{"paper_id":"81d5c433-05b1-4329-bb4d-5501b0f4f9c1","body_text":"Deciduoma, a Large Intrauterine Mass of Deciduosis\nMegha Dasani, BA 1 Hwa Jeong Lee, MD 2 Asha Rijhsinghani, MD 1,3\n1 Department of Obstetrics and Gynecology, Albany Medical Center,\nAlbany, New York\n2 Department of Pathology, Albany Medical Center, Albany, New York\n3 Division of Maternal and Fetal Me dicine, Albany Medical Center,\nAlbany, New York\nAm J Perinatol Rep 2019;9:e337 –e340.\nAddress for correspondence Asha Rijhsinghani, MD, Department of\nObstetrics and Gynecology, Division of Maternal and Fetal Medicine,\nAlbany Medical Center, 391 Myrtle Avenue, 2nd Floor, Albany, NY\n12208 (e-mail: rijhsia@mail.amc.edu).\nDeciduosis is the presence of ectopic decidual tissue in loca-\ntions outside the uterus. This is a phenomenon first described\nin 1887 by Walker.1 Deciduosis has been reported to occur in\nvarious pelvic and abdominal organs.2 Although international\nliterature has only a few case reports published on ectopic\ndeciduosis, the condition is more frequent than initially be-\nlieved. Deciduosis is usually asymptomatic and can remain\nundetected throughout pregnancy.\n2 Based on a recent report,\nthe condition was present in 10% of patients that underwent\nCesarean section.2 Typically, deciduosis occurs during preg-\nnancy but has been reported in nonpregnant women as well. In\nthe absence of pregnancy, ectopic decidual changes are caused\nby progesterone released by the corpus luteum. 3 During\npregnancy, it is considered to be a benign lesion, not associated\nwith any obstetric complications, and does not have any\npathological impact during pregnancy. Total remission occurs\nin the postpartum period.\n2 Intrauterine deciduosis has not\nbeen previously reported. We described a case of a large\nvascular intrauterine mass initially suspected to be a malig-\nnant tumor, which regressed during the pregnancy, and was\nsubsequently diagnosed as deciduosis.\nCase Report\nA 28-year-old female, G1 P0 was referred at 14 4/7 weeks for\nreasons of abnormal twin gestation with early onset oligohy-\ndramnios. The referral document indicated a hydropic struc -\nture with cardiac activity and a normal second fetus with a\nheart rate of 145 bpm. The hydropic structure was identified as\nhaving prominent vessels and no extremities, and referred\nwith diagnosis of suspected acardiac twin. The patient had no\nhistory of spotting, bleeding, discomfort, chronic headaches, or\nrespiratory symptoms at the time of referral.\nIn our assessment the pregnancy was a singleton at 14\n4/7\nweeks with a large vascular mass protruding into the lower\nuterine cavity, arising from the cervicouterine area ( ►Figs. 1\nand 2). There was a small amount of fluid around the mass.\nThe pulse rate in the blood vessels within the mass was\nsimilar to the maternal heart rate. The singleton fetus\nappeared normal with normal growth. The differential diag-\nnosis included a pedunculated fibroid, a large vascular polyp,\nor a malignant growth. The patient was counseled regarding\nthe possible causes and options, and that if the mass was\nKeywords\n► intrauterine mass\n► placenta\n► deciduoma\n► ectopic uterine tissue\nAbstract Deciduosis is the presence of ectopic decidual tissue outside the uterus, pelvic, or\nabdominal organs usually associated with pregnancy. It usually presents as smaller\nlesions but can be larger vascular lesions . Typically, these masses are detected\nincidentally during operative procedures. Our patient was referred at 14 weeks for a\nlarge intrauterine mass detected on ultrasound examination that was initially thought\nto be an acardiac twin. The mass was highly vascularized. However, since the patient\nwas asymptomatic, she strongly desired to continue the pregnancy. The pregnancy was\nfollowed closely from 14 to 39 weeks with serial ultrasound examinations. The\nvascularity was documented to diminish overtime and the mass appeared to convolute\nas well. Due to the decrease in vascularity of the mass, the patient was allowed\nspontaneous vaginal delivery at term. Following delivery of the fetus and the placenta,\nthe mass was easily extracted manually without any complications.