Seven-year retained broad ligament lithopedion presenting as an abdominal mass: a rare case report

Abstract

Introduction:

Lithopedion, an extremely rare complication of abdominal ectopic pregnancy, may remain undiagnosed for a long time due to nonspecific symptoms. Only two cases have been reported from Bangladesh, and approximately 350 cases have been documented globally in the existing literature on lithopedion.

Case presentation:

A 35-year-old multiparous woman from a low socioeconomic background presented with mild lower abdominal pain and a palpable abdominal mass, with a history of an untreated, previously diagnosed ruptured ectopic pregnancy 7 years earlier. Ultrasonography revealed a calcified extrauterine fetus in the right adnexal region corresponding to approximately 18–21 weeks' gestation. Exploratory laparotomy confirmed a macerated fetus located within the broad ligament, with dense adhesions to the surrounding bowel structures. The fetus and associated necrotic tissues were successfully removed.

Clinical discussion:

While evaluating a multiparous woman from a low-resource setting with a long-standing abdominal mass, the outcomes of all previous pregnancies should be inquired about, with lithopedion considered among the differential diagnoses. A pelvic ultrasound serves as a cost-effective initial diagnostic tool. Exploratory laparotomy is the definitive management for symptomatic cases to prevent long-term complications.

Conclusion:

This case highlights that disparities in access to healthcare, lack of awareness, and negligence are the main contributing factors behind rare events like lithopedion formation following ectopic pregnancy, which is considered almost obsolete in modern obstetric practice. Early diagnosis and timely management of ectopic pregnancy, as well as the development of a proper surveillance system, especially in resource-limited settings, and increased awareness can help prevent conditions like this.

Introduction

Ectopic pregnancy refers to implantation of the fertilized ovum outside the endometrial cavity and accounts for approximately 1–2% of all pregnancies. The most common site is the fallopian tube; however, implantation may also occur in other locations, such as the cervix, ovary, abdominal cavity, uterine cornua, or a previous cesarean section scar^[1,2^].

Abdominal pregnancy is an uncommon form of ectopic pregnancy, representing approximately 1.4% of all ectopic pregnancies. It is associated with significant maternal morbidity due to complications such as massive hemorrhage, injury to intra-abdominal organs, and fetal abnormalities^[3^]. Among abdominal pregnancies, implantation within the broad ligament is extremely rare and usually results from secondary implantation following tubal abortion or rupture^[4^].

HIGHLIGHTS

• Lithopedion is a rare complication of undiagnosed or untreated abdominal pregnancy in which a dead fetus becomes calcified within the maternal body, typically resulting from secondary abdominal implantation following a ruptured ectopic pregnancy, and may be retained for years due to unawareness of the abdominal ectopic pregnancy or negligence even after it is known.

• Broad ligament lithopedion is extremely uncommon and usually results from secondary abdominal implantation following tubal rupture or abortion.

• Patients may remain asymptomatic for many years and may present later with nonspecific symptoms such as abdominal pain or an abdominal mass.

• Multiparous women aged 30–80 years, of low socioeconomic status and with limited healthcare access, are the ones affected in incidentally diagnosed cases.

• Ultrasonography is an important initial diagnostic tool, while computed tomography or magnetic resonance imaging may further define the anatomical location.

• Surgical removal is the definitive treatment, especially in symptomatic cases or when complications are suspected.

In rare circumstances, when an abdominal pregnancy remains undiagnosed and the fetus dies, the fetal tissues may undergo calcification within the maternal abdomen, resulting in a condition known as lithopedion, or “stone baby,” derived from the Greek words lithos, meaning “stone,” and paidion, meaning “child.” As a protective mechanism against infection and foreign-body reaction, the fetal tissues gradually become calcified when the dead fetus is too large to be resorbed by the maternal body, leading to the formation of a lithopedion. Lithopedion is an exceptionally rare phenomenon, with approximately 350 cases reported globally and only two cases from Bangladesh reported in the medical literature to date. Its occurrence in the broad ligament is even rarer, as broad ligament ectopic pregnancies themselves account for only about 1 in 300 ectopic pregnancies, making the formation of a lithopedion in this location extremely uncommon. Because symptoms are often nonspecific, patients may remain asymptomatic for many years. When present, symptoms may include abdominal pain, vaginal bleeding, gastrointestinal discomfort, or a palpable abdominal mass. Imaging modalities such as ultrasonography, computed tomography (CT), and magnetic resonance imaging help establish the diagnosis^[3–8^].

