Abnormal Pregnancy Outcome Leading to Formation of Lithopedion

Arpita S. Shah*, Padmaja Y. Samant**, Shashank V Parulekar***

Abstract The word Lithopedion is derived from the Greek word Lithos meaning stone and pedion meaning child thus implying a foetus that has become stony. We present two interesting cases seen within a period of six months presenting with abnormal uterine bleeding after an abnormal pregnancy outcome. The first patient had undergone a curettage for medical termination of pregnancy. The second patient had undergone a curettage following an incomplete abortion which was followed by secondary infertility.

Introduction 1. Lithokelyphos (stone sheath or egg etention of foetal bones in the uterus shell), membranes alone get calcified Ris a rare complication of an MTP or forming a hard shell surrounding the curettage for an abortion.1 When not foetus. The foetus may undergo slight related to previous pregnancy loss, change only, or may be completely metaplasia of mature endometrial stromal skeletonised, but is not involved in the cells into bony tissue occurs as a response process of calcification. to chronic inflammation or trauma as 2. Lithokelyphopedion (stone sheath hypothesised by Roth and Taylor.2 child), in which both the membranes Prolonged retention of foetal bony and the foetus are calcified. tissue may cause pelvic inflammatory 3. True lithopedion (stone child), in which disease, chronic pelvic pain, menorrhagia, the foetus is infiltrated with calcium infertility, irregular bleeding, offensive salts and calcification of the vaginal discharge or passage of bony membranes is negligible. fragments per vaginum. It may prevent Case 1 implantation by causing an intrauterine A 34 year old woman, Para 4 Living 4 Abortion 1 came with a complaint of heavy regular menses for 4 contraceptive device like action. years following a first trimester MTP. She also 3 In 1881, Kuchenmeister noted that reported having blood tinged mucoid vaginal calcification may involve either the foetus, discharge for the rest of the cycle. On clinical examination the uterus was the membranes or the or a retroverted and bulky in size. Both fornices were combination of any of the above. Giving the clear. Ultrasonography showed a normal sized uterus following classification : with a 2.9 cm bright echogenic lesion with shadowing seen in the endometrium and adjacent myometrium, Third Year Resident *, Associate Professor, Professor suggestive of either submucosal calcific fibroid or and Head of Dept.***, Dept. of Obstetrics and endometrial calcification. The patient was taken for Gynaecology, Seth G. S. Medical College & K.E.M Hospital, Dr. E., Borges Marg, Parel, Mumbai, dilatation and curettage. During uterine sounding, a Maharashtra - 400012. gritty sensation was felt and there was difficulty in

Bombay Hospital Journal, Vol. 57, No. 2, 2015 249 passing the uterine sound and dilators. A haemostat was cautiously introduced into the uterine cavity and hard bony bits of tissue suggestive of foetal long bones and ribs were extracted (Fig. 1). The material was sent for histopathological examination. It showed endometrium with inflammatory infiltrate and osseus metaplasia and the bony fragments revealed irregular membranous calcified structures, probably foetal bones. After undergoing curettage the patient's symptoms were relieved.

Fig 2 : Gross appearance of the material obtained from the endometrial cavity Discussion Prolonged retention of foetal bony tissue or osseous metaplasia of e n d o m e t r i u m m a y c a u s e p e l v i c inflammatory disease, chronic pelvic pain, menorrhagia, menometrorrhagia, infertility, offensive vaginal discharge or passage of bony fragments per vaginum. It may prevent pregnancy by causing an Fig 1 : Gross appearance of the material obtained intrauterine contraceptive device like from the endometrial cavity. 4 Case 2 action. A 28 year old woman, married for 10 years, Para Schrenk, quoted by Schumann, in 0, Abortion 1, Living 0, came with a complaint of 1893 reported 11 cases of lithopedion excessive menstrual bleeding for 4 days with soakage among 610 cases of . of 3-4 pads per day and passage of clots. She reported undergoing a uterine curettage six years ago for Bainbridge in 1912 estimated the missed abortion and had not conceived after that. incidence as 1.5 per cent, or 9 among 626 On clinical examination the uterus was cases. In 1928 Masson and Simon at the anteverted and bulky in size. Both fornices were Mayo Clinic reported 9 cases of lithopedion clear. Ultrasonography showed a normal sized uterus with endometrial thickness of 15 mm. A hysteroscopy in 445 extra-uterine pregnancies. In 1939, was performed. It showed calcified fragment like Mathieu, adding 31 cases to those material in the endometrial cavity along with previously collected, reported a total of 229 endometrial tags. A laparoscopy was done, which cases in the literature. Of the 31 cases, 8 showed normal findings. Curettage of endometrial cavity was performed under laparoscopic guidance were discovered by roentgenography. and the material (Fig. 2) was sent for Reeves and Lipman, in 1941, brought the histopathological examination. It showed grand total of previously reported cases to inflammatory infiltrate in the endometrium with approximately 236, covering five multiple foci of calcification and ossification.

