Enlargement of the breast during puberty and gestational period is a normal physiological process, but massive and diffuse enlargement during the gestational period is a rare condition referred to as Gigantomastia.

Case 1 history
A 24-year-old woman was admitted on August 28, 2003, gravida 2, in 28 weeks` gestation. She was complaining of huge enlargement of both her breasts, pain and discomfort. This enlargement started at 21 weeks` gestation and continued to increase rapidly as the pregnancy progressed, complicated by infection, ulcerations, and subsequent hemorrhage.
Three years ago, she had induced abortion in 20 weeks` gestation, due to intrauterine fetal death of unknown etiology, without any pathologically confirmed macroscopical and microscopical fetal malformations. During her first pregnancy no significant enlargement of the breast was noted, and also, there was no significant personal medical or family history.

During her hospitalization, breasts continued to increase in size, with multiple ulcers measuring 1-6 cm in diameter, especially around the area of the nipple complex. Additional infection with �Klebsiella aerogenes� appeared hence she started receiving antibiotics with daily dressings of the ulcers. Gynecological examinations and ultrasound of the pelvis revealed a viable, progressing normal fetus. She underwent complete laboratory investigations including complete blood count, coagulation screen, chemistry and hormonal assay with normal results, except Rh incompatibility (negative direct Coomb`s test).

We performed simple mastectomy as a life-saving procedure, during her 29 week` of gestation. However free areola-nipple graft was not done due to damages to this complex from ulcerations. The procedure finished without any complications or large amount of blood loss.

Spontaneous regression of this huge enlargement of the breast, after delivery, is not very likely to occur. Reduction mammoplasty was not possible because of the enormous enlargement of both breasts in the second trimester of pregnancy, and life threatening complications. Also regrowth to the remnant breast tissue until the delivery and during next pregnancies is possible. Complications as ulcerations, followed by sepsis and bleeding may be fatal. They are absolute indications for surgical treatment. In our case simple mastectomy is a treatment of choice as a life-saving procedure. This was performed without reimplantation of the areola-nipple complex due to the big damages caused by ulcerations.

She had good postoperative period, with solid recovery and normal pregnancy. She was discharged from the hospital one week later.

Later the patient�s pregnancy progressed to a spontaneous, normal, vaginal delivery with a viable healthy baby.

Gross examination showed total breast weight of 33 kg, (70x60cm in diameter) with deep ulcerations to the skin flap, with lobular arrangement of the mammary parenchyma on the cut surface.  Microscopically extensive lobular hyperplasia is seen, as well as dilated ductuses and pseudoangiomatous hyperplasia. Pronounced interstitial edema and lymphoplasmocytes in the stroma was noticed. Foci of increased fat and connective tissue were seen. Immunochistochemically proliferative factors (Ki67, PCNA) were negative as well as estrogen and progesterone receptors.

Conclusion:
Gigantomastia in pregnancy is a rare condition with ill-understood ethological factors.
Simplex mastectomy with immediate implantation of the nipple-areola complex in gigantomastia with complications is a treatment of choice.


Case 2 history
We present an extreme case of Gigantomastia in pregnancy in a 30 year old woman, in her second gemelar pregnancy. Her first pregnancy 8 years ago was also gemelar and finished with cesarean section. From the beginning of her current pregnancy, the patient noted growing of her both breasts that reached enormous dimensions till the end of pregnancy. This kind of breast changes wasn`t noted during her first pregnancy. She has myasthenia gravis, in remission during this pregnancy, without any therapy.

My first experience with Gigantomastia in pregnancy was 5 years ago and case was published in the same magazine from 2007, 275:149-153. In this case in a 24 year old woman, in a beginning of 29 weeks` of gestation I`ve performed a bilateral simple mastectomy and removed total breasts weight of 33 kg complicated by ulcerations, infection and hemorrhage. In this second case in a 38 weeks` of gestation, a delivery with cesarean section was performed as well as breasts reduction in the same time. Puerperal mastitis that could develop on these enormous breasts, a small regression of these huge breasts during bromocriptine treatment, as well as a intention for avoiding other operative traumas because of possibility of exacerbation of myasthenia gravis, lead me to performed this two interventions in the same act.

I`ve performed bilateral reduction mammoplasty with free areola - niplle graft, when a tissue with total weight of 20 kg (2 x 10 kg.) was removed. The patient has excellent post operation recovery course and great esthetic look.