Here, we report a rare, well-documented case of a lithopedion retained within the broad ligament for 7 years in a 35-year-old woman, due to her own negligence. We aim to highlight an overall management plan for lithopedion, emphasizing its continued relevance in surgical practice despite its rarity.

Methods

Study design

The study is a case report (prospective, single-center, formal, consecutive, and clinical). This case report was prepared in accordance with the SCARE 2025 criteria^[9^].

Case presentation

A 35-year-old woman, a garment worker, para two (two previous vaginal deliveries) with one previous abortion, normotensive and non-diabetic, with no significant medication or allergy history, presented to the gynecology outpatient clinic with a 1-month history of mild right lower abdominal pain associated with a palpable mass. She also reported a pregnancy that did not result in delivery 7 years earlier. She attained menarche at 15 years of age and has regular menstrual cycles, occurring every 28 days and lasting 4–5 days.

Seven years earlier, she conceived spontaneously and experienced 3 months of amenorrhea. At that time, she was diagnosed with a ruptured ectopic pregnancy with mild free fluid in the cul-de-sac on transabdominal ultrasonography. Her gynecologist advised an emergency laparotomy; however, she refused the procedure due to job insecurity and a lack of family support. She gradually recovered from the acute condition without surgical intervention.

Approximately 22 weeks after the initial diagnosis, she again consulted a physician due to mild lower abdominal pain. On clinical examination, a palpable right adnexal mass was found. Ultrasonography demonstrated a right-sided complex mass with fetal bony structures casting posterior acoustic shadows. She was again advised to undergo laparotomy, but she declined further treatment and did not seek additional medical consultation.

Over the following 7 years, the swelling persisted but remained largely asymptomatic, except for occasional mild lower abdominal pain. Gradually, the size of the mass decreased until the recent onset of discomfort prompted her to seek medical attention.

She denied any history of abnormal vaginal bleeding, vaginal discharge, fever, or bowel or urinary symptoms. There was no history of abdominal surgery, and she had never used contraception.

On clinical examination, the patient was hemodynamically stable with normal vital signs. Abdominal examination revealed a firm, moderately tender mass in the right hypogastric region. There was no guarding or rigidity, and no hepatosplenomegaly was noted. Bowel sounds were normal. Per vaginal examination revealed a healthy vulva and vagina with a closed cervical os. A moderately tender right-sided adnexal mass was palpated, which appeared to be adherent to the right side of the uterus, and the uterus could not be clearly delineated from the adnexal mass.

Abdominal ultrasonography demonstrated a bulky anteverted uterus measuring 10.1 × 5.0 × 4.2 cm, with no evidence of an intrauterine gestational sac or retained products of conception. A well-defined calcified mass measuring approximately 4.0 × 4.9 cm was noted in the right adnexal region. Transvaginal ultrasonography confirmed an empty uterine cavity with an endometrial thickness of 8.8 mm and revealed a well-formed extrauterine fetus in the right adnexa. Biometric measurements showed a collapsed biparietal diameter of 6.3 cm, corresponding to 18 weeks and 1 day of gestation, and a femoral length of 3.6 cm, corresponding to 21 weeks and 4 days of gestation, with posterior acoustic shadowing (Fig. 1). No fetal cardiac activity or fetal movements were detected, consistent with fetal demise. Based on these findings, a diagnosis of chronic abdominal pregnancy was made.

Figure 1.

Twenty-one weeks and 4 days of gestational age and a 7-year old lithopedion.

