Gestational gigantomastia in the early postpartum period presenting with severe refractory pain: a case report

Abstract

Introduction:

Gestational gigantomastia (GG) is a rare, benign breast disorder characterized by rapid, excessive, and disproportionate breast enlargement during pregnancy. Affected patients may develop severe breast pain, skin breakdown, secondary infection, and musculoskeletal complications, resulting in significant functional impairment and psychosocial distress.

Case presentation:

We report the case of a 24-year-old woman (G2P1A1) who presented on the second postpartum day with a 5-month history of rapidly progressive bilateral breast enlargement and severe, disabling breast pain of 2 days’ duration. Despite treatment with bromocriptine and multimodal analgesia, her pain remained refractory, necessitating emergent bilateral simple mastectomy. Histopathological examination confirmed GG, and the patient had an uneventful postoperative recovery.

Discussion:

GG is an uncommon clinical entity, with an estimated incidence ranging from 1 in 28 000 to 1 in 100 000 pregnancies. Although hormonal hypersensitivity is presumed to play a role, its etiology remains poorly understood. Medical management is generally recommended as first-line therapy; however, complete regression is uncommon, and the clinical response is often limited. Consequently, surgical management remains the definitive treatment option in many cases, particularly when complications arise or conservative therapy fails.

Conclusion:

Early postpartum GG with severe refractory pain requiring emergent bilateral mastectomy is exceedingly rare. Bilateral mastectomy with planned reconstruction may be an appropriate definitive treatment option when conservative measures fail, particularly for patients wishing to reduce the risk of recurrence during future pregnancies. Furthermore, this approach avoids the potential risk of life-threatening hemorrhage associated with the alternative surgical option of reduction mammoplasty.

Introduction

Gigantomastia is a rare condition characterized by excessive enlargement of one or both breasts, causing weight-bearing difficulties, skin stretching, and ulceration in otherwise non-obese women^[1–3^]. Although no universally accepted quantitative definition exists, it is generally defined as enlargement exceeding 3% of body weight or requiring excision of more than 1500–2500 g of breast tissue^[2,4^].

HIGHLIGHTS

• Gigantomastia, also referred to as macromastia, is a rare clinical condition characterized by rapid and excessive enlargement of one or both breasts.

• Gestational gigantomastia (GG) is a distinct subtype in which disproportionate breast enlargement occurs during pregnancy.

• It is extremely rare, occurring in approximately 1 in 28 000 to 1 in 100 000 pregnancies worldwide.

• Patients with GG may present with breast pain, ulceration, infection, and shoulder or back pain, causing postural instability along with significant psychosocial disability.

• Early postpartum GG with severe refractory pain requiring emergent bilateral mastectomy is exceedingly rare.

• Complete spontaneous resolution of GG is uncommon, and surgical intervention remains the mainstay and the most effective form of management.

Gigantomastia has been described since the 17th century as hypertrophy of the mammae, with pregnancy-associated cases later recognized as a distinct entity and termed gestational gigantomastia (GG)^[5–9^]. The first report was by Palmuth in 1648[6]. GG involves disproportionate breast enlargement during pregnancy, with an estimated incidence of 1 in 28 000 to 1 in 100 000 pregnancies^[1,4,10^]. Its etiology remains unclear, although hormonal variations and tissue hypersensitivity are implicated^[5,11,12^].

Patients may present with breast pain, ulceration, infection, and shoulder or back pain, causing postural instability and psychosocial distress^[10,12^]. Diagnosis requires evaluation to exclude other causes of breast enlargement[3]. We present a 24-year-old G2P1A1 woman with progressive bilateral breast enlargement and severe, refractory pain on postpartum day 2, requiring emergency bilateral mastectomy and highlighting the rare early postpartum presentation of GG.

This report follows the SCARE 2025 guidelines[13].

Case presentation

A 24-year-old woman, gravida 2 para 1 with one previous spontaneous abortion (G2P1A1), presented to our medical and surgical center on postpartum day 2 after a spontaneous vaginal delivery of a live male neonate at 38 weeks and 1 day on 6 October 2025.