250 Bombay Hospital Journal, Vol. 57, No. 2, 2015 centuries. At the time of their publication, literature.2,4,6-12 Other complications 247 cases had been reported. Mathieu's include menometrorrhagia, vaginal summary shows the patients to range in discharge, pelvic inflammatory disease age from thirty to one hundred years, with and chronic pelvic pain and rarely, a period of retention from four to sixty passage of bony fragments per vaginum. years. Mathieu also collected 274 recorded Retained bony fragments may not be instances (up to 1936) of combined intra- visualised while performing an HSG and extra-uterine pregnancies, but was during evaluation of infertility. Diagnosis able to find among these only one case in can be made by a transvaginal USG or which lithopedion developed. Another radiographic study of the pelvis. example was added. Umnowa, in 1934, Hysteroscopy is an important tool for reported a case in which calcified masses diagnosis as well as removal of such bony were removed from either side of the fragments. Correlation of history and abdomen. sonographic findings is important. Taylor and colleagues in a study of Curettage should be done under nine patients reported secondary laparoscopic control so as to avoid uterine infertility in seven, pelvic pain in one and perforation during the procedure. Its passage of bony fragments in one.5 Verma completion should be confirmed under et al reported the case of a 20-year-old sonographic control so as to ensure woman with history of multiple complete removal of the bony tissue as well termination of pregnancy leading to as to prevent uterine perforation. chronic pelvic pain which got relieved after References hysteroscopic removal of the intrauterine 1. Shashank V. Parulekar, Shashank Shah and N. M. Nerurkar. Lithopedion formation after foetal bones.6 In another study, a case of incomplete abortion. The Journal of Obstetrics secondary infertility was reported and Gynaecology of , August 1986, Volume following MTP by dilatation and XXXVI, No. 4 , page no. 736. evacuation procedure at 22 weeks of 2. Roth E, Taylor HB. Heterotopic cartilage in the 6 uterus. Obstet Gynecol 1966;27:838-44. gestation. A similar case with secondary 3. D. Hamley and Aaron Shwinger. Lithopedion - infertility for a prolonged period of six Case Report and Survey : Samuel Brooklyn, N. Y. years was noted by other workers. Eleven 4. Moon HS, Park YH, Kwon HY, Hong SH, Kim SK. cases were reported from a Korean medical Iatrogenic secondary infertility caused by residual intrauterine foetal bone after centre in which retained fragments of midtrimester abortion. Am J Obstet Gynecol foetal bone after midtrimester abortion 1997; 176:369-70. were contributing to secondary infertility.4 5. Taylor PJ, Hamou J, Mencaglia L. Hysteroscopic The reported incidence of retained foetal detection of heterotopic intrauterine bone formation. J Reprod Med 1988;33:337-9. bones among diagnostic hysteroscopies is 6. Verma U, Chong D, Perez I, Medina C. Fetal 0.15%.7 bones retained in the uterine cavity as a rare Only a few cases of secondary cause of chronic pelvic pain: a case report. J Reprod Med 2004;49:853-5. infertility following intrauterine retained 7. Makris N, Stefanidis K, Loutradis D, foetal bone have been reported in world

Bombay Hospital Journal, Vol. 57, No. 2, 2015 251 Anastasiadou K, Hatjipappas G, Antsaklis A. The 10. Bakshi PS, Allahbadia GN, Kaur K, Virk SPS. incidence of retained foetal bone revealed in Hysteroscopic removal of intrauterine retained 2000 diagnostic hysteroscopies. J Soc fetal bones. Gynecol Surg 2004;1:159-66. Laparoendoscopic Surgeons 2006;10:76-7. 11. Van den Bosch T, Van Schoubroeck D, 8. Goldberg JM, Roberts S. Restoration of fertility Timmerman D, Depres J. Uterine intramural after hysteroscopic removal of intrauterine bone bone after mid trimester termination of fragments. Obstet Gynecol 2008;112:470-2. pregnancy may not affect fertility: a case report. 9. Graham O, Cheng L, Parsons J. The ultrasound Ultrasound Obstet Gynecol 2003;22:407-8. diagnosis of retained foetal bones in West African 12. Dawood MY, Jarrett JC 2nd. Prolonged patients complaining of infertility. Br J Obstet intrauterine Retention of fetal bones after Gynecol 2000;107:122-4. abortion causing infertility 1982;143:715-7.

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Asthma diagnosis and control Diagnosis of asthma is not clear cut. It relies on clinical judgement of patient history, symptoms (breathing problems, wheezing, and coughing), and objective measures of airflow obstruction, using spirometry or peak flow, or respiratory inflammation by measuring fractional exhaled nitric oxide (FeNO). However, no single diagnostic test, or set of tests, can definitively confirm asthma. According to the guidance, some estimates indicate that as many as 30% of people might have an asthma diagnosis without evidence of current clinical symptoms, underscoring the capacity for over- diagnosis and over-treatment. However, it is important to caution that the converse is also true-for many people, asthma can be under-recognised and undertreated. It can be difficult to accurately diagnose and it is certainly difficult to control in some patients. The Lancet, 2015, Vol 385, 482

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