Cervical Deciduosis in Early Pregnancy Mimicking Malignancy: A report of two cases

Summary

Deciduosis is a benign condition characterised by the transformation of subepithelial connective tissue into decidual-like cells, typically occurring in response to hormonal changes during pregnancy. Although benign, cervical deciduosis may macroscopically resemble malignant lesions, leading to diagnostic uncertainty. This report presents two cases of cervical deciduosis diagnosed in early pregnancy. Both patients presented with first-trimester vaginal bleeding, and speculum examination revealed extensive wart-like lesions covering the cervix. Histopathological examination of cervical biopsies confirmed decidual changes. In pregnant women presenting with threatened miscarriage, a thorough local examination and biopsy of atypical cervical lesions are essential to exclude malignancy. As cervical deciduosis is a benign and self-limiting condition, no further treatment is usually required.

1. Introduction

Deciduosis refers to the presence of decidualised tissue outside the uterine cavity. This phenomenon is most commonly associated with pregnancy and is primarily mediated by progesterone. Accordingly, deciduosis may also occur in women receiving exogenous progesterone therapy. The cervix and ovaries are the most frequently reported sites, although cases involving the peritoneal cavity, appendix, and bowel have also been documented.^1,2,3,4 The most common clinical presentation is vaginal bleeding, although some cases may be asymptomatic. Here, we report two cases of cervical deciduosis that presented to our hospital with vaginal bleeding during the first and second trimesters, respectively.

2. Case report

A 33-year-old G2P1 female patient presented at 17 weeks of gestation with unprovoked vaginal bleeding. The bleeding was profuse and non-postcoital. An ultrasound scan revealed a viable fetus and an upper segment placenta. Per speculum examination revealed an irregular 4 cm growth on the posterior lip of the cervix with foul-smelling discharge. She subsequently underwent an examination under anaesthesia and cervical biopsy, as the growth in the cervix was suspicious for malignancy.

There was torrential bleeding following the biopsy, which was managed with vaginal packing and intravenous tranexamic acid. The biopsy report confirmed decidual changes in the cervix. The detailed histopathology described stromal fragments with prominent decidual transformation, lacking surface epithelium. Focal surface ulceration, dense neutrophilic infiltrate, and granulation tissue formation were also noted. A few glands with secretory changes were present [Fig. 1]. The patient had no further episodes of vaginal bleeding during the remainder of her pregnancy. She delivered preterm at 32 weeks of gestation, without any postpartum complications. At the 6-week postnatal follow-up, the cervix appeared normal, and a Pap smear was reported as negative for intraepithelial lesion or malignancy.

Fig. 1.

A & B: Haematoxylin and Eosin-stained microscopy (magnification at × 10 for panel A and magnification at × 20 for panel B) of the cervical mass biopsy showing prominent stromal decidual changes with surface ulceration.

A G4P3 woman presented at 10 weeks of gestation with minimal unprovoked vaginal bleeding. There was no history of postcoital bleeding. Her obstetric history included 3 previous caesarean deliveries. An abdominal ultrasound confirmed a viable fetus. Speculum examination revealed a 0.75 cm exophytic, warty lesion on the anterior lip of the cervix and vaginal fornix. A biopsy was performed in the outpatient department to rule out malignancy. Minimal bleeding occurred during the procedure, which settled with local pressure.

Histopathology revealed cervical deciduosis. The biopsy showed tissue fragments with decidual change, characterised by large, rounded cells with abundant pale eosinophilic cytoplasm and large, bland nuclei with prominent nucleoli, admixed with neutrophils and lymphocytes. Occasional endocervical gland was seen. There was no evidence of dysplasia or malignancy [Fig. 2]. The patient underwent an elective caesarean section at 36 weeks of gestation, and the 6-week postnatal follow-up showed complete resolution of the cervical lesion.

Fig. 2.

Haematoxylin and Eosin-stained sections showing (A cervical tissue with decidual reaction and mild acute inflammation (magnification at × 4) and (B decidual cells with large nuclei and abundant eosinophilic cytoplasm with a background of mild acute inflammatory infiltrate (magnification at × 10).

