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102 www.jkscience.org Vol. 17 No.2, April - June 2015

CASE REPORT

From the Department of Pathology and *Obst and Gyane, Govt Medical College Jammu J&K-IndiaCorrespondence to : Dr. Ruchi Khajuria, Assistant professor, Department of Pathology, Govt. Medical College, Jammu J&K India

Peritoneal Deciduosis: A Case ReportRuchi Khajuria, Sudhaa Sharma*, Kuldeep Singh, Neelam*

Ectopic decidua has been commonly observed inpregnant women in the ovaries, uterus andcervix.However, the presence of gross nodules withinperitoneal cavityand omentum(deciduosis)is a rareincidental finding on caesarean section (1).This isconsidered to be a metaplastic process of submesothelialmesenchymal cells related to progesterone.It is a benignself -limited condition but occasionally can present withhaemorrhage, abdominal pain,dystocia,irritable bowelsyndrome and can mimic appendicitis. Peritonealdeciduosis can be confused with carcinomatosis orgranulomas and can cause distress during a naturallystressful period of new parenthood. Biopsy of the lesionssolves the dilemma.We report here a case of peritonealdeciduosis in a 25 year old asymptomatic womandiscovered during caesarean section which raisedsuspicion of tubercular granulomas.Case Report

A 25 year old female,G2P1, admitted in SMGS hospital,Govt. Medical College Jammu as full term pregnancy inlabour, underwent caesarean under spinal anaesthesiafor imminent fetal distress and delivered a healthy malebaby.Here antenatal period in the both the pregnancieswas uneventful.During surgery,the surgeon noticed diffuse

Abstract Peritoneal deciduosis is a rare incidental finding on caesarean section.This is a self- limited metaplasticchange of submesothelial mesenchymal cells during pregnancy. We report a case of diffuse peritonealectopic decidual reaction discovered during caesarean section as pale whitish nodules simulating tubercles.Histology showed omentum studded with nodular groups of decidual cells with transition to spindle cellsresembling myofibroblasts.

Key WordsDecidua, Pregnancy, Peritoneal, Deciduosis

Introductionnodularityon anterior and posterior surface ofuterus,cervix,external surfaces of fallopian tubes, uterineligaments and omentum. The ovaries were normal. Onthe omentum, the area covered over by nodularity wasabout 10 cm in d. The nodules were pale white coloredand varied from 2 to 4 mm in size raising suspicion ofgranulomatous disease;though there was no history oftuberculosis in the past. Malignancy was not suspectedkeeping in view young age of the woman. Surgical biopsyof the omentum was taken and sent for histopathology.The postpartum period was normal and she wasdischarged on 7thday.

Pathological Findings: The omental biopsy consistedof a piece of omentum 3x2 cm, yellow brown,firm withcongested areas.It showed greyish nodularity varyingfrom 2 to 4 mm nodules (Fig 1).Microscopic examinationof H&E stained paraffin sectionsshowed the omentumstudded with nodular collections of cells with abundantgranular eosinophilic cytoplasm and nuclei with openchromatin and inconspicuous nucleoli resembling decidualcells (Fig 2).The nodules were vascular with sprinklingof lymphocytes .Some of the nodules were confluent.Decidual cells in part transforming to spindled cellswerepresent. Some of the cellular nodules were predominantlyspindle shaped resembling myofibroblasts (Fig 3).

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References1. Kinara P, Sen A, Sharma JC. Ectopic decidual reaction:a

case report. MJAFI 2006;62:280-812. Buttner A, Bassler R, Theele C. Pregnancy associated

ectopic decidua (deciduosis) of the greater omentum. Ananalysis of 60 biopsies with cases of fibrosing deciduosisand leiomyomatosis peritonealis disseminata. Pathol ResPract 1993; 18 :352-59

3. MalpikaA ,Deavers MT, Shahab I. Gross deciduosisperitonei obstructing labour: a case report and review ofthe literature. Int J Gynaecol Pathol 2002;21:273-75

4. ShuklaS,PunjaniM,SinghSK.Ectopic decidual reactionmimicking peritoneal tubercles: a case report of three cases.Ind J Pathol Microbiol 2008;51:519-50.

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DiscussionGross peritoneal deciduosis is a rare lesion. It can

involve ovaries, uterus, pelvis, omentum (2) and intestines.The surgeon can mistake the lesion for carcinomatosisand granulomas (3,4,5).A few case reports of grossperitoneal deciduosis have been reported in Indianliterature. Shukla et al (4)reported a series of three casesof this condition in young pregnant women withinvolvement of omentum and suspected the nodules tobe tubercular granulomas.In the present case, theobstetrician while doing caesarean section noted widespread nodules and suspected it to be tuberculousgranulomas. Carcinomatosis was not considered becauseof young age of the woman.Histology is important fordiagnosis.The differential diagnosis of peritonealdeciduosis includes deciduoid mesothelioma, metastaticcarcinoma and metastatic melanoma (6). No cellularatypia or mitotic activity was present in our case..Ectopicdecidual change is thought to be due to metaplasia ofsubmesothelial mesenchymal cells due to stimulation byprogesterone or progesterone like substances from corpusluteum or the adrenal cortex. The lesion involutes 4 to 6weeks postpartum. Occasionally the condition isassociated with intraperitoneal haemorrhage, dystocia (3),irritable bowel syndrome (7) , subacute intestinalobstruction and appendicitis.

Spindle cells probably derived from submesothelialmesenchymal cells may be admixed (1). Decidual celland cells transitional in form between muscle and decidualcells may be found in nodules (2) in pregnant women asobserved in the present case. This finding has not beendescribed in any of the case reports from India.

ConclusionGross deciduosis peritonei is a rare benign self- limited

metaplastic condition of peritoneum incidentallydiscovered during caesarean section and it can raisesuspicion of tubercles and carcinomatosis. Histology isimportant for diagnosis.

Fig 1. Omentum Showing Diffuse Nodularity Fig 2. Shows Subperitoneal Nodular Groups of Epithelioid Decidual Cells in Omentum (H&E X 100)

Fig 3. Shows Cellular Nodules Predominantly Composed of Spindled Cells