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Bloody Nipple Discharge Post Delivery:
A Case of “Rusty Pipe Syndrome”
Noraini Mohamad1,*, Zaharah Sulaiman2, Tengku Alina Tengku Ismail3, Sahida Ahmad4
1School of Dental Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Malaysia
2Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Malaysia
3Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Malaysia
4Lactation Secretariat, Hospital Universiti Sains Malaysia, Kubang Kerian, Malaysia
“Rusty pipe syndrome” is a condition that needs to be considered in a primiparous woman who presents with bi-
lateral bloody nipple discharge in the early postpartum period. Its prevalence is low and can occur due to physio-
logical condition that arises primarily in primiparous women with increased alveolar and ductal vascularization
associated with the onset of lactation. Here, we report a case of a 29-year-old primigravida who presented with bi-
lateral painless bloody nipple discharge after delivery. Her breast examination showed no signs of infection or
structural changes, and breast ultrasound did not reveal any significant observations except for a bilateral simple
breast cyst. Six days after the onset of lactation, the bloody nipple discharge ceased and lactation continued on de-
mand.
Keywords: Rusty Pipe Syndrome; Bloody Nipple Discharge; Primiparous; Postpartum Period
Received: March 27, 2020, Accepted: April 29, 2020
*Corresponding Author: Noraini Mohamad https://orcid.org/0000-0002-1179-3005
Tel: +60-97675894, Fax: +60-97675505, E-mail: mnoraini@usm.my
https://doi.org/10.4082/kjfm.20.0057 • Korean J Fam Med
Case Report
eISSN: 2092-6715
Noraini Mohamad, et al. • A Case of “Rusty Pipe Syndrome”2
www.kjfm.or.kr
https://doi.org/10.4082/kjfm.20.0057
INTRODUCTION
Discharge of blood-stained maternal milk after delivery is a rare phe-
nomenon, with an estimated prevalence rate of 0.1%.1) This uncom-
mon phenomenon can elicit anxiety and concern among the mother
and the medical staff.2) Bloody nipple discharge during lactation oc-
curs as a result of several factors such as cracked nipples, mastitis,
trauma, or intraductal papilloma.3,4) However, a rare physiological con-
dition, known as “rusty-pipe syndrome”, can cause painless bloody
nipple discharge in pregnant and post-partum women.2,3,5) Rusty pipe
syndrome is a breastfeeding condition in which the color of the breast
milk looks pink, orange, brown, or rust-colored, similar to dirty water
coming out of an old rusty pipe, and hence, the name of the syndrome.
The rusty color is usually due to mixing of colostrum, or first breast
milk, with a small amount of blood.2) The rusty-colored milk usually
appears during the first few days of breastfeeding. In most cases, the
syndrome is spontaneously cured within 3 to 7 days after the onset of
lactation.2,5) In other cases, this condition persists for the first few
weeks of lactation, and is eventually resolved spontaneously.6)
CASE REPORT
A 29-year-old primigravida delivered a baby boy, with a birth weight of
3,000 g, after 38 weeks of gestation through spontaneous vaginal deliv-
ery. She attempted to feed her newborn after delivery; however, the
milk did not come out due to the poor attachment technique associat-
ed with the bilateral inverted nipple. She was attended by a staff nurse
in the ward for inverted nipple using the syringe technique. She no-
ticed bilateral painless bloody nipple discharge while expressing her
breast. She observed this phenomenon occurring more on the left
breast than on the right breast as shown in Figure 1. She was referred
to a lactation unit for further management. The patient denied having
any history of trauma to her breast. Her breast examination showed no
signs of inflammation, engorgement, tenderness, or palpable masses.
The nipples were inverted and showed no cracks, ulcers, or fissures.
Examination of the newborn’s mouth revealed no natal teeth. She no-
ticed that the nipple discharge color changed from dark brown in the
morning to light brown in the afternoon, as shown in Figure 2. She was
advised to express her breast every 2 to 3 hours and continue breast-
feeding on demand to avoid breast engorgement. A discharge sample
was collected for cytological analysis to exclude the presence of malig-
nant cells. Ultrasound of the breasts revealed bilateral simple breast
cyst measuring up to 0.5 cm×0.7 cm×0.6 cm on the right and 0.4
cm×0.4 cm×0.7 cm on the left breast. No ductal lesions or enlarged ax-
illary lymph node was observed. The bloody discharge resolved spon-
taneously 6 days after delivery with the onset of normal milk produc-
tion, after which, the bloody discharge did not recur.
Informed consent was obtained from the patient for publication of
this case report and accompanying images.
