A case of ovarian deciduosis in pregnancy

Decidua; Ovarian cyst; Pregnancy CASE REPORT Received: 2011. 3. 2. Revised: 2011. 5.12. Accepted: 2011. 6. 2. Corresponding author: Y ong Won Park, MD Department of Obstetrics and Gynecology, Y onsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul 120-752, Korea Tel: +82-2-2228-2230 Fax: +82-2-364-7762 E-mail: [email protected] Th is is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2011. Korean Society of Obstetrics and Gynecology Korean J Obstet Gynecol 2011;54(7):373-376 doi: 10.5468/KJOG.2011.54.7.373 pISSN 2233-5188 · eISSN 2233-5196 The occurrence of ectopic decidua (deciduosis) has been observed most often in the cervix and appendix [1]. It has been established in approximately 90% of patients who have undergone laparot- omy during pregnancy [2]. Ovarian deciduosis, however, is a less frequent in pregnancy. Ectopics decidua is a physiological phe- nomenon of pregnancy and arises from a progesterone-induced metaplasia of subserosal stromal cells [2,3]. We experienced an unusual case of ovarian deciduosis found at 21 weeks gestation in a primigravida with features of ovarian cyst. Case Report A 32-year-old woman, gravida 1, para 0, abortus 0 was referred to our institute because of an accidentally detected left ovarian cyst at 21 weeks gestation. She had no signifi cant medical or gyneco- logical history before. On admission, transvaginal ultrasound scan showed 10.9 × 3.9 cm sized heterogenous cystic mass with solid portion. The peritoneal cavity was fi lled with small amount of free fl uid. Doppler utrasonogram image of the mass shows vasculariza- tion with pulsatility, a finding that is suggestive of a malignant mass (Fig. 1) [4,5]. The magnetic resonance imaging also showed 10 × 7 × 4.8 cm sized mass lesion consisted of multicystic compo- nent and large amount of solid component, mainly along the cyst wall suggestive of left ovarian tumor, borderline to malignancy (Fig. 2) [4,5]. As the result of the imaging studies was suspicious for malig- nancy, we thoroughly explained the natural history, prognosis of disease, available treatment methods, and their possible risks and discussed with the patient and her family. At last, they decided to conserve pregnancy. An exploratory laparotomy was planned at 21 weeks gestation. Through a midline incision, laparotomy was performed in the supine position. Intraoperative fi ndings revealed about 12 × 6 × 8 cm sized multiloculated mass on the left ovary, with mixed serous and solid portion. The tubes and uterus were grossly normal. The left salpingo-oophorectomy was done. A piece of ovarian tissue was taken for histopathological examination. Frozen sections of the mass revealed a benign cyst that might be a mucinous cystadenoma. The surgery has been completed suc- cessfully. Postoperatively patient was treated with antibiotics and tocolytics. After uneventful recovery she was discharged on 11 st postoperative day with ongoing pregnancy. The rest of the preg- nancy was unremarkable. At 40 weeks gestation an uneventful vaginal delivery resulted in a 3,440 g normal male baby with Ap- gar of 7/10 and 8/10. She was doing well at the 6 month follow- WWW.KJOG.ORG374 KJOG Vol. 54, No. 7, 2011 Fig. 1. (A) Transvaginal utrasonogram image shows a 10.9 × 3.9 cm sized heterogenous cystic mass with 6.6 × 3.5 cm, 2.5 × 1.4 cm and 1.8 × 1.4 cm of solid portion on left adnexa. (B) Doppler ultrasonogram image of the mass shows vascularization with pulsatility, a fi nding that is suggestive of a malig- nant mass (resistance index [RI], RI=0.37). PSV , peak systolic velocity; EDV , end-diastolic velocity; S/D, systolic:diastolic ratio. AB Fig. 2. Axial T2-weighted (A), coronal 2-weighted (B) and sagittal T2-weighted (C) images demonstrate late 2 nd trimester pregnant state and about 10 × 7 × 4.8 cm sized mass at left adnexa. The solid component along the cyst wall shows intermediate to high signal intensity on T2-wei ghted images (T2WI). The nodule (arrow) with low signal intensity on T2WI is possibility of paramagnetic component such as hemosiderin. Twen ty-one gestational week sized fetus is noted in (C). A BC WWW.KJOG.ORG 375 Jeong Hyeon Kim, et al. Ovarian deciduosis in pregnancy up after delivery. 1. Pathological fi ndings On microscopic examination, nest of epithelioid cells in small islands were seen. These cells were large with abundant granular cytoplasm in the specimen from the ovary. These cells were identi- fied as decidual cells. The ovarian cyst was reported as ovarian deciduosis in permanent pathologic examination (Fig. 3).

