{"paper_id":"15b08650-4a2d-4f7e-9213-e65b81b34f73","body_text":"128\nFallopian tube deciduosis with massive hemoperitoneum in a  \nsecond-trimester pregnancy: a case report of ultrasound findings\nDiana Camorlinga-Ornelas 1,2 * and David Garza-Cruz 3\n1Department of Radiology, High Specialty Medical Unit 71, Mexican Social Security Institute; 2School of Medicine, Autonomous University  \nof Coahuila; 3Diagnostic and Therapeutic Imaging Department, Hospital Angeles, T orreon. Coahuila, Mexico\nCASE REPORT\n*Corresponding author:  \nDiana Camorlinga-Ornelas  \nE-mail: dra.camorlinga@gmail.com\n2696-8444 / © 2024 Federación Mexicana de Radiología e Imagen, A.C. Published by Permanyer. This is an open access article under the \nCC BY-NC-ND ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).\nAvailable online: 10-07 -2024\nJ Mex Fed Radiol Imaging. 2024;3(2): 128-131\nwww.JMeXFRI.com\nFEDERACIÓN MEXICANADE RADIOLOGÍA E IMAGEN, A.C\nJournal of the Mexican Federation of Radiology and Imaging\nOfficial Journal of the \nJournal of the Mexican Federation \nof Radiology and Imaging\nReceived for publication: 06-04-2024\nAccepted for publication: 25-04-2024\nDOI: 10.24875/JMEXFRI.24000016\nABSTRACT \nDeciduosis is a decidual reaction outside the uterus that typically occurs during pregnancy. It is usually asymptomatic, but \nseveral life-threatening complications have been reported. Imaging features of this condition are lacking. This case report \ndescribes the ultrasound and clinical findings in a pathologically confirmed case of deciduosis. A 28-year-old primigravida \nwith 23 weeks of gestation was referred to our department with severe abdominal pain. Pelvic ultrasound showed a left-sided, \noval, well-circumscribed, solid, heterogeneous, predominantly hypoechoic pelvic mass without vascularity. There was abundant \nfree fluid in the perihepatic and perisplenic spaces. The patient went into hypovolemic shock, leading to emergency surgery. \nActive bleeding from the left fallopian tube and a large hemoperitoneum of 1500 ml were found in this area and evacuated. \nA congestive fallopian tube with an arborescent zone and bleeding near the fimbria was removed. The histopathological \nfeatures of the left salpingeal mass were consistent with decidual tissue surrounded by a hematoma. This case report is the \nfirst in Mexico to emphasize the imaging findings of this entity. It is presented as an educational tool that highlights deciduo -\nsis as a potential differential diagnosis in the emergency abdominopelvic ultrasound of pregnant patients.\nKeywords: Decidua. Fallopian tube. Pregnancy complications. Ultrasonography. Hemoperitoneum. Case report.\nINTRODUCTION\nDeciduosis is the presence of an ectopic decidual \nreaction outside the uterus. It consists of a metaplastic \nchange in submesothelial mesenchymal cells 1 induced \nby progesterone or progesterone-like substances \nreleased by the corpus luteum or adrenal cortex 2,3. \nDeciduosis has been reported at gynecological, gas -\ntrointestinal, renal, lymph node, diaphragmatic, surgical \nscar, and omentum sites2,4,5. The etiology of deciduosis \nis unclear, and there are two main theories. One is that \ndecidual cells are already outside the uterus, and the \nother is that the superficial coelomic stroma undergoes \nmetaplasia. The latter is the most widely accepted 3,5,6.\nAlthough deciduosis was first described by Walker von \nSolothurn in 18645, knowledge of the imaging features, \nparticularly ultrasonography, is limited. The available lit -\nerature provides no specific information, with reported \nultrasound findings related primarily to free fluid detec -\ntion (usually without debris) or bowel distension, partic -\nularly in the context of reactive ileus or bowel obstruction \ndue to complications1. There are no ultrasound diagnos-\ntic or prognostic criteria, and histopathological examina-\ntion remains the gold standard for diagnosis 5.\nAlthough deciduosis is usually asymptomatic, its \nclinical manifestations may include abdominal pain, \nobstructive ileus 2,4, hematuria 2, recurrent pneumotho -\nrax, obstructed labor, or hemoperitoneum 7. The main \n\nD. Camorlinga-Ornelas, D. Garza-Cruz. Deciduosis with hemoperitoneum in pregnancy \n129\ncontribution of imaging in abdominal pain is to rule out \nother causes of acute abdomen 8. No specific findings \nfor deciduosis have been described by any imaging \nmethod, implying that it could be dismissed due to its \nsimilar density to the surrounding tissues 8. This case \nreport describes the clinical and ultrasound findings \nin a 28-year-old primigravida with 23 weeks of gesta -\ntion, severe abdominal pain, and a pathologically con -\nfirmed diagnosis of deciduosis.