She reported progressive bilateral breast enlargement beginning at approximately 16 weeks’ gestation and continuing throughout her pregnancy. On presentation, she had severe bilateral breast pain for 2 days, radiating to both shoulders and significantly limiting mobility; she arrived in a wheelchair because of the severity of her discomfort. The patient and her family initially considered the enlargement physiologic, and reassurance from her attending obstetrician contributed to delayed evaluation.

Her history included progesterone therapy during the first trimester for a threatened miscarriage following a previous spontaneous abortion. Her breasts had been normal before the current condition, and she denied a family history of similar breast pathology. Breastfeeding was not possible because severe pain and enlargement prevented adequate neonatal grasping.

She was tachycardic at 112 beats per minute, with otherwise normal vital signs. Both breasts were markedly enlarged, with tense, shiny, stretched, diffusely thickened skin, and minimal erythema around the nipple–areolar complex. They were firm and diffusely tender, without discrete palpable masses (Fig. 1).

Figure 1.

A 24-year-old female patient with massively enlarged breasts bilaterally (supine position).

Laboratory investigations showed WBC 9.6 × 10³/µL, hemoglobin 9.3 g/dL, platelets 233 × 10³/µL, and a normal prolactin level (32.3 ng/mL). Ultrasonography demonstrated diffuse, heterogeneous parenchyma; a few dilated periareolar vessels and ducts; and skin thickening, without a discrete mass, abscess, nipple retraction, or architectural distortion. Although core needle biopsy is an important component of triple assessment and may guide the extent of surgery, it was deferred because the clinical and imaging findings strongly supported GG, and severe, refractory pain with progressive enlargement required urgent intervention.

A provisional diagnosis of GG was made, and bromocriptine and analgesics were initiated. She returned the same day with worsening pain and was admitted for multimodal analgesia with paracetamol, nonsteroidal anti-inflammatory drugs, and opioids; however, her pain progressed. Following discussion of treatment options, the patient and her family elected an emergency bilateral mastectomy with planned future reconstruction. Bilateral simple mastectomy was performed under general anesthesia (Fig. 2) after skin preparation with alcohol and povidone–iodine, and administration of prophylactic antibiotics 30 minutes before incision. Bilateral elliptical incisions were used, and the procedure lasted approximately 3 hours with an estimated blood loss. Marked breast hypervascularity caused significant bleeding, requiring meticulous hemostasis, and bilateral chest-wall drains were placed. Simple mastectomy was chosen over reduction mammoplasty because it provided definitive removal of hypertrophic tissue while avoiding extensive parenchymal dissection and the preservation of highly vascularized breast tissue, thereby reducing hemorrhagic risk. The approach was also preferred by the patient and her family after counseling and allowed the preservation of viable skin flaps for planned reconstruction; no postoperative flap necrosis occurred.

Figure 2.

Gross appearance of the mastectomy specimens. The left breast (L) measures 30 × 20 × 12 cm and weighs 3 kg, while the right breast (R) measures 22 × 12 × 12 cm and weighs 2.5 kg.

Histopathology confirmed GG (Fig. 3). Postoperatively, mild-to-moderate wound pain was managed with intravenous morphine and paracetamol, and two units of cross-matched blood were transfused. Recovery was uneventful, and she was discharged on postoperative day 3. At the 1-, 2-, 6-, and 9-month follow-ups, she remained clinically stable with satisfactory recovery and received counseling on psychosocial support and future breast reconstruction (Table 1).

Figure 3.

Low-power view (4× magnification) of H&E-stained tissue showing a markedly expanded lobular unit with glandular proliferation and stromal collagen deposition (a and b). High-power view (40× magnification) of H&E-stained tissue showing tubules and glandular structures lined by benign epithelial and myoepithelial cells (black arrow), with focal apocrine metaplasia. The glands demonstrate intact basement membranes and intraluminal secretory material, consistent with milk (red arrow). The intervening stroma shows fibroblastic proliferation, focal edema, and collagen deposition (c and d).

Table 1.

Chronological timeline of the patient’s clinical course.

