BREASTFEEDING MEDICINE Volume 9, Number 8, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2014.0052
Case Report
Rusty Pipe Syndrome, a Cause of Bloody Nipple Discharge: Case Report Joana Raquel Silva, Rita Carvalho, Catarina Maia, Marta Oso´rio, and Marta Barbosa
Abstract
Breastfeeding has universally known advantages to the mother and child that include nutritional and immunological benefits but also involve reasons of ecological and economic order. Initiation and maintenance of breastfeeding can be associated with common problems. The beginning of milk production may course with bloody nipple discharge, which, after exclusion of pathological entities, concerns a self-resolving physiological syndrome called rusty pipe. We present a case of rusty pipe syndrome and discuss the implications.
Introduction
B
reastfeeding is recognized as the preferred method of infant feeding, with advantages not only to children, including nutritional and immunological, but also to mothers regarding their present and future health. It facilitates the establishment and development of parental bonding and has inherent psychological advantages for mothers. Economic and ecological reasons can be seen as well as potential benefits. Nonetheless, although most women initiate breastfeeding after delivery, only half of them are still nursing 6 months later.1 Several problems can compromise the initial success of breastfeeding and decrease nursing maintenance, like inadequate milk production or extraction, nipple pain or injury, and breast engorgement.2 Bloody or serosanguineous nipple discharge may also occur in some women during the onset of lactation.2–6 Cracked nipples and trauma may be a cause, but pathological conditions like intraductal papilloma or fibrocystic disease should be excluded, especially before a persistent discharge.2–5 Intraductal papilloma usually is associated with a spontaneous, painless, unilateral, and unicanalicular discharge.3 Fibrocystic disease most frequently appears with mastalgia and palpable lumpiness.3,4 Clinical history and examination should always be performed thoroughly in order to rule out these entities. Ultrasound and galactography are recommended when nipple bloody discharge is present for more than 7 days or occurs from a single duct, respectively. A physiological condition that arises primarily in primiparous women in the first days of lactation can also cause bloody milk production. The so-called ‘‘rusty pipe syndrome’’ is a self-limited entity associated with increased alveolar and
ductal vascularization related to lactation onset, is usually painless and bilateral, and generally resolves within a few days.3–6 It may happen during pregnancy, more often during the third trimester, when breast vascularity suffers significant increment.5 Nipple manipulation should be discontinued,3 but breastfeeding is safe. The authors report here a case of nipple bloody discharge within lactation onset in a primiparous woman. Case Presentation
The authors present a case of a 31-year-old primigravida, with no relevant medical or surgical history. She was admitted in labor at 39 weeks of gestation and vaginally delivered a male infant, weighing 3,400 g. Within the first hours of newborn breastfeeding, a bloody nipple bilateral discharge was noticed during milk expression (Fig. 1). She had no associated breast pain or history of trauma. Physical examination revealed no tenderness, mass, or breast engorgement. The nipples were not inverted and showed no cracks, ulcers, or fissures. Nevertheless, bilateral ultrasound was performed, revealing no solid or cystic glandular or ductal lesions. A discharge sample was collected for cytological analysis, excluding the presence of malignant cells. Based on these facts, the diagnosis hypothesis of rusty pipe syndrome was considered, and breastfeeding was encouraged. The bloody discharge decreased gradually and spontaneously resolved 4 days after delivery with onset of normal milk production. Conclusions
Spontaneous bloody nipple discharge is a rare clinical condition occurring in pregnant women or within the first
Gynecology/Obstetrics Department, Vila Nova de Gaia–Espinho Hospital Center, Vila Nova de Gaia, Portugal.
411
412
SILVA ET AL.
tially necessary, ultrasound and discharge smears were performed, excluding pathological conditions. Disclosure Statement
No competing financial interests exist. References
FIG. 1. Bloody nipple discharge (rusty pipe syndrome) in a primiparous woman during lactation onset. days of breastfeeding. After exclusion of pathological entities and when the condition is self-limited, not unicanalicular, painless, and not associated with other physical examination findings, rusty pipe syndrome should be considered. This situation usually resolves without any treatment after the first week of lactation onset and is related to increased breast vascularization. As long as the infant tolerates breastfeeding, it should be encouraged. Further evaluation is recommended if discharge persists for more than 7–10 days. This case represents a typical rusty pipe syndrome, concerning a healthy primiparous woman, with spontaneous and self-resolving bloody nipple discharge after the first days of beginning lactation. Although further studies were not ini-
1. Centers for Disease Control and Prevention. Breastfeeding Report Card, United States, 2013. www.cdc.gov/breast feeding/pdf/2013BreastfeedingReportCard.pdf (accessed March 8, 2014). 2. Bergmann RL, Bergmann KE, Weizsacker K, et al. Breastfeeding is natural but not always easy: Intervention for common medical problems of breastfeeding mothers—A review of the scientific evidence. J Perinat Med 2014;42:9–18. 3. Virdi VS, Goraya JS, Khadwai A. Rusty-pipe syndrome. Indian Pediatr 2001;38:931. 4. Thota U, Machiraju VM, Jampana VR. Rusty pipe syndrome: A case report. Health 2013;5:157–158. 5. Gueye M, Kane-Gueye SM, Mbaye M, et al. Rusty pipe syndrome in a 22-year-old primigravida at 26 weeks’ gestation. South Afr J Obstet Gynecol 2013;19:17–18. 6. Cizmeci MN, Kanburoglu MK, Akelma AZ, et al. Rustypipe syndrome: A rare cause of change in the color of breastmilk. Breastfeed Med 2013;8:340–341.