\nCASE DESCRIPTION \nOur patient was a 28-year-old Caucasian female, \ngravida 1, para 0, with 23 weeks of pregnancy, referred \nto the imaging department because of diffuse abdomi -\nnal pain radiated to the anal region and persistent nau -\nsea and vomiting. Before this event, her pregnancy had \nbeen carefully screened and was uneventful. Physical \nexamination revealed pallor, drowsiness, stable cardio -\npulmonary function, a distended abdomen secondary \nto pregnancy, and generalized abdominal pain with ten -\nderness, guarding, and a positive rebound sign. Vital \nsigns and laboratory values were normal. She was ini -\ntially treated with indomethacin for early preterm labor \nwith a poor response. An ultrasound was requested.\nImaging findings\nAbdominopelvic and obstetric ultrasounds were per -\nformed with an ACUSON Sequoia VA25 SW Ultrasound \nSystem (Siemens Medical Solutions, Inc., Mountain \nView, CA, USA) with a 5-MHz curved transducer. The \nobstetric ultrasound showed no significant abnormalities \n(Figure 1). The upper abdominal examination revealed \nno abnormal findings in the solid organs. Pelvic ultra -\nsound showed a left-sided, oval, well-circumscribed, \nsolid, heterogeneous, predominantly hypoechoic pel -\nvic mass with no vascularity detected on color Doppler \nexamination. Abundant free fluid was noted in the \nperihepatic and perisplenic spaces and the right lower \nquadrant ( Figures 2  and 3).\nClinical course\nThe patient eventually presented hypovolemic shock, \nand an emergency laparotomy was performed. During the \nprocedure, a hemoperitoneum of 1500 ml was evacuated. \nActive bleeding from the left fallopian tube and a large \nhematoma were observed; therefore, a left salpingectomy \nwas performed, and hemostasis was achieved. An emer-\ngency cesarean section was not required. An arborescent \nzone and a bleeding area near the fimbria were found on \nthe excised congested fallopian tube. The patient was \ndischarged with an ongoing pregnancy. \nA\nB\nFigure 1. Ultrasound examination of the fetus at 23 weeks gestation. \nA: the fetal heart rate is normal, and the fetus is in a cephalic position. \nB: color Doppler duplex ultrasound image along the umbilical cord \nshowing a typical flow pattern with a pulsatility index in the 46 th \npercentile for gestational age (normal).\nFigure 2.  Longitudinal ultrasound of the right upper quadrant of the \nabdomen in a pregnant 28-year-old female shows abundant free fluid \naround the liver.\n\nJ Mex  Fed  Radiol  iMaging . 2024;3(2):128-131\n130\nHistopathological findings\nThe wall and mucosa of the left fallopian tube were \nundamaged and showed typical histological characteristics.  \nTissue with a decidual appearance was found on the \nserosa with extensive areas of fresh hemorrhage alter -\nnating with lakes of erythrocytes, fibrin, and polymorpho-\nnuclear debris in a diffuse distribution. These findings \nwere consistent with focal peritoneal deciduosis with \nhemorrhage and acute inflammation ( Figure 4).\nDISCUSSION\nWe present the case of a 28-year-old primigravida \ndiagnosed with hemorrhagic salpingeal deciduosis with \nultrasound findings of a left, oval, well-circumscribed, \npredominantly hypoechoic pelvic mass in the left fallo -\npian tube, attributed to a large hematoma with active \nbleeding and typical histological characteristics. This is \nthe first case report from Mexico of deciduosis localized \nin the fallopian tube, which is presented for educational \npurposes to highlight the importance of ultrasound \nexamination.\nWe found that information on ultrasound findings in \ndeciduosis is lacking in the literature. In four cases doc -\numented by Chai et al. 9, three underwent ultrasound \nexamination. Two of these had a nondiagnostic ultraso -\nnography, while the third had a nonspecific mass and \nfree fluid. These findings suggest that ultrasound is of \nlimited use in diagnosing deciduosis or there is a lack \nof knowledge on the subject. A case report by Jeong  \net al.10 described an ovarian mass with a heterogeneous \ncystic pattern, solid components, and vascularization \non Doppler examination. These findings were similar to \nthose of ours. Furthermore, Wong et al.11 documented \na case of intracystic vegetations in ovarian deciduosis \nthat appeared as a multilocular mass with nodular \nthickening of its septa and internal vascularization, \nwhich are features not identified in our case. \nDeciduosis is usually avascular on Doppler exam -\nination, although it may show some vascularity, as \nmentioned in previous cases. Complications can be \naccompanied by free fluid, especially in case of hemo -\nperitoneum. No additional features, such as calcifications, \nacoustic shadowing, or lymphadenopathy, have been \nreported. The reported cases demonstrate the wide vari-\nety of findings associated with deciduosis and emphasize \nthe importance of a comprehensive imaging study.