No.	Time point	Clinical event
1	Approximately 16 weeks of gestation	Progressive bilateral breast enlargement began.
2	Second trimester	Breast enlargement continued to progress. The patient and her family initially considered the changes to be normal pregnancy-related breast enlargement.
3	Third trimester	Progressive breast enlargement continued, with increasing breast-related symptoms.
4	Delivery date (6 October 2025)	Spontaneous vaginal delivery at 38 weeks and 1 day of gestation. A live male neonate was delivered.
5	Postpartum day 1	Severe bilateral breast pain significantly worsened.
6	Postpartum day 2 (8 October 2025)	Presented to our medical and surgical center with severe refractory bilateral breast pain and massive bilateral breast enlargement. Baseline clinical and diagnostic evaluation was performed. Bromocriptine 10 mg orally once daily was initiated. Because of persistent severe pain, the patient subsequently returned to the emergency department and was started on multimodal analgesia. After 8 hours of conservative management with multiple analgesics, the patient remained unable to tolerate the pain, and alternative treatment options were discussed. The patient opted for surgical management, and emergent bilateral mastectomy was performed.
7	Immediate postoperative period	The patient was transferred to the intensive care unit and received 2 units of blood. On postoperative day 1, she was transferred to the ward. The drains were removed on postoperative day 3, and she was discharged with follow-up scheduled after 1 week.
8	First postoperative follow-up (1 week)	The wound was clean and healing well with complete resolution of her pain. The biopsy results were discussed with the patient and her family.
9	Second postoperative follow-up (1 month)	The patient demonstrated an uncomplicated recovery. Psychological support and counseling were provided, and she was referred for further psychiatric and psychological rehabilitation as appropriate.
10	Third postoperative follow-up (6 months)	The patient and her family reported satisfactory psychological recovery. Breast reconstruction options were discussed.
11	Fourth follow-up (9 months postoperatively)	The patient had recovered well, reported improved psychological well-being, and had resumed her daily activities. The patient was also counseled regarding the implications of bilateral mastectomy for future lactation and the potential risk of recurrence during future pregnancies. Discussed the importance of appropriate antenatal follow-up and early evaluation of any recurrent breast enlargement or related symptoms.

Discussion

Gigantomastia is a rare condition characterized by rapid, massive enlargement of one or both breasts, potentially causing significant asymmetry^[1,2,10^]. Although no universally accepted quantitative definition exists, it is generally characterized by enlargement exceeding 3% of total body weight or requiring the removal of more than 1500–2500 g of breast tissue^[2,4^]. GG is a pregnancy-associated subtype; other forms include juvenile, drug-induced, and idiopathic gigantomastia^[1,10^]. Its prevalence is estimated to be between 1 in 28 000 and 1 in 100 000 pregnancies^[5,7,10^].

The etiology and pathophysiology of GG remain incompletely understood, with estrogen or prolactin activity and hormonal hypersensitivity implicated^[2,3,12^]. Onset typically occurs in the first or second trimester and is rarely reported postpartum[10]. This may reflect pregnancy-associated hormonal changes and their rapid postpartum decline^[5,6,9^]. Our patient’s second-day postpartum presentation may suggest breast-tissue hypersensitivity rather than absolute hormone levels. Reported risk factors include Caucasian ethnicity, previous GG, multiparity, and autoimmune disorders^[3,4,10^]. Although her hormonal profile was normal, she had received progesterone during the first trimester for threatened abortion following a previous miscarriage. Delayed recognition may occur because of the rarity of GG, as in our patient, who was initially reassured that the enlargement represented normal pregnancy-related changes[4].

Clinical manifestations include rapid unilateral or bilateral enlargement, pain, prominent nipple–areolar complexes, skin ulceration, infection, shoulder or back pain, and psychological distress^[1,4,7,9,12,14^]. Emergency bilateral mastectomy is generally reserved for advanced complications such as ulceration, infection, or necrosis^[1,4^]. In our patient, severe refractory pain despite multimodal analgesia necessitated emergency bilateral mastectomy, suggesting that refractory pain alone may justify definitive surgery in selected patients.

