Intrauterine and extrauterine lithopedion following cesarean scar rupture

⁎ Corresponding author. Xueshi Rd #2, Hangzhou, 310006, China. Tel.: +86 571 87061501; fax: +86 571 87061878. E-mail address: lbh8888@163.com (B.-H. Li). The steady rise in cesarean delivery rates has become one of the most serious topics in maternity care worldwide. In China, the rate of cesarean delivery increased rapidly from 6.7% in 1993 to 20.6% in 2003 [1]. We report a rare lithopedion formation following rupture of a cesarean scar. A 34-year-old patient (G2, P1) is described. The patient underwent a cesarean delivery in 2001 owing to preterm labor of a breech position fetus in her first pregnancy. The neonate died on the second day of life as a result of congenital alveolar dysplasia. The patient became pregnant for the second time in 2004. At 21 weeks of pregnancy the patient presented to hospital with a 1-day history of lower abdominal pain and irregular vaginal bleeding after sexual intercourse. Subsequently, fetal movement stopped and the patient did not seek further medical care. Regular menstrual cycles resumed 3 months later. Although the patient did not use contraception, no subsequent pregnancies ensued. A strong desire for fertility led the patient to seek evaluation at our hospital in June 2009. A computerized tomography (CT) scan showed a calcified external surface and images of bones within a mass that appeared to partially include the uterus (Fig. 1). The patient underwent exploratory laparotomy, which revealed a large calcified oval tumor adherent to the fundus of the uterus. The uterus was equivalent in size to an 8-week-old gestation. A connection between the uterine and abdominal cavities was identified. Thorough exploration revealed a calcified fetal skull located in the uterine cavity, whereas the other body parts, including the spine and limbs, were situated in the abdominal cavity. A uterine incision surrounded by the old scar was observed in the anterior wall of the uterus. Hence, it seems likely that rupture of the cesarean scar had caused the fetus to partly enter into the abdominal cavity. The lithopedion and calcified ovular membrane, as well as the old uterine scar, were completely resected and the uterus was repaired with interrupted sutures. To accelerate the healing of the uterine endometrium, treatment with estrogen followed by progesterone was used for 3 months. A favorable reproductive outcome for the patient is anticipated. For the diagnosis of lithopedion, ultrasound is able to demonstrate an echogenic mass, but is unable to differentiate such a formation from other calcified masses, such as ovarian tumors, myomas, or epiploic calcifications [2]. CT has the advantage of identifying the position, content, and integration of a calcified mass. Our CT results, coupled with evidence from the literature [3], demonstrated the criteria for diagnosis of a lithopedion. The diagnostic criteria are as follows: a largewell-defined calcifiedmass in the abdomen; regular or irregular images of bones observed in the mass; and ovular membranes surrounding the mass usually calcified and forming a hard eggshell like surface.