\nAlthough specific imaging findings in deciduosis \nremain elusive, available reports indicate a wide \nspectrum in size, border definition, sonographic pattern, \nFigure 3. Longitudinal ultrasound of the left flank in a pregnant 28-year-\nold female shows a left mass adjacent to the uterus (arrowhead). It is \noval and well-circumscribed with a predominantly hypoechoic hetero-\ngeneous pattern. Color Doppler examination showed no flow (data not \nshown).\nA\nB\nFigure 4. A: a microscopic examination of the resected tissue shows \nseveral foci of atypical decidual reaction consisting of a cluster of \npolygonal cells with abundant homogeneous eosinophilic cytoplasm, \nlarge nuclei, and some areas of vacuolar degeneration. No cellular \natypia or mitotic areas were detected; hematoxylin and eosin stain \n40×. B: the adjacent blood vessels are damaged (arrowhead); hema -\ntoxylin and eosin stain 10×.\n\nD. Camorlinga-Ornelas, D. Garza-Cruz. Deciduosis with hemoperitoneum in pregnancy \n131\nechogenicity, and inner characteristics. Our imaging \nfindings are consistent with the literature and showing \nnonspecific mass features. Some authors report multiple \nnodules at different sites 6,7. They can be isolated or \ncoalescent6 and tend to be millimeter-sized nodules but \nthey also occur as large masses6 appearing as predom-\ninantly cystic and well-circumscribed lesions with vascu-\nlarity6,7. There is one documented case of a large \nintrauterine mass consisting of an ectopic decidua with \nhigh internal vascularity on Doppler (known as a decid -\nuoma)6. We infer a wide spectrum of findings and decid-\nuosis may present as a single or multiple solid masses12, \nlocalized at any site with submesothelial mesenchymal \ncells1, including the salpinges, as in our case.\nThe symptoms of deciduosis are non-specific and they \nmimic other pathologies. Although the clinical course is \nusually benign, complications such as massive hemo -\nperitoneum can occur, compromising maternal and fetal \nlife. In some cases, emergency surgery may be required. \nMacroscopically, they appear as whitish-yellow nodules \nwith or without hemorrhagic areas that can be mistaken \nfor carcinomatosis 2. The final diagnosis of deciduosis \nwas confirmed by immunohistopathology after surgery \nin all the reported cases. This tissue must be differ -\nentiated from the decidual variant of mesothelioma, \nmetastatic malignant melanoma 7, carcinomatosis, and \ngranulomas1,8. The main limitation of this report is the \nlack of immunochemical correlation.\nCONCLUSION \nThe possibility of deciduosis should be considered for \npregnant women with acute abdominal pain and free \nfluid, especially when other causes of spontaneous \nhemoperitoneum have been ruled out. A complementary \nstudy of the imaging findings with detailed ultrasound \ndescriptions is crucial to increasing our knowledge of \nthis topic. Therefore, this case report serves as a valu -\nable basis for discussion and future research.\nAcknowledgments\nThe authors thank Alexis Zúñiga, MD, Radiologist in \nHospital Angeles Torreon, for his help in obtaining repre-\nsentative ultrasound images, and Luis Vitiénez, MD, \nDepartment of Pathology, Hospital Angeles Torreon, for \nhis support with pathological data. They also extend their \nsincere thanks to Professor Ana M. Contreras-Navarro for \nher guidance in preparing and writing this scientific paper.\nFunding\nThis research received no external funding.\nConflicts of interest\nThe authors declare no conflicts of interest.\nEthical disclosures\nProtection of human and animal subjects.  The \nprocedures of this case report were conducted in \nagreement with the Declaration of Helsinki (1964) and \nits amendments.\nConfidentiality of data. The authors followed the pro-\ntocols of their work center for the publication of patient \ndata.\nRight to privacy and informed consent.  Informed \nconsent was not required for this case report of rou -\ntinely collected clinical data.\nUse of artificial intelligence.  The authors did not \nuse generative artificial intelligence to prepare this \nmanuscript or create figures or figure legends.\nREFERENCES\n 1. Khajuria R, Sharma S, Singh K, Neelam. Peritoneal Deciduosis: A Case \nReport. JK Science. 2015;17(2):102-103.\n 2. Jadhav T, Doshetty R. 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Decidual \nBleeding as a Cause of Spontaneous Hemoperitoneum in Pregnancy and \nRisk of Preterm Birth. Gynecol Obstet Invest. 2017;(82):313-321. \ndoi:10.1159/000468933.","source_license":"CC0","license_restricted":false}