Ultrasonography is the preferred breast-imaging modality during pregnancy, and reported findings include heterogeneous parenchymal echotexture, glandular hypertrophy, prominent ducts, and cystic changes, consistent with our patient’s imaging[15]. Histopathologically, GG typically demonstrates abundant stroma, stromal fibrosis, glandular hyperplasia, and lymphocytic infiltration^[2,5^]. Histopathology demonstrated characteristic glandular and stromal proliferation without atypia or malignancy, consistent with GG. Immunohistochemistry was not performed because the histomorphology was characteristic (Fig. 3).

Diagnosis requires the exclusion of fibroadenoma, phyllodes tumor, fibrocystic changes, infectious mastitis, and malignant neoplasms, particularly inflammatory breast cancer^[2,10,15^]. In our patient, inflammatory breast carcinoma was considered unlikely because of bilateral symmetric enlargement, its temporal relationship with pregnancy, and the absence of a discrete mass, nipple retraction, or architectural distortion. Giant fibroadenoma and phyllodes tumor were similarly unlikely because imaging demonstrated diffuse bilateral enlargement without a focal solid lesion, and infection was considered unlikely given the absence of fever, leukocytosis, or an abscess on ultrasonography. Given the characteristic clinical and imaging findings and the urgent need for intervention because of refractory pain, core needle biopsy was deferred because it was unlikely to alter immediate management; the diagnosis was subsequently confirmed histopathologically.

Because GG pathophysiology remains poorly understood, optimal management is debated^[7,16^]. Medical therapies include tamoxifen, danazol, progesterone, testosterone, and bromocriptine, although outcomes remain inconsistent^[2,7,17–19^]. Complete spontaneous resolution is uncommon^[2–4,20^]. Surgery is therefore the most effective definitive treatment, generally indicated for necrosis, ulceration, infection, or massive hemorrhage^[2,14,21^]. During pregnancy, surgery is usually deferred because of fetal risks, whereas immediate postpartum surgery may be considered for severe enlargement refractory to medical therapy^[2,7,15^].

The principal surgical options are reduction mammoplasty and bilateral mastectomy^[7,14^]. Reduction mammoplasty may provide better esthetics and preserve breastfeeding but has a substantial recurrence risk in subsequent pregnancies, approaching 100% in some reports^[2,4,5^]. Bilateral mastectomy with planned reconstruction is therefore favored in women desiring future pregnancies because it minimizes recurrence and may reduce hemorrhage from engorged, friable vessels^[2,3,10,14,18^]. In resource-limited settings such as Ethiopia, its definitive nature may further reduce the need for repeated interventions[22]. Skin-sparing mastectomy may be considered when preserving the skin envelope for reconstruction is desirable[3]. In our patient, simple bilateral mastectomy was chosen because of marked hypervascularity, hemorrhage risk, severe refractory pain, and the need for definitive treatment while preserving future reconstruction options.

Conclusion

To our knowledge, early postpartum GG presenting with severe refractory pain requiring emergency bilateral mastectomy is exceedingly rare. This case highlights that postpartum presentation with debilitating pain may warrant definitive surgery when conservative measures fail. Bilateral mastectomy with delayed reconstruction may reduce the risk of recurrence in future pregnancies and may avoid potentially life-threatening hemorrhage associated with reduction mammoplasty in selected patients.

Ethical approval

Ethical approval was not required because this manuscript is a case report. The institutional IRB has exempted it from the requirement for ethical approval.

Consent

Written informed consent was obtained for publication of the case and accompanying images; a copy is available upon request.

Sources of funding

No funding was received for this case report.

Author contributions

E.A.A.: Operated the patient, conceptualization, methodology, manuscript writing and submission, and followed the patient. T.A.D.: Diagnosed the case, operated the patient, followed the patient and involved in the conceptualization of the case, and reviewed the final manuscript. L.Y.: Diagnosed the patient, assisted in the manuscript writing, and edited the case report. Y.G.S.: Assisted in the histologic diagnosis of the case and prepared the histologic image of the case. E.M.N.: Reviewed the final manuscript and edited the case report.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Research registration unique identifying number (UIN)

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Guarantor

Eskinder Amare Assefa.

Provenance and peer review

Not applicable.

Data availability statement

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Use of AI-assisted technologies

During the preparation of this manuscript, the authors used Grammarly and other AI-assisted language editing.