Breast Hypertrophy with Pregnancy (Gigantomastia)

Massive hypertrophy of the breast with pregnancy is a rare condition of unknown cause. It is often referred to as gigantomastia of pregnancy.101 The first recorded report of this condition was made by Palmuth in 1648.102 Moss103 Has revealed that this condition may affect women of all races during the childbearing years but that Caucasian women are more likely to experience this phenomenon than African-American women.104 The disorder is less common than juvenile (virginal) hypertrophy of the breast, which classically progresses independent of pregnancy and occurs usually between the ages of 11 and 19 years. Gigantomastia of pregnancy usually occurs during the first few months of pregnancy and may progress to necrosis, incapacity, and possibly death.103 Bilateral breast gigantism is usually observed, although unilateral gigantomastia ofpregnancy

Has been reported.105

The typical history is that of a healthy pregnant woman who observes gradual bilateral massive enlargement of her breasts within the first few months of pregnancy. The breasts may enlarge to several times their normal weight and size to become grotesque, huge, and incapacitating. The skin and parenchyma become firm, edematous, and tense and may have prominent subcutaneous veins with a diffuse peau d'orange appearance. As a consequence of rapid breast enlargement and skin pressure, insufficient vascularity of the skin may initiate ulceration, necrosis, infection, or hemorrhage.

In the immediate postpartum period, the hypertrophied breasts recede to approximately their previous volume. With delivery of the fetus, the breasts regress in size but almost always hypertrophy again with succeeding pregnancies. Most authors agree that this condition is hormonal in etiology, but its precise mechanism is unclear. Swelstad and colleagues104 have proposed multiple inciting factors as possible causes for this problem, including hormonal abnormalities, tissue receptor sensitivity, malignancy, and autoimmune disorders. Whether there is an overproduction of mammotropic hormone from the pituitary or an enhanced sensitivity of breast parenchyma to the hormones of pregnancy (e. g., estriol, estradiol, human chorionic gonadotropin, progestins) has not been firmly established. Parham106 determined that estrogen and testosterone were of no value in the treatment of gigantism of pregnancy; however, norethindrone maybe of value.107 Hydrocortisone therapy has been attempted without success by Nolan108; testosterone has been used with divided results. Moss103 Used fluoxymesterone unsuccessfully, whereas diuretics have been successfully used but with moderate and temporary effect.

Luchsinger109 Was one of the first to suggest that this condition may occur as a consequence of specific individual reactivity of the breast to hormonal stimuli. This author questioned whether in addition to possible hormonal dysfunction, estrogenic placental hormones were sufficiently metabolized in the presence of insufficient liver function. Lewison and colleagues110 postulated that gigantism of pregnancy may be related to the depression of all steroid hormones and decreased liver function as measured by the salicylate conjugation test. These investigators advocated the use of the progestational agent norethindrone to reduce breast size; however, it was used with mestranol and had to be discontinued when thrombophlebitis occurred. Although liver dysfunction and the inability to metabolize estrogenic hormones have been postulated to be a possible cause for the disorder, it must be noted that many normal pregnancies are accompanied by severe liver failure without the development of gigantomastia. Bromocriptine is the most widely used medical treatment of this problem. It has shown variable results with arrested breast hypertrophy or mild breast size regression; the agent has an inability to return breast to pregestational size.104 Although the medical approach has variable results, it should be the first line of treatment in an effort to avoid surgical intervention during pregnancy.

In most instances, gigantomastia is self-limiting and does not progress to pyogenic abscesses, skin ulcerations, necrosis, or systemic illness. Breast size will spontaneously regress to its approximate nonpregnant configuration after delivery. The patient should be advised of proper brassiere support, good skin hygiene, and adequate nutrition. Operative intervention may be necessary to relieve severe pain, massive infection, necrosis, slough, and ulceration or hemorrhage if delivery is not imminent. The operative choices include bilateral reduction mammaplasty versus bilateral mastectomies with delayed reconstruction. Gigantomastia is likely to recur with reduction mamma-plasty in subsequent pregnancies. Bilateral mastectomies with delayed reconstruction offer the best chance of avoiding recurrence if the patient should become pregnant again. If there is any retained breast tissue, it is likely to hypertrophy with additional pregnancies.104

Scott-Conner and Schorr111 Reviewed in detail the diagnosis and management of breast problems during pregnancy and lactation. Furthermore, Howard and Gusterson112 reviewed the histology of normal physiologic states of the human breast, including prenatal, prepubertal, and pubertal development; adult resting gland; pregnancy; lactation; and postinvolution.

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