figure 1.jpg
figure 2.jpg
figure 3.jpg

Lithopedion Causing Intestinal Obstruction

Riogi B1 MBChB, Odhiambo K1 MBChB, MMED (Surgery), Ogutu O2 MBCB, M.MED (O/G),PGDRM Affi liation: 1- Level 5 Kisii

Hospital 2-Department of Obstetrics & Gynaecology, University of Nairobi. Correspondence: Bahaty Riogi, MBChB, Department of

surgery, Kisii Level 5 Hospital, P.O Box 92-40200 Kisii, E-mail:

 

Summary

The formation of a mummified intra-abdominal pregnancy (lithopedion) is rare. A 25 year old Para 4 + 0 gravida 5 presented with features of intestinal obstruction and a four year history of an intra abdominal mass. Examination revealed a solid mass in the right upper quadrant. Ultrasound imaging showed a poor echo-calcified mass while an erect abdominal x ray revealed foetal bones within the abdominal cavity. At laparatomy a lithopedion with a normal uterus was found. Her last normal delivery was one year prior to this current presentation.

 

A lithopedion causing a mass effect (intestinal obstruction) and predating a normal intra uterine pregnancy followed by spontenous vertex delivery has not been reported in Kenya.

Introduction

Abdominal pregnancy accounts for up to 1.4% of all ec-topic pregnancy (1). It is usually associated with high morbidity and mortality. A large lithopedion is a rare obstetric phenomenon with less than 300 cases reported worldwide (2,3) . It occurs when a fetus dies during an abdominal pregnancy, is too large to be absorbed and instead calcifies to shield the mother from the dead tis-sues and infection. A case of a large lithopedion present-ing with intestinal obstruction has not been reported in Kenya.

 

Case Report

This is a case report of a 25 year old woman, Para 4 +0 gravida 5 who was referred to Kisii level 5 Hospital(KL5H) with a diagnosis of intestinal obstruction . She pre-sented with complaints of abdominal pain, constipa-tion, abdominal distension and vomiting for two days and a four year history of a non progressive abdominal swelling. On examination there was a large mass in the right upper quadrant, extending from the umbilicus to the epigastric region, hard in consistency, measured ap-proximately 20 by 20 cm, non tender, mobile with ill defined margins. Abdominal ultrasound revealed a poor echo-calcified mass on the right hypochondrium mea-suring 11.7 by 9.2 cm and a normal liver, gall bladder, kidneys and spleen appear normal. A plain abdominal x-ray revealed a non viable intra abdominal gestation, with positive Spalding sign.

 

Further obstetric history was then sought. She reported to have been pregnant 4 years prior to the time of pre-sentation. She had not attended any antenatal care clinic and had perceived foetal movements. Nine months later, she reported having lower abdominal pain radiating to the back which was increasing in intensity and was ad-mitted in labour for delivery. Two days later however, the abdominal pain ceased and no more foetal move-ments felt. She was released from the health facility and discharged with no explanation as to why there was no delivery. The abdominal swelling progressively reduced in size, with the development of swelling in the right up-per abdomen with intermittent low grade pains.

 

Three years later in August 2008, the patient presented to KL5H and a diagnosis of a non viable extrauterine pregnancy was made. She declined admission. She later conceived and delivered at home to a live female infant in May 2009.

 

With the presence of a mummified intra-abdominal pregnancy and features of intestinal obstruction, she was optimized for a laparotomy. At surgery a 25 cm wide hard mass (Figure 1) in the right upper quadrant was dissected off the gall bladder, the right lobe of the liver, hepatic flexure and anterior abdominal wall. The uterus, ovaries, adnexia were normal.The thick capsule covering the mass was opened to expose a hyper flexed fetus (Figure 2) which was extended to confirm a fully formed fetus (Figures 3). The patient recovered and was discharged on the 10th post-operative day.

 

Discussion

 

This case is presented due to its uniqueness. This pa-tient had an abdominal pregnancy which mummified and she was able to conceive three years later and carry a baby to term.