Address correspondence to: Joana Raquel Rocha Ferreira da Silva, MD Rua Fa´brica da La˜, n 168-Hab. 3.2 4400-706 Vila Nova de Gaia, Portugal E-mail: [email protected]
Case Report
Rusty Pipe Syndrome, a Cause of Bloody Nipple Discharge: Case Report Joana Raquel Silva, Rita Carvalho, Catarina Maia, Marta Oso´rio, and Marta Barbosa
Abstract
Breastfeeding has universally known advantages to the mother and child that include nutritional and immunological benefits but also involve reasons of ecological and economic order. Initiation and maintenance of breastfeeding can be associated with common problems. The beginning of milk production may course with bloody nipple discharge, which, after exclusion of pathological entities, concerns a self-resolving physiological syndrome called rusty pipe. We present a case of rusty pipe syndrome and discuss the implications.
Introduction
B
reastfeeding is recognized as the preferred method of infant feeding, with advantages not only to children, including nutritional and immunological, but also to mothers regarding their present and future health. It facilitates the establishment and development of parental bonding and has inherent psychological advantages for mothers. Economic and ecological reasons can be seen as well as potential benefits. Nonetheless, although most women initiate breastfeeding after delivery, only half of them are still nursing 6 months later.1 Several problems can compromise the initial success of breastfeeding and decrease nursing maintenance, like inadequate milk production or extraction, nipple pain or injury, and breast engorgement.2 Bloody or serosanguineous nipple discharge may also occur in some women during the onset of lactation.2–6 Cracked nipples and trauma may be a cause, but pathological conditions like intraductal papilloma or fibrocystic disease should be excluded, especially before a persistent discharge.2–5 Intraductal papilloma usually is associated with a spontaneous, painless, unilateral, and unicanalicular discharge.3 Fibrocystic disease most frequently appears with mastalgia and palpable lumpiness.3,4 Clinical history and examination should always be performed thoroughly in order to rule out these entities. Ultrasound and galactography are recommended when nipple bloody discharge is present for more than 7 days or occurs from a single duct, respectively. A physiological condition that arises primarily in primiparous women in the first days of lactation can also cause bloody milk production. The so-called ‘‘rusty pipe syndrome’’ is a self-limited entity associated with increased alveolar and
ductal vascularization related to lactation onset, is usually painless and bilateral, and generally resolves within a few days.3–6 It may happen during pregnancy, more often during the third trimester, when breast vascularity suffers significant increment.5 Nipple manipulation should be discontinued,3 but breastfeeding is safe. The authors report here a case of nipple bloody discharge within lactation onset in a primiparous woman. Case Presentation
The authors present a case of a 31-year-old primigravida, with no relevant medical or surgical history. She was admitted in labor at 39 weeks of gestation and vaginally delivered a male infant, weighing 3,400 g. Within the first hours of newborn breastfeeding, a bloody nipple bilateral discharge was noticed during milk expression (Fig. 1). She had no associated breast pain or history of trauma. Physical examination revealed no tenderness, mass, or breast engorgement. The nipples were not inverted and showed no cracks, ulcers, or fissures. Nevertheless, bilateral ultrasound was performed, revealing no solid or cystic glandular or ductal lesions. A discharge sample was collected for cytological analysis, excluding the presence of malignant cells. Based on these facts, the diagnosis hypothesis of rusty pipe syndrome was considered, and breastfeeding was encouraged. The bloody discharge decreased gradually and spontaneously resolved 4 days after delivery with onset of normal milk production. Conclusions
Spontaneous bloody nipple discharge is a rare clinical condition occurring in pregnant women or within the first
Gynecology/Obstetrics Department, Vila Nova de Gaia–Espinho Hospital Center, Vila Nova de Gaia, Portugal.
411
412
SILVA ET AL.
tially necessary, ultrasound and discharge smears were performed, excluding pathological conditions. Disclosure Statement
No competing financial interests exist. References
FIG. 1. Bloody nipple discharge (rusty pipe syndrome) in a primiparous woman during lactation onset. days of breastfeeding. After exclusion of pathological entities and when the condition is self-limited, not unicanalicular, painless, and not associated with other physical examination findings, rusty pipe syndrome should be considered. This situation usually resolves without any treatment after the first week of lactation onset and is related to increased breast vascularization. As long as the infant tolerates breastfeeding, it should be encouraged. Further evaluation is recommended if discharge persists for more than 7–10 days. This case represents a typical rusty pipe syndrome, concerning a healthy primiparous woman, with spontaneous and self-resolving bloody nipple discharge after the first days of beginning lactation. Although further studies were not ini-
1. Centers for Disease Control and Prevention. Breastfeeding Report Card, United States, 2013. www.cdc.gov/breast feeding/pdf/2013BreastfeedingReportCard.pdf (accessed March 8, 2014). 2. Bergmann RL, Bergmann KE, Weizsacker K, et al. Breastfeeding is natural but not always easy: Intervention for common medical problems of breastfeeding mothers—A review of the scientific evidence. J Perinat Med 2014;42:9–18. 3. Virdi VS, Goraya JS, Khadwai A. Rusty-pipe syndrome. Indian Pediatr 2001;38:931. 4. Thota U, Machiraju VM, Jampana VR. Rusty pipe syndrome: A case report. Health 2013;5:157–158. 5. Gueye M, Kane-Gueye SM, Mbaye M, et al. Rusty pipe syndrome in a 22-year-old primigravida at 26 weeks’ gestation. South Afr J Obstet Gynecol 2013;19:17–18. 6. Cizmeci MN, Kanburoglu MK, Akelma AZ, et al. Rustypipe syndrome: A rare cause of change in the color of breastmilk. Breastfeed Med 2013;8:340–341.
Address correspondence to: Joana Raquel Rocha Ferreira da Silva, MD Rua Fa´brica da La˜, n 168-Hab. 3.2 4400-706 Vila Nova de Gaia, Portugal E-mail: [email protected]
