D Gopinath, C Panayotidis, T Onon
caesarean section, ectopic decidua, pregnancy
D Gopinath, C Panayotidis, T Onon. Ectopic Decidua Suspicious Of Malignancy In Pregnancy: A Case Report. The Internet Journal of Gynecology and Obstetrics. 2004 Volume 5 Number 1.
Ectopic decidua although uncommon, may present a diagnostic dilemma. We present a case of a 33 year old primigravida lady with a history of endometriosis who was noted to have abnormal appearance of the ovaries and sigmoid serosa during Caesarean section. Histology revealed extensive stromal decidualisation.
A 33 year old primigravida with uneventful antenatal care required during labour at term an emergency Caesarean section for fetal distress. In the past she had laparoscopic laser treatment for moderate endometriosis. Suspicious lesions having vascular polypoid appearance were found on the ovaries and sigmoid colon. The histology report from biopsies revealed extensive stromal decidualisation without any endometrial glands. The patient had no further problems postnatally.
Extra uterine deciduosis (EUD) is an histological benign condition which can mistaken macrospicaly as malignancy resembling peritoneal carcinomatosis. EUD can be discovered accidentally in pregnancy during caesarean sections but as well, during pelvic surgery in women under oral contraception (Tang et al. 1985) or for cervical cancer (Cobb 1988). Deposits can be found mainly on the ovary and cervix (Zaytsev, Taxy 1987) but in different pelvic locations such as: bowel serosa, peritoneum, vagina, lungs, pleura, retroperitoneal lymph nodes and rarely skin. Life threatening events leading to maternal and fetal mortality (Richter et al. 1983 have been reported with symptomatic EUD in rare presentations during pregnancy including pseudo-acute appendicitis, haemoperitoneum, pulmonary pathology (Flieder et al. 1998), cutaneous swellings and abnormal appearance of cervix .Gross peritoneal deciduosis can cause obstruction in labour (Malpica et al. 2002). After histological diagnosis most lesions do not require further treatment and spontaneously involute within the first four to six weeks post partum (Buttner et al. 1993). Lesions presenting with symptoms may require diathermy or laser ablation. Little is known about EUD physiology and two theories have been proposed to explain this condition (Zaystev, Taxy 1987).The more accepted theory considers that the sub-coelomic mesenchymal cells undergo a progesterone-induced metaplasia, which usually is temporary and reverts back to normal once the hormonal influence disappears. The second theory claims that the decidual cells are already distributed in the peritoneum. In non pregnant women the source of progesterone is either exogenous or progestagens secreted by corpus luteum or the adrenal cortex.
In our case, histopathological examination did not identify any endometrial glands, but only stromal cells, which had decidualised. Little is known about endometriosis and subsequent development of ectopic decidua. In pregnancy, deciduosis was found coexistent with endometriosis in the same lesion. It is disconcerting to note that progesterone, which is used to suppress endometriosis, appears to be able to induce ectopic deciduosis, though not necessarily at the same sites. This reinforces the fact that ectopic deciduosis is again a separate entity.