of pathological microflora in 11% of cases. In other cases, Staphylococcus aureus was verified (72%), in several cases, epidermal streptococcus was detected (17%).

The average duration of drainage was 4.4±1.2 days, only in 4 patients the duration of drainage was more than 7 days. In 2 cases, drainage migration was noted, which required repeated surgical intervention. In 2 more cases, with an hourglass-shaped abscess, it was necessary to install 2 drains to create a flushing flow drainage. All patients were interviewed by phone or on an outpatient basis 1 week, 3 weeks and 2 weeks after surgery to assess the presence of a relapse of the disease, wound healing, duration of breastfeeding, as well as to assess the cosmetic factor. None of the patients had a relapse of the disease or the formation of a chronic fistula within 2 months after the operation. All incisions healed within 1 week after drainage removal, no cases of wound infection were observed. The average score of satisfaction with the cosmetic result was 3.0±0.2, no negative assessment of satisfaction with the cosmetic result was obtained.Breastfeeding continued in 87.5% of patients after 3 days, in 84.3% - after 4 weeks and in 78.1% after 8 weeks after surgery. Two patients stopped breastfeeding due to the fact that mastitis occurred against the background of the completion of breastfeeding. 4 patients stopped breastfeeding due to the presence of concomitant pathology and fatigue. In other cases, the patients continued breastfeeding.ConclusionThe algorithm for the treatment of lactation mastitis is shown in Figure 1.Figure 1. Algorithm of lactation mastitis treatment in urgent surgeryFigure 1. Algorithm of lactation mastitis treatment in urgent surgery

Lactostasis and lactation mastitis are the main causes of breast abscesses. The presence of cracked nipples is also one of the risk factors for complicated mastitis. With the development of lactation mastitis, outpatient treatment is preferable (including with breast abscesses).The diagnosis of "lactation mastitis" requires continued breastfeeding. The presence of an infectious agent in the milk culture does not indicate the presence of purulent mastitis.Minimally invasive surgical techniques in the treatment of breast abscesses (punctures and drainage of the subcutaneous navigation) are the operation of choice. The optimal treatment of lactation mastitis complicated by a breast abscess, in addition to surgical treatment, includes effective emptying of the breast, the appointment of antibacterial drugs, non-steroidal anti-inflammatory drugs.

About the authors

Olga Igorevna Yakovenko

North-Western State Medical University named after I. I. Mechnikov

Email: Olga.Yakovenko@szgmu.ru

Ph.D., Assistant of the Department of Surgery named after N. D. Monastyrsky

Russian Federation, Saint Petersburg, Russian Federation

Vladimir Pavlovich Akimov

North-Western State Medical University named after I. I. Mechnikov

Email: Vladimir.Akimov@szgmu.ru

M.D., Professor, Head of the Department of Surgery named after N. D. Monastyrsky

Russian Federation, Saint Petersburg, Russian Federation

Alexandr Nikolaevich Tkachenko

North-Western State Medical University named after I. I. Mechnikov

Author for correspondence.
Email: altkachenko@mail.ru

M.D., Professor of the Department of Traumatology and Orthopedics

Russian Federation, Saint Petersburg, Russian Federation

Taras Vasilievich yakovenko

North-Western State Medical University named after I. I. Mechnikov

Email: Taras.Yakovenko@szgmu.ru

Ph.D., Associate Professor of the Department of Hospital Surgery

Russian Federation, Saint Petersburg, Russian Federation

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