3. Discussion

Decidualisation is an essential physiological process in implantation and placental development. When decidual tissue is identified outside the uterine cavity, the condition is termed ectopic deciduosis. The cervix and ovaries are the most commonly reported sites; however, deciduosis has also been identified in the vagina, peritoneum and even within the uterine cavity in the form of a tumour-like mass.^5,6 Rarer sites of involvement include the kidneys, lungs and skin.^7,8,9

Ectopic deciduosis is typically a microscopic finding, detected in histopathology specimens taken during caesarean sections, postpartum tubal ligations or in the context of tubal ectopic pregnancies.⁶ Although this condition is common, it is generally asymptomatic.¹⁰ Burnett and Millan reported decidual cells in 100% of omental biopsy specimens.¹¹ Moreover, macroscopic ectopic decidual tissue has been observed in approximately 10% of patients undergoing caesarean section. Peritoneal tubercles are often seen during caesarean delivery, particularly on the posterior surface of the uterus and ovaries. When biopsied, these may represent subtle manifestations of deciduosis.

Although deciduosis is usually asymptomatic, rare but serious clinical presentations have been reported, including hemoperitoneum, obstructed labour, pulmonary involvement and even perforation of hollow viscera. The exact pathogenesis of deciduosis remains debated. One theory suggests that cervical decidual change results from an abnormal response of normal stromal cells to hormonal stimulation in pregnancy, particularly progesterone.¹² Another theory proposes that ectopic decidualisation in extrapelvic sites (such as the peritoneal cavity or omentum) occurs due to metaplasia of the superficial coelomic stroma in response to progesterone.¹³

Cervical deciduosis typically presents as small, sessile polyps or elevated, highly vascular single or multiple nodules.¹⁴ However, lesions as large as 8 cm have been reported.¹⁵ This variation in presentation underscores the importance of thorough per speculum examination to identify local causes of antepartum haemorrhage.

Colposcopy is frequently utilised to investigate abnormal cervical cytology. During pregnancy or the immediate postpartum period, cervical deciduosis may be encountered during colposcopic examination. It generally presents as small, elevated vascular nodules or, more rarely, as sessile polyps. Colposcopic assessment is especially important if cervical dysplasia is suspected during pregnancy. However, interpretation may be challenging due to pregnancy-associated cervical changes, including hypertrophy, eversion, endocervical gland hyperplasia and increased vascularity.¹⁶

Under such circumstances, decidual lesions may resemble invasive carcinoma macroscopically.^{1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17} Other differential diagnoses include cervical polyps, adenomas, infections, cervical dysplasia and carcinoma. Histological examination is therefore necessary to distinguish deciduosis from malignancy, particularly when the lesion appears suspicious macroscopically. Nonetheless, the presence of normal cervical cytology, absence of abnormalities on colposcopic evaluation and localisation of lesions outside the transformation zone may help differentiate deciduosis from cervical dysplasia.

Although cervical deciduosis is a benign condition and typically resolves spontaneously within 4–6 weeks postpartum, it should be considered in the differential diagnosis of antepartum haemorrhage.¹⁸

4. Conclusion

In pregnant women presenting with vaginal bleeding, a thorough local examination and biopsy of any suspicious cervical lesion are essential to exclude malignancy. While cervical deciduosis may appear alarming on macroscopic examination, it is a benign condition that typically requires no further intervention.

Authors' Contribution

Ajit Sebastian: Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Writing - Original Draft, Validation, Supervision. Nada Salih: Formal Analysis, Writing - Original Draft. Shiby Jose: Investigation, Data Curation, Formal Analysis. Vaidyanathan Gowri: Conceptualization, Methodology, Validation, Supervision, Writing - Review & Editing. Tamima Al Dughaishi: Validation, Supervision, Writing - Review & Editing.

Ethics Statement

Consent was obtained from both patients for the publication of this report.

Data Availability Statement

Data is available upon reasonable request from the corresponding author.