Decidual reaction is a well-documented physiological phenom- enon of pregnancy which arises from a progesterone-induced metaplasia of subserosal stromal cells [3]. With increasing dura- tion of pregnancy, there is vacuolar degeneration and fragmenta- tion of the decidua cells as a manifestation of regressive changes. The involution of the decidua takes place in four to six weeks post partum [6]. In the absence of pregnancy, it has been considered that stimulation of appropriate cells by progesterone and pro- gesterone-like substances from the corpus luteum or the adrenal cortex causes ectopic decidual formations [7,8]. It has been ob- served most often in the cervix and appendix [1,3]. Gross ovarian deciduosis is a rare lesion. The intraoperative appearance suggests mucinous cystadenoma. Deciduosis is an incidental fi nding that has not been associated with clinical symptoms [3,9], however, rare life-threatening events have been reported [10]. Deciduosis is usually an incidental mi- croscopic finding, detected in biopsies taken during caesarian sections, postpartum tubal ligations, appendectomies and in-tubal pregnancies [1]. The decidual cells on microscopy appear large with abundant cytoplasm and a bland nucleus. We experienced an unusual case of ovarian deciduosis in a primi- gravida that was suspicious for ovarian malignant tumor. Though a rare event, it should be considered as a differential diagnosis in cases presenting as ovarian malignant tumor during pregnancy.

1. Piccinni DJ, Spitale LS, Cabalier LR, Dionisio de Cabalier ME. Decidua in the peritoneal surface mimicking metastatic nod- ules. Findings during cesarean section. Rev Fac Cien Med Univ Nac Cordoba 2002;59:113-6. 2. Fenjvesi A, Zivkoviæ S. Deciduosis peritonei: a case report. Med Pregl 2005;58:196-9. 3. Szopi ñski TR, Sudoł-Szopiñska I, Dzik T, Borówka A. Ectopic decidual reaction in the urinary bladder presenting as a vesi- cal tumor. Urology 2009;74:1232-3. 4. Ghossain MA, Buy JN, Lignères C, Bazot M, Hassen K, Malbec L, et al. Epithelial tumors of the ovary: comparison of MR and CT fi ndings. Radiology 1991;181:863-70. 5. Troiano RN, McCarthy S. Magnetic resonance imaging evaluation of adnexal masses. Semin Ultrasound CT MR 1994;15:38-48. Fig. 3. Histologic fi ndings: ovary revealed a pinkish tan colored edematous stroma (A, H&E; ×40), deciduosis with hemosiderin laden ma crophage (B, H&E; ×100). AB WWW.KJOG.ORG376 KJOG Vol. 54, No. 7, 2011 6. Büttner A, Bässler R, Theele C. Pregnancy-associated ectopic decidua (deciduosis) of the greater omentum. An analy- sis of 60 biopsies with cases of fibrosing deciduosis and leiomyomatosis peritonealis disseminata. Pathol Res Pract 1993;189:352-9. 7. Tang LC, Cheung MY , Ma HK. Intraperitoneal bleeding from ectopic decidua following hormonal contraception. Case re- port. Br J Obstet Gynaecol 1985;92:102-3. 8. Weller CV . The Ectopic Decidual Reaction and its Signifi cance in Endometriosis. Am J Pathol 1935;11:287-90 1. 9. Papp Z, Petri I, Villányi E, Tiszlavicz L, Ugocsai G. Deciduosis causing perforating appendicitis in the early postpartum pe- riod following caesarean section. Orv Hetil 2008;149:329-31. 10. Shukla S, Pujani M, Singh SK. Ectopic decidual reaction mim- icking peritoneal tubercles: a report of three cases. Indian J Pathol Microbiol 2008;51:519-20. 임신 중 발견된 ovarian deciduosis 1예 연세대학교 의과대학 산부인과학교실 김정현, 남가현, 권자영, 김영한, 박용원 이소성 탈락막(ectopic decidua)은 자궁 이외의 부위에 발생하는 것으로 특히 난소의 이소성 탈락막은 드문 질환이다. 이는 임신 중 난소호 르몬과 태반의 호르몬, 그중에서도 특히 황체호르몬(progesterone)의 영향으로 변형된 자궁내막의 기질세포(stroma cell)로 구성된다. 우리 는 임신 21주에 좌측 난소 낭종의 크기 증가를 주소로 내원한 임신부에서 개복수술 후 조직학적으로 이소성 탈락막의 존재 여부를 확인한 1예를 경험하였기에 간단한 문헌 고찰과 함께 보고하는 바이다. 중심단어: 이소성 탈락막, 난소 낭종, 임신