Following proper counseling and informed consent, the patient underwent an elective exploratory laparotomy under general anesthesia. Intraoperatively, dense adhesions were noted between the gestational sac, adjacent bowel loops, and the right pelvic sidewall. Careful adhesiolysis was performed to avoid injury to surrounding structures. An irregular mass was observed on the right side of the uterus within the broad ligament. An incision was made in the anterior leaf of the broad ligament, and a calcified and macerated fetus was identified within it. Carefully, the entire sac was removed. Slight bleeding was controlled using diathermy. The size of the fetus corresponded to an 18–21-week gestation and was surrounded by necrotic membranes and calcified tissue remnants. The placental tissue was densely adherent to the surrounding structures and was carefully dissected and removed together with the fetus. No significant intraoperative hemorrhage occurred, and adjacent pelvic organs and bowel loops were preserved without injury.

Following complete excision of the lithopedion and associated tissues, meticulous hemostasis was achieved. The peritoneal cavity was irrigated thoroughly with warm normal saline, and a pelvic drain was placed before closure of the abdomen in layers. The excised specimen was sent for histopathological examination.

The postoperative course was uneventful. The pelvic drain was removed on postoperative day 2, and the patient was discharged in stable condition on postoperative day 6. At follow-up assessment, she remained asymptomatic with no evidence of postoperative complications.

Discussion

Lithopedion reflects the consequences of delayed diagnosis and limited access to healthcare. The overall incidence of lithopedion is extremely low, approximately 0.0054% of all gestations and 1.5–1.8% of abdominal pregnancies. Abdominal pregnancy itself is a rare form of ectopic pregnancy, accounting for approximately 1–2% of all ectopic pregnancies^[2,3^]. Among these cases, implantation within the broad ligament is extremely rare. Broad ligament pregnancy usually results from secondary implantation following tubal rupture or tubal abortion, allowing the conceptus to implant between the two layers of the broad ligament^[4^]. Lithopedion may remain within the maternal abdomen for several years, up to 70 years, with affected patients ranging in age from 30 to 100 years^[5,10^].

In Bangladesh, only two previously reported cases of lithopedion are available to date. The other two already published studies are from 2012 to 2024^[7,8^]. In all three cases, patients were multiparous and aged between 35–48 years at the time of diagnosis, which is within the lower end of the typical age limit. The age of lithopedion in our case was quite similar to the case of Rahman et al (around 8 years), while age was not specifically mentioned by Hossain et al. While only ultrasound was used in our case for diagnosis, abdominal X-ray, CT scan, and color Doppler were performed in addition to ultrasound by Rahman et al and Hossain et al. The size of the lithopedion was the smallest in our case in comparison to Rahman et al (12 × 8 cm) and Hossain et al (7.5 × 5 cm) (Table 1).

Table 1.

Comparative analysis of lithopedion cases from Bangladesh.

Timepoint/variable	Current case (2026)	Rahman et al (2012)	Hossain et al (2024)
7 years prior	Diagnosed with ruptured ectopic pregnancy; patient refused laparotomy.	Conception of heterotopic twins; delivered live baby at home while extrauterine twin calcified.	Unspecified latency (~22 years since last delivery); slow-growing mass.
Patient demographics	35 years old, multiparous (garment worker).	35 years old, multiparous.	48 years old, Multiparous.
Anatomical location	Right broad ligament.	Right broad ligament.	Adherent to sigmoid mesentery.
Mass size and gestation	4.0 × 4.9 cm (~18–21 weeks).	12.0 × 8.0 cm (~25 weeks).	7.5 × 5.0 cm (fully formed bones).
Diagnostic pathway	Transabdominal and transvaginal ultrasound only.	X-ray, 2D Ultrasound, Color Doppler.	Plain abdominal X-ray, contrast-enhanced CT.
Surgical management	Elective laparotomy; extensive cecal/ileal adhesiolysis.	Exploratory laparotomy; minor adhesions noted.	Elective midline laparotomy; dissected from mesentery.
Clinical outcome	Uneventful recovery; discharged stable on day 6.	Discharged stable after complete mass extirpation.	Resolved symptoms; unremarkable 6-week follow-up.

The incidence of lithopedion is influenced by factors such as the prevalence of ectopic pregnancy in the population, socioeconomic conditions, educational status, accessibility of healthcare services, and utilization of medical care^[10^].