 

Abdominal pregnancies are rare and are secondary to aborted tubal pregnancy or intra abdominal fertilization of ova (1, 4). The mortality and morbidity are higher as the pregnancies advance in gestation. (5). The patients commonly present with an abdominal mass, nausea and vomiting, painful foetal movements and less frequently vaginal bleeding (6). Recurrent pain in the gravid patient may signal an abdominal pregnancy. Patients may ex-perience spurious labour, loss of foetal movements and persistence of abdominal swelling (6). This is followed by history of lactation which can either be spontaneous or expressive.

 

Though diagnosis is usually through ultrasound, this may not be very sensitive. Magnetic resonance imaging (MRI) is now the most accurate investigative tool (5, 7). There are cases reported which do go undetected/unno-ticed till at an advanced gestational age while in others the diagnosis is only made after a laparotomy (6).

 

Once the diagnosis of abdominal pregnancy has been made, surgical intervention is vital to avoid complica-tions. Methotrexate treatment has been used with mini-mal success (8). Methotrexate can work better in early gestation, but shows minimal response in larger gesta-tions, where it may not be recommended due to its po-tential to lead to sepsis and maternal death (9). Com-plications after lithopedion formation include volvulus formation (10), intestinal obstruction, haemorrhage, disseminated intravascular coagulopathy, fistula forma-tion, and cephalopelvic disproportion of a concominant pregnancy (11) and pelvic abscess (12). The case present-ed had complication of partial intestinal obstruction.

 

In advanced abdominal pregnancy resorption is not pos-sible. It therefore undergoes a calcification process, re-sulting in the formation of a lithopedion. The diagnosis is usually confirmed with good imaging technique, and also based on the high clinical index of suspicion. In situations where the clinician is not alert to the clinical details then the case can be easily missed as was seen in this patient. Return of fertility after abdominal preg-

 

Click to view figure 1

 

Click to view figure 2

 

Click to view figure 3

 

nancy is not assured though patients do resume normal menstrual cycles and conceive thereafter with the litho-pedion in situ, as was seen in the case presented. The important lesson to be learnt in the case presented is that in the developing countries where alternative medi-cine is common many patients may fear undergoing sur-gery and may therefore decline only to present later with serious complications as seen in this case.

 

References

 

  1. Atrash H K. Friede A, Hogue C. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gy-necol 1987; 69: 333-337

  2. Zaheer SA. Acute intestinal obstruction caused by lithopae-dion. Br J Surg 1971; 58(5)401–2.

  3. Bondeson J. The earliest known case of a lithopaedion. J R Soc Med. 1996;89:13-8

  4. Dover R W. Powell M C. Management of a primary abdomi-nal pregnancy. Am J Obstet Gynecol 1995; 172: 1603-1604

  5. Varma R. Successful outcome of advanced abdominal preg-nancy with exclusive omental insertion. Ultrasound obstet gynaecol 2003; 21:192-194

  6. Rahman M S. Al-Suleiman S, Rahman J et al. Advanced ab-dominal pregnancy—observations in 10 cases. Obstet Gyne-col 1982; 59: 366-372

  7. Gavin L, Crawley C. Clinical use of magnetic resonance im-aging for the evaluation of abdominal pain during pregnan-cy. Int J Obstet Gynecol 2010; 111: 82–90

  8. Zinger M, Rosenfeld D. Failed treatment of abdominal preg-nancy with methotrexate. J Reprod Med 2001; 46(4): 392-394

  9. Mi SK, Soyoon P, Tae S L. Old abdominal pregnancy present-ing as an ovarian neoplasm. J Korean Med Sci 2002; 17: 274-5

  10. Glass BA, Abramson PD. Volvulus of cecum due to lithope-dion. Am J Surg 1953; 86:348 –52

  11. Leke RJ, Nasah BT, Shasha W, et al. Cephalopelvic dispro-portion at term involving a lithopedion: A case report. Int J Gynaecol Obstet 1983; 21:171– 4.

  12. Tarun J, Eckert, L.O. Abdominal pregnancy with lithopedion formation presenting as a pelvic abscess. Obstet Gynecol 2000; 96:808 –10.