Retained pregnancy for five years in a rudimentary uterine horn

Abstract

A 42-year-old Columbian woman presented with complaints of left iliac fossa pain since the last two months, which had become acutely worse over the previous few hours. It was associated with nausea, night sweats and anorexia. On vaginal examination a tender mass measuring 10 cm in diameter was found in the left adnexum arising from the uterus. Blood tests were suggestive of anaemia and infection. After admission she received a blood transfusion and IV antibiotics. An ultrasound scan revealed a calcified mass 10 cm in diameter. At this stage differential diagnosis included a dermoid cyst and a chronic pelvic abscess or a calcified pedunculated fibroid. The patient's hospital records revealed that she had had four full term normal vaginal deliveries, the last being delivered 5 months previously. She did not have any other significant history. At antenatal booking (16 weeks) a fibroid had been suspected clinically, and on ultrasound scan a calcified mass of 10 cm in diameter had been found. There was no further comment on this mass during her pregnancy. After 4 days of conservative management in the hospital the patient still had a swinging pyrexia and the mass was unchanged. Therefore, it was decided to proceed with laparotomy. At laparotomy, a foul smelling, 12-cm necrotic mass was found arising from the left side of the uterus with the transverse colon densely adherent to it. Attempting to divide these adhesions, the outer necrotic surface of the mass disintegrated and the transverse colon was seen to be perforated by the ossified remnants of a retained fetus. Further dissection revealed the mass to be a noncommunicating rudimentary horn of the uterus. The left uterine horn along with the fetus was removed. Resection anastomosis was performed on the perforated segment of the sigmoid colon. The patient then made an uneventful recovery. Postoperatively, when informed of the existence of the dead fetus in utero, the patient informed us that 5 years previously in Columbia she had developed the symptoms and signs of pregnancy. When what she described as labor pain had started, she had been admitted to the local hospital, but no baby had been delivered. She was discharged some days later and gradually her symptoms and signs had diminished. Histology revealed the ossified remnants of a dead fetus, the femur length being consistent with a fetus of 37 weeks' gestation, perforating the smooth muscle of the rudimentary horn. A lithopaedion, or stone child, is a dead fetus, usually the result of a primary or secondary abdominal pregnancy that has been retained by the mother and subsequently calcified. Identification of a 3100-year-old lithopedion in the Archaic South-west antedates its first clinical notation by 2100 years. It was only the ‘autopsy’ of the time (excavation of the site) that allowed its presence to be brought to light (1). The earliest known case was discovered in 1582, at the autopsy of a 68-year-old woman in the French city of Sens, and was described in a thesis by the physician Jean d′ Ailleboust (2). Our case was, truly speaking, not a lithopaedion because it was not a case of abdominal pregnancy. In this case the fetus was retained in a rudimentary uterine horn. From the history it would appear that this dead fetus had been retained for 5 years and had been carried through three normal pregnancies without complication. During her last pregnancy, in the UK, a mass had been identified, but because of its size, position and the presence of calcification within it, it was assumed to be a fibroid. This case is presented because of its rarity, as an extensive Medline literature search did not reveal any similar case report. In addition, it demonstrates that exotic diagnoses must sometimes be considered in patients from exotic locations. Address for correspondence: Santanu Acharya Department of Obstetrics and Gynecology Southern General Hospital 1345 Govan Road Glasgow, G51 4TF e-mail: drsantanuacharya@aol.com