Decidualisation of ovarian endometriomas in pregnancy: a management dilemma. A case report and review of the literature

Introduction Increased progesterone levels during pregnancy may cause decidualisation of endometriomas mimicking malignancies on radiology and causing management dilemmas. Case An ovarian cyst was detected in a 33-year-old woman at her routine 12-week gestation ultrasound scan. By 18 weeks, the unilocular mass was increasing in size with features suggestive of early ovarian malignancy. The cyst was monitored throughout pregnancy and caesarean section at 38 weeks delivered a healthy male. Histology confirmed a decidualised endometrioma and benign dermoid cyst with no evidence of malignancy. Literature Review The evidence for decidualised ovarian endometriomas in pregnancy was explored; 14 papers were identified, which reported 26 cases, excluding our index case. Of the 27 cases, 19 (70 %) were managed surgically, 4 of which were delayed till caesarean section with concomitant cyst excision; 8 cases were managed conservatively through serial monitoring of the cyst, which spontaneously regressed following delivery.

Surgical management of the cyst provides histological diagnosis but may introduce risks to mother and fetus; a conservative approach may cause anxiety but limits interventions. Elective caesarean section following monitoring throughout pregnancy may bridge the gap between surgical and purely conservative approaches if appropriate. Limited available evidence makes a definitive decision regarding management difficult. Decidualisation should be considered as a differential for suspicious ovarian lesions in pregnancy. Similar content being viewed by others

