Rare presentation of cervical deciduosis as antepartum haemorrhage

Abstract

Cervical deciduosis refers to the condition in which ectopic decidual changes take place in the cervix. It is mostly asymptomatic but sometimes may have various clinical presentations. In our case, patient had a rare clinical presentation of cervical deciduosis, in the form of an antepartum haemorrhage at 32 weeks. On examination, there were multiple friable lesions measuring 5–15 mm in size on both the lips of the cervix and it was very much simulating to malignancy, so biopsy was done. However, biopsy led to uncontrolled bleeding and finally the patient required premature lower segment caesarean section. Both mother and baby were well. Biopsy report was diagnostic of cervical deciduosis. On follow-up at 6 weeks post partum, the cervix was found to be absolutely healthy. Since, cervical deciduosis is a benign condition which gets resolved 4–6 weeks post partum. So, keeping differential diagnosis of cervical deciduosis in mind is very important to avoid unnecessary cervical biopsies during pregnancy. And patient with suspicion of cervical deciduosis should be followed up postpartum strictly.

Background

During implantation, decidual changes occur in whole of the uterus except cervix. Cervical deciduosis refers to the condition in which ectopic decidual changes happen in the cervix. Although this condition is rare, it is clinically important. Cervical deciduosis is a benign condition; however, it may sometimes mimic dysplasia or malignancy. Lesions of cervical deciduosis are multiple, small elevated vascular nodules or may be as sessile polyps. This case highlights the fact that cervical deciduosis should always be kept in differential diagnosis for cause of antepartum haemorrhage for the angry-looking cervix which gives suspicion of malignancy. If we would have been aware of this entity and biopsy would have been avoided, probably premature delivery would not have been required. This is a benign condition which resolves spontaneously 4–6 weeks post partum and does not need any treatment. This case has been written for creating awareness for keeping cervical deciduosis in differential diagnosis of antepartum haemorrhage.

Case presentation

We present a case of 28-year-old pregnant woman, third gravida with two living issues at 32 weeks 5 days gestation with previous caesarean section with antepartum haemorrhage with mild anaemia. She came with complaint of bleeding per vaginum since last one day. Bleeding was mild in amount, bright red in colour, and was not associated with pain abdomen. On general examination, she had a pallor of 1+ with stable vitals. On per abdominal examination, fetal growth was corresponding to 32 weeks and uterus was relaxed. On per speculum examination, no active bleeding was present; however, cervix was hypertrophied. Several lesions varying from 5 to 15 mm were seen on the cervix involving anterior and posterior lip of the cervix giving high suspicion of malignancy as shown in figure 1 with black arrows. On ultrasonography, single live fetus of 31 weeks 3 days gestation with right anterolateral placenta, adequate liquor and no abruption was seen. In view of high suspicion of malignancy, procedure of cervical biopsy was planned in emergency operation theatre after taking written informed consent. The patient was laid down in lithotomy position and biopsy was taken. Biopsy resulted into torrential haemorrhage, so bilateral descending cervical arteries were ligated in an attempt to control bleeding. The patient kept bleeding continuously, so immediately decision of caesarean section was taken. Female baby of 1.93 kg was delivered with APGAR score of 7/8. Peroperatively bleeding was present from lower uterine segment, so bilateral uterine artery ligation was done and intrauterine balloon tamponade was placed to control residual bleeding. Two units Packed red blood cell (PRBC) were transfused in peroperative period. Postoperative period was uneventful and patient was discharged on day 8 in satisfactory condition with advice of follow-up with histopathology report of cervical tissue.

Figure 1.

Multiple size friable lesions on the cervix as shown with black arrows.

Investigations

Ultrasound at 32 weeks gestation: single live fetus corresponding to 32 weeks gestation, placenta right anterior lateral, amniotic fluid index 10 cm, no abruption

On histopathology, section showed sheets of decidual cells in between normal endocervical glands. On higher power, these cells were polygonal with centrally placed nuclei, prominent nucleoli and abundant eosinophilic cytoplasm. These cells were negative for pan cytokeratin, ruling out malignancy (figure 2).

Figure 2.

Section shows sheets of decidual cells in between normal endocervical glands (A) (H&E 200×). On higher power, these cells are polygonal with centrally placed nuclei, prominent nucleoli and abundant eosinophilic cytoplasm (B) (400×). These cells are negative for pan cytokeratin (C) (200×).

Treatment

Ligation of bilateral descending cervical arteries was done in an attempt to control bleeding. When failed, immediately caesarean section was done followed by bilateral uterine artery ligation. For residual bleeding, intrauterine tamponade was placed.

Outcome and follow-up

The patient was first followed up with histopathology report, which came out to be cervical deciduosis. The patient was further followed up at 6 weeks post partum with per speculum examination. Per speculum examination was normal (figure 3), and liquid-based cytology was negative for intraepithelial lesion or malignancy.

Figure 3.

6 weeks postpartum cervix.

Discussion

Decidual transformation is a physiological process that occurs normally during pregnancy, but when this transformation occurs at places other than uterus, it is called as ectopic decidua or deciduosis. It can occur at different places, such as cervix, ovary, appendix, omentum, diaphragm or peritoneum. The most common site of deciduosis is the cervix and the ovary with maximum incidence of 34% during pregnancy.¹ The true incidence of deciduous is unknown.

Decidual changes are due to progesterone-induced changes in stroma which normally occur during implantation in pregnancy. Zaytsev et al² suggested two theories of ectopic deciduosis. First, progesterone-induced superficial coelomic stromal metaplasia, and second, that decidua is present normally in many places that undergo decidual change under control of hormone. Concerning the cervix, the current opinion is that decidual change is a reaction of normal stromal cells to hormonal stimulation.³

Deciduosis is an accidental finding in pregnancy or is detected during caesarean section, appendicectomy, ectopic pregnancy or during follow-up of cervical premalignant dysplastic change. Most patients are asymptomatic and require no active intervention; however, sometimes there may be a life-threatening condition such as haemorrhage,⁴ recurrent pneumothorax,⁵ perforating appendicitis⁶ and obstruction of labour due to gross peritoneal deciduosis.⁷

On gross examination, it appears like multiple small yellow or red elevations of cervical mucosa which are soft, friable, bleed easily and rarely is fungating and resembles carcinoma.

On colposcopy examination, the decidual change may present as features of invasive cervical carcinoma⁸ due to vascularisation of epithelium hypertrophy,⁹ hyperplasia and eversion of endocervical glands; however, diagnosis of cervical polyp, adenoma, infection or carcinoma should be considered. Histological investigation may be required to make a definitive diagnosis to differentiate between dysplasia and deciduosis.

The case highlights the fact that the presence of multiple friable polyps-like lesions on the cervix simulating to malignancy may be presentation of cervical deciduosis, so differential diagnosis of cervical deciduosis in such cases should be kept in mind and doctor should decide carefully whether or not to biopsy. Written informed consent is very important. Patient should be followed up in postpartum period because cervical deciduosis is a benign change of cervix during pregnancy that resolves within 4–6 weeks post partum.

Learning points.

• Cervical deciduosis is a rare cause of antepartum haemorrhage.

• Cervical deciduosis may simulate to malignancy clinically.

• In presence of pregnancy, multiple friable red or yellow elevation on cervix can be cervical deciduosis, so biopsy can be avoided during pregnancy in these cases.

• Cervical deciduosis is a benign change of cervix during pregnancy that resolves within 4–6 weeks postpartum.

Ethics statements

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Consent obtained directly from patient(s).