\nreceived\nMay 4, 2019\naccepted after revision\nMay 14, 2019\nDOI https://doi.org/\n10.1055/s-0039-1697647.\nISSN 2157-6998.\nCopyright © 2019 by Thieme Medical\nPublishers, Inc., 333 Seventh Avenue,\nNew York, NY 10001, USA.\nTel: +1(212) 584-4662.\nTHIEME\nCase Report e337\nPublished online: 2019-11-14\n\nsuspected to be malignant on further workup she would have\nthe option of pregnancy termination. The patient declined to\npregnancy termination irrespective of the diagnosis. A mag-\nnetic resonance imaging (MRI) was ordered, and the patient\nwas subsequently referred for a consultation with the gyne-\ncologic services for assessment of the tumor.\nAn MRI at 18\n5/7 weeks reported a soft tissue mass of\n1.6 /C22.0 /C24.9 cm, eccentric and crescentic shaped with dif-\nferential diagnosis of a “Stuck Twin syndrome ” with demise\nof the presenting stuck twin. At 19 3/7 weeks, on a repeat\nobstetrical ultrasound, the fluid surrounding the mass and\nthe vascularity were signi ficantly reduced. The mass contin-\nued to have minimal arterial circulation with a pulse rate\nconsistent with the maternal heart rate.\nUltrasound examinations were initially repeated every\nmonth. At 21\n3/7 weeks, the mass stayed stable in size,\nmeasuring 4.36 /C22.00 /C23.26 cm and, at 25 3/7 weeks, it\nwas essentially unchanged measuring 4.7 /C22.6 /C21.8 cm.\nDue to the stable size of the mass, as well as signi ficantly\nreduced vascularity, the patient was reexamined at 33 5/7\nweeks and the mass had reduced in size measuring 3.6 /C22.2\n/C23 cm. Over time, the vascularity was documented to de-\ncrease with minimal blood flow. The mass stayed adherent to\nthe lower portion of the posterior uterine wall.\nAt 39 4/7 weeks, the patient experienced spontaneous labor\nand underwent a normal vaginal delivery. Following the\ndelivery of the baby, the uterine cavity was explored and,\nwith complete ease, the mass was manually extracted in full,\nwith no additional blood loss. It was a smooth soft spongy mass\nwith no raw edges (\n►Fig. 3). On pathology, the mass measured\n7.5 /C24.7 /C22.6 cm and was described as an ovoid, membra-\nnous, dark red, soft tissue with a hemorrhagic surface. On the\nFig. 1 Increased vascularity within the Intrauterine Mass at 14 4/7 weeks ’ gestation.\nFig. 2 Intrauterine mass surrounded by fluid, at 14 4/7 weeks ’ gestation.\nAmerican Journal of Perinatology Reports Vol. 9 No. 4/2019\nFeatures of Deciduoma Dasanie338\n\n\nfinal histopathologic diagnosis, the mass was reported as\ndeciduosis (►Fig. 4). Three weeks after delivery a postpartum\nultrasound was performed which was normal. Findings indi-\ncated anteverted normal appearing midline uterus and cervix.\nEndometrial stripe was normal. Ovaries were normal bilater-\nally with no cysts or masses. There was no evidence of the\npreviously observed lower uterine mass.\nDiscussion\nEctopic deciduosis has been defined as decidual tissue found in\nan extrauterine location during a pregnancy. There are various\ntheories on the pathogenesis of deciduosis. It has been sug-\ngested that progesterone can induce ectopic decidua, a revers-\nible phenomenon.\n6,7 In association with pregnancy, the\nectopic decidual cells have been reported in the fallopian\ntube, ovaries, uterine serosa, cervix, and vagina, as well as\noutside the genital tract including the peritoneum, omentum,\nappendix, and lymph nodes but not intrauterine.4,7 The lesions\nare described as white nodules less than 1 cm in diameter that\nmay coalesce or be isolated. 7 Ectopic decidua is usually an\nincidental finding, detected during surgical procedures, which\ninclude Cesarean sections, postpartum tubal ligations, and\nappendectomies.7 Typically asymptomatic, deciduosis can\npresent with clinical symptoms of shortness of breath, hemop-\ntysis, pneumothorax, progressive anemia, pelvic pain, and risk\nof infections depending on the site. Rarely, complications, such\nas massive intra-abdominal bleeding have been reported.