When a woman has more than two active nipples

Simi*’s pregnancy was dramatic! I first met her when I was called from the outpatient department that my patient was being admitted with severe hyperemesis gravidarum. I did not have a patient in my care going by the name Simi and I sought clarification from the emergency department doctor whether she had not confused me with my namesake in the profession.

The doctor called back again and confirmed that the patient was indeed mine and I headed out to the hospital to meet my mystery patient. When I arrived at the ward, I knew for a fact that I had not met Simi before, and it wasn’t just because she looked grey under the covers. I introduced myself and before I could say anything else, the door opened and in walked a familiar face.

Simi is the sister-in-law to my patient Debbie*; a flamboyant, jolly lady who had been under my care a year before, with a difficult twin pregnancy that had ended successfully with the delivery of beautiful twin girls. She was the one who had insisted that I take care of Simi. So, here we were, starting the pregnancy journey with another member of the family. Simi was nine weeks along.

The ultrasound revealed that Simi was carrying triplets, a report that had Simi going temporarily insane. It explained the horrific morning sickness that had put her to bed — and earned her an earful from Debbie who had been insisting that she visits my office for two whole weeks since Simi had found out she was expecting their first baby. Well, we were here now and we had to get this show on the road.

Besides the extreme dehydration occasioned by the incessant vomiting, Simi was otherwise alright. Her general full body examination was normal, save for the nondescript finding of supernumerary nipples on both sides of her body. These are extra nipples that occur along what is described as the mammary line in humans and other mammals. This imaginary line stretches from the inside of the upper arm, curves across the armpit, and descends down the chest wall, the abdomen, up to the upper inner side of the thigh. In other mammals, nipples line most of the mammary line, such as in dogs.

Supernumerary nipples are fairly common in the general population and tend to occur above the normal nipple or below it, especially just below the breast. Many people may not even notice that it is actually a nipple and may assume it is a birthmark since it tends to be darker than normal skin, just like the regular nipple.

For Simi, she had three; one on either side, above the normal nipple, far back towards the armpit, and a solitary one that was under the left breast. I explained this finding to Simi and reassured her that it was not a finding that required any intervention. Simi didn’t pay much attention to it. She had bigger things to worry about at the moment, such as not vomiting out her babies, as she kept joking.

Simi went home after five days, with the vomiting under some control on medication. She could tolerate bland plain boiled rice and semolina porridge. That, alongside sips of ice water, would have to do for now. The next three weeks were rough but she finally started improving.

At 18 weeks, Simi was glowing. Her crazy days were behind her and she was back to her workaholic habits. She even took up pregnancy yoga and swimming twice a week despite her tummy expanding like a whale. She had a smooth ride until she got to 34 weeks when her blood pressure started rising. Within a week, the delivery was scheduled for delivery by caesarian section, with mother and babies safely pulling through.

Within eight hours, Simi’s blood pressure was looking good and she was up and about, walking around the room. The babies were stable enough to initiate breastfeeding and the family was having a field day taking pictures of them. Due to the anticipated high demand for breastmilk, Simi was already on multiple galactagogues to help her make milk quickly and in plentiful supply. She was responding well.

I checked in on them in the evening and all was well. Or so I thought, until Simi woke me up at midnight in a panic. The babies had been taken away at about 9 p.m. to allow her to rest. She promptly fell asleep after her pain medication but when she woke up to use the rest room, she was shocked to find her armpits swollen and a watery discharge oozing from the swelling. She was sitting on her bed with her arms akimbo scared of touching the swelling.

It took me a minute to figure out what Simi was telling me. She had not even remembered to inform the nurse. My attempts to reassure her were not successful. I had to call the nurse to check on her before it dawned on me that Simi’s supernumerary nipples were active! They were not just rudimentary nipples but had underlying breast tissue that was actually lactating.

Thankfully for Simi, this lasted a few days and they dried up on their own. Supernumerary nipples, for most people, are unremarkable. In a small minority, they may be associated with additional congenital abnormalities such as kidney disorders, Turner syndrome, Fanconi anaemia, and other blood disorders. Further, being made up of breast tissue, they are capable of developing breast cancer, hence requiring evaluation during regular breast examination.

Rarely do they require treatment. The commonest reason for surgery is for aesthetics when the patient is concerned about appearance. In the rare instance, cancer happens, treatment is in accordance with standard cancer treatment protocols.

Simi, ever sarcastic, declared that though she may have extra nipples, she had no inclination whatsoever to use them, even with three babies! Dr Bosire is an obstetrician/gynaecologist