Hill LM, Connors-Beatty DJ, Nowak A, Tush B (1998) The role of ultrasonography in the detection and management of adnexal masses during the second and third trimesters of pregnancy. Am J Obstet Gynecol 179:703–707 Balci O, Gezginc K, Karatayli R et al (2008) Management and outcomes of adnexal masses during pregnancy: a 6-year experience. J Obstet Gynaecol Res 34:524–528 Bromley B, Benacerraf B (1997) Adnexal masses during pregnancy: accuracy of sonographic diagnosis and outcome. J Ultrasound Med 16:447–452 Zaytsev P, Taxy JB (1987) Pregnancy-associated ectopic decidua. Am J Surg Pathol 11:526–530 Büttner A, Bässler R, Theele C (1993) Pregnancy-associated ectopic decidua (deciduosis) of the greater omentum. An analysis of 60 biopsies with cases of fibrosing deciduosis and leiomyomatosis peritonealis disseminata. Pathol Res Pract 189:352–359 Whitecar MP, Turner S, Higby MK (1999) Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 181:19–24 Asch E, Levine D (2007) Variations in appearance of endometriomas. J Ultrasound Med 26:993–1002 Tamai K, Koyama T, Saga T et al (2006) MR features of physiologic and benign conditions of the ovary. Eur Radiol 16:2700–2711 Takeuchi M, Matsuzaki K, Uehara H, Nishitani H (2006) Malignant transformation of pelvic endometriosis: MR imaging findings and pathologic correlation. Radiographics 26:407–417 Telischak NA, Yeh BM, Joe BN et al (2008) MRI of adnexal masses in pregnancy. Am J Roentgenol 191:364–370 Miyakoshi K, Tanaka M, Gabionza D et al (1998) Decidualized ovarian endometriosis mimicking malignancy. Am J Roentgenol 171:1625–1626 Fruscella E, Testa AC, Ferrandina G et al (2004) Sonographic features of decidualized ovarian endometriosis suspicious for malignancy. Ultrasound Obstet Gynecol 24:578–580 Sammour RN, Leibovitz Z, Shapiro I et al (2005) Decidualization of ovarian endometriosis during pregnancy mimicking malignancy. J Ultrasound Med 24:1289–1294 Iwamoto H, Suzuki M, Watanabe N et al (2006) Case study of a pregnant woman with decidualized ovarian endometriosis whose preoperative findings suggested malignant transformation. Eur J Gynaecol Oncol 27:301–303 Machida S, Matsubara S, Ohwada M et al (2008) Decidualization of ovarian endometriosis during pregnancy mimicking malignancy: report of three cases with a literature review. Gynecol Obstet Invest 66:241–247 Poder L, Coakley FV, Rabban JT et al (2008) Decidualized endometrioma during pregnancy: recognizing an imaging mimic of ovarian malignancy. J Comput Assist Tomogr 32:555–558 Takeuchi M, Matsuzaki K, Nishitani H (2008) Magnetic resonance manifestations of decidualized endometriomas during pregnancy. J Comput Assist Tomogr 32:353–355 Yoshida S, Onogi A, Shigetomi H et al (2008) Two cases of pregnant women with ovarian endometrioma mimicking a malignant ovarian tumor. J Clin Ultrasound 36:512–516 Barbieri M, Somigliana E, Oneda S et al (2009) Decidualized ovarian endometriosis in pregnancy: a challenging diagnostic entity. Hum Reprod 24:1818–1824 Sayasneh A, Naji O, Abdallah Y et al (2012) Changes seen in the ultrasound features of a presumed decidualised ovarian endometrioma mimicking malignancy. J Obstet Gynaecol (Lahore) 32:807–811 Guerriero S, Ajossa S, Piras S et al (2005) Serial ultrasonographic evaluation of a decidualized endometrioma in pregnancy. Ultrasound Obstet Gynecol 26:304–306 Tohya T, Tajima T (2011) Conservative management of decidualized ovarian endometriotic cyst during pregnancy mimicking malignancy: case report and a review of the literature. Eur J Gynaecol Oncol 32:347–349 Tanaka YO, Shigemitsu S, Nagata M et al (2002) A decidualized endometrial cyst in a pregnant woman: a case observed with a steady-state free precession imaging sequence. Magn Reson Imaging 20:301–304 Ueda Y, Enomoto T, Miyatake T et al (2010) A retrospective analysis of ovarian endometriosis during pregnancy. Fertil Steril 94:78–84 Fauconnier A, Chapron C (2005) Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update 11:595–606 Child TJ, Tan SL (2001) Endometriosis: aetiology, pathogenesis and treatment. Drugs 61:1735–1750 Phupong V, Rungruxsirivorn T, Tantbirojn P et al (2004) Infected endometrioma in pregnancy masquerading as acute appendicitis. Arch Gynecol Obstet 269:219–220 Van Holsbeke C, Van Calster B, Guerriero S et al (2010) Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol 35:730–740 Timor-Tritsch I, Monteagudo A, Santos R, Holcomb K (2006) OP21.08 Decidualized hypervascularized ovarian endometrioma in pregnancy: can it be distinguished from cancer to avoid surgery? Ultrasound Obstet Gynecol 28:508 Akira S, Yamanaka A, Ishihara T et al (1999) Gasless laparoscopic ovarian cystectomy during pregnancy: comparison with laparotomy. Am J Obstet Gynecol 180:554–557 Wood C, Maher P, Hill D (1992) Diagnosis and surgical management of endometriomas. Aust N Z J Obstet Gynaecol 32:161–163 Garcia-Bournissen F, Shrim A, Koren G (2006) Safety of gadolinium during pregnancy. Can Fam Physician 52:309–310 Moolthiya W, Yuenyao P (2009) The risk of malignancy index (RMI) in diagnosis of ovarian malignancy. Asian Pacific J cancer Prev 10:865–868 Ercan Ş, Kaymaz Ö, Yücel N, Orçun A (2012) Serum concentrations of CA 125, CA 15-3, CA 19-9 and CEA in normal pregnancy: a longitudinal study. Arch Gynecol Obstet 285:579–584 Ness RB, Modugno F (2006) Endometriosis as a model for inflammation-hormone interactions in ovarian and breast cancers. Eur J Cancer 42:691–703 Conflict of interest None. Author information Authors and Affiliations Corresponding author Rights and permissions About this article Cite this article Taylor, L.H., Madhuri, T.K., Walker, W. et al. Decidualisation of ovarian endometriomas in pregnancy: a management dilemma. A case report and review of the literature. Arch Gynecol Obstet 291, 961–968 (2015). https://doi.org/10.1007/s00404-014-3531-y Received: Accepted: Published: Issue date: DOI: https://doi.org/10.1007/s00404-014-3531-y