\n5\nThough the lesions are typically described in mm, larger\nlesions in the cervix and the omentum have been reported.\nThe cervical lesions have been described as large masses with\nthe largest reported being 8 cm.\n4 In the omentum, the lesions\ncan be large as well. When the mass is large, it is frequently\nmistaken for malignancy and requires histopathology for\nfinal diagnosis.\n2,4 Omental and peritoneal lesions are more\ncommon and with increasing duration of pregnancy regres-\nsive changes have been reported. 8\nTo our knowledge, there are no reported cases of intrauter-\nine deciduosis during the course of a normal pregnancy. In our\ncase, we had the advantage of following the lesion longitudi-\nnally from the end of the first trimester until delivery at term.\nTo our surprise, the vascularity, as well as the size of the mass,\nwas seen to reduce remarkably by the third trimester, making\nit highly unlikely that we were dealing with a malignant tumor.\nAt delivery we were prepared for an adherent mass and\npostpartum hemorrhage. However, the entire mass was easily\nextracted manually, without any complications. Fortunately, in\nour case, in spite of the lesion being large, the patient did not\nexperience any episode of heavy bleeding antenatally or\nduring the time of delivery. Perhaps, since the vascularity\nregressed overtime, the delivery was uncomplicated.\nConclusion\nIn conclusion, based on our case and those reported in the\nliterature, we believe that there are two separate entities of\nectopic deciduosis, diffuse deciduosis with smaller lesions\nand the larger vascular mass lesions. We propose to classify\nectopic deciduosis into two categories, as benign diffuse\nectopic deciduosis which is typically asymptomatic, and a\ndeciduoma which is a large vascular lesion with potential for\nhemorrhage. By categorizing the larger vascular lesions as\ndeciduoma, the lesion may be accurately diagnosed prena-\ntally more frequently, and it could help the obstetrician\nprepare for the possible hemorrhagic complications. It would\nalso guide the obstetrician in continuing with expectant\nmanagement, with the hope of reduction in vascularity\nand size of the lesion as the pregnancy progresses.\nConflicts of interest\nNone.\nReferences\n1 Walker A. Der bau der Eihaeute bei Graviditatis abdominalis.\nVirch Arch Path Anat. 1887;197:72 –99\nFig. 3 Mass extracted during delivery, measured 7.5 /C24.7 /C22.6 cm.\nFig. 4 Histopathology of the intrauterine mass.\nAmerican Journal of Perinatology Reports Vol. 9 No. 4/2019\nFeatures of Deciduoma Dasani e339\n\n\n2 Markou GA, Goubin-Versini I, Carbunaru OM, Karatzios C, Muray JM,\nFysekidis M. Macroscopic deciduosis in pregnancy is finally a\ncommon entity. Eur J Obstet Gynecol Reprod Biol 2016;197:54–58\n3 Kinra P, Sen A, Sharma JC. Ectopic decidual reaction: a case report.\nMed J Armed Forces India 2006;62(03):280 –281\n4 Gornall AS, Naftalin NJ, Brown LJ, Konje JC. Massive necrosis of\ncervical ectopic decidua presenting in labour. BJOG 2000;107\n(04):573–575\n5 Lüdders DW, Henke RP , Saba M, Raddatz L, Soliman A, Malik E.\nSevere maternal pre- and postpartum intra-abdominal bleeding\ndue to deciduosis. Geburtshilfe Frauenheilkd 2015;75(03):259–262\n6 Ellis CL, Maleki Z, Ali SZ. Ectopic decidua in abdominal washings\nfound intraoperatively at cesarean section. Diagn Cytopathol 2010;\n38(10):740–741\n7 Shukla S, Pujani M, Singh SK. Ectopic decidual reaction mimicking\nperitoneal tubercles: a report of three cases. Indian J Pathol\nMicrobiol 2008;51(04):519 –520\n8 Büttner A, Bässler R, Theele C. Pregnancy-associated ectopic\ndecidua (deciduosis) of the greater omentum. An analysis of\n60 biopsies with cases of fibrosing deciduosis and leiomyoma-\ntosis peritonealis disseminata. Pathol Res Pract 1993;189(03):\n352–359\nAmerican Journal of Perinatology Reports Vol. 9 No. 4/2019\nFeatures of Deciduoma Dasanie340","source_license":"CC0","license_restricted":false}