DISCUSSION
“Rusty pipe syndrome” is a rare benign and self-limiting physiological
condition that should be included in the differential diagnosis in
women who present with painless bloody nipple discharge during
gestation and lactation.3) Rusty pipe syndrome occurs due to elevated
vascularization of rapidly developing alveoli that have a delicate net-
work of capillaries. These capillaries are easily traumatized, which re-
sults in bleeding from the nipples.3,7) This condition commonly occurs
in primiparous women who present with bilateral painless nipple dis-
charge after delivery, with no signs of inflammation in the breast and
no previous history of trauma.3) The syndrome may begin at the time
of birth, during early lactation, or during pregnancy. The onset of the
syndrome may involve unilateral breast.4) It is usually associated with
nipple stretching exercises, such as Hoffman’s procedure, which is of-
ten recommended for flat or inverted nipples.4,5) However, in our case,
the syringe technique was employed to treat the inverted nipple based
on the guidelines of “session 12: breast and nipple conditions” by the
World Health Organization and United Nations Children’s Fund, and
Baby-Friendly Hospital Initiative, 2009.8) In addition, physical exami-
nation did not reveal any skin changes, nipple cracks or fissures, breast
engorgement or lump, and fever.3)
Initial diagnosis of “rusty pipe syndrome” is based on medical histo-
ry and routine physical examination, followed by specialized investi-
Figure 1. Rusty-colored milk from the breast. Informed consent was obtained from
the patient for publication of this case report and accompanying images.
Figure 2. Rusty-colored breast milk drawn into a syringe on day 1. The color
changed from dark brown in the morning to light brown in the afternoon.
9.00 am 9.30 am 3.00 pm
Noraini Mohamad, et al. • A Case of “Rusty Pipe Syndrome”
https://doi.org/10.4082/kjfm.20.0057
www.kjfm.or.kr 3
gations, if necessary, including cytological analysis of the bloody dis-
charge, to exclude the presence of malignant cells, and breast ultra-
sound, which could help rule out other pathological conditions.3,4)
Bloody nipple discharge during lactation can be related to the breast-
feeding technique that causes cracked nipples, mastitis, or trauma,
and its occurrence can be attributed to various pathological causes
such as intraductal papilloma.3,4) Intraductal papilloma is a benign tu-
mor found within the breast ducts, in which abnormal proliferation of
ductal epithelialcells causes tumor growth. A solitary intraductal pap-
illoma is usually found located centrally posterior to the nipple that af-
fects the central duct. Patients often present with spontaneous bloody
or clear nipple discharge. An intraductal papilloma may be occasion-
ally palpable. The breast ultrasound usually reveals a mass near the
nipple. Tissue sampling, in addition to imaging, is necessary for the di-
agnosis of intraductal papilloma. Treatment of intraductal papilloma
involves surgical excision and complete removal of the tumor.9)
Persistent bloody nipple discharge immediately after the postpar-
tum period should be evaluated using diagnostic imaging. Ultrasonog-
raphy is recommended as the initial diagnostic imaging modality in a
breastfeeding woman. If the ultrasonography reveals suspicious find-
ings or is discordant with the clinical examination, additional imaging
using mammography or digital breast tomosynthesis (DBT or “three-
dimensional mammography”) may be indicated. This is related to the
fact that mammography or DBT can visualize architectural distortion
and/or calcifications that cannot be seen on ultrasonography, as well
as delineate the extent of the disease in case of malignancy.6)
In summary, “rusty pipe syndrome” during pregnancy and lacta-
tion is an uncommon and harmless condition, but can be alarming to
the mother, caregivers, and medical personnel.10) It is a self-limiting
condition and is usually resolved within three to seven days after onset
of lactation.2,5) In our case, the patient is a healthy primiparous woman
who exhibits a typical “rusty pipe syndrome,” with spontaneous and
self-resolving bloody nipple discharge. In “rusty pipe syndrome” cases,
if the infant tolerates the milk, then breastfeeding can be continued
and encouraged to strengthen exclusive breastfeeding practice for 6
months.7,10) The discharge should be further examined if the bleeding
persists for more than one week to exclude papillomas.7) It is impor-
tant to create awareness among the medical healthcare personnel re-
garding proper counseling and management of this benign condition,
to avoid causing anxiety to the mothers and unnecessary investiga-
tions.7)
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
ORCID
Noraini Mohamad: https://orcid.org/0000-0002-1179-3005
Zaharah Sulaiman: https://orcid.org/0000-0002-4023-1845
Tengku Alina Tengku Ismail: https://orcid.org/0000-0001-6689-4527
Sahida Ahmad: https://orcid.org/0000-0002-8873-8872
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