In most cases, including ours, patients were aware of their pregnancy, which neither came to term nor resulted in a miscarriage. However, some patients may remain asymptomatic and may be diagnosed incidentally with lithopedion during imaging studies or abdominal surgery performed for a nonobstetric indication. This is due to a lack of classic clinical signs or symptoms. However, some patients may present with symptoms such as an abdominal mass, chronic pelvic pain, lower abdominal pain, constipation, umbilical hernia, urinary complaints, or other pressure-related symptoms. Long-term complications include pelvic abscess, fistula formation, infertility, cephalopelvic disproportion in future pregnancies, extrusion of fetal parts, bowel obstruction, bowel necrosis, and intestinal perforation caused by lithopedion-related adhesions or anatomical distortion, and, rarely, chronic kidney disease and malignancy. In some cases, distortion of pelvic anatomy may lead to infertility, which can be improved after surgical removal of the lithopedion. These outcomes are influenced by the duration of retention and variation in anatomical location. The retention period can range from 4 to 60 years before diagnosis. Failure of proper history-taking is one of the key factors behind such delayed diagnosis^[3,10–12^]. In our case, the patient presented with mild lower abdominal pain and a palpable mass in the right lower quadrant of the abdomen after 7 years.

In resource-limited settings, delayed diagnosis and lack of follow-up may contribute to prolonged retention of abdominal pregnancies. A low-cost antenatal ultrasound for suspected ruptured ectopic pregnancy is sufficient to prevent this. However, even in the 21st century, we are still not able to ensure access to antenatal ultrasound, although it has been more than 50 years since ultrasound began to be used in obstetrics and gynecology^[13^]. Lithopedion is most often diagnosed by abdominal X-rays, ultrasonography, and, most reliably, a CT scan^[3,11^]. Differential diagnoses of lithopedion include mature cystic teratoma, calcified leiomyoma, and mesenteric cysts. A calcified uterine leiomyoma (fibroid) is very common but typically demonstrates rough, whorled calcifications restricted within the contours of the myometrium. Mature cystic teratomas (ovarian dermoid cysts) frequently contain calcified structures like teeth or bone but are characterized by distinctive fat-fluid levels on imaging. Other pelvic lesions, such as calcified mesenteric or omental cysts, lack distinct fetal morphology. On the other hand, the classic presentation of a lithopedion includes distinct visualization of a fetal skeletal outline, cranial bones, or long-bone silhouettes on imaging modalities, which effectively rules out these differentials^[8^]. In our case, abdominal ultrasonography followed by transvaginal ultrasonography was sufficient to confirm the diagnosis. A CT scan may be more helpful for determining the type of lithopedion. The standard treatment for lithopedion is elective exploratory laparotomy, allowing for intact excision of the calcified mass without intraoperative complications^[3,11^]. An overall clinical timeline chart is available in Table 2.

Table 2.

Clinical timeline table.

Time point	Clinical events and interventions
7 years prior	Spontaneous conception followed by diagnosis of ruptured ectopic pregnancy at 3 months on transabdominal ultrasound. Emergency laparotomy was recommended, but the patient refused due to financial constraints.
7 years prior (+22 weeks)	Consultation sought for persistent mild right adnexal pain. Ultrasound revealed fetal bony structures. Laparotomy was advised for a second time and rejected.
Intervening 7 years	The right-sided pelvic swelling persisted but remained asymptomatic.
1 month prior	Onset of continuous, mild right lower abdominal pain associated with a palpable mass led her to visit the hospital at last.
Admission/diagnostic workup	Transabdominal & transvaginal sonography identified an empty uterus and a well-formed, calcified extrauterine fetus (4.0 x 4.9 cm) in the right adnexa.
Surgical intervention	An exploratory laparotomy was performed with intact removal of a broad-ligament lithopedion with meticulous adhesiolysis from surrounding bowel structures.
Postoperative day 2	Abdominal pain resolved; pelvic drain was safely removed.
Postoperative day 6	Discharged in stable condition with regular healing.
Follow-up	Remained completely asymptomatic with a well-healed surgical wound.

In our patient, low socioeconomic status, job insecurity, and lack of family support led her to not seek additional necessary medical advice after being diagnosed with a ruptured ectopic pregnancy. Overall, lack of awareness, poor compliance with medical advice, and socioeconomic barriers may contribute to this issue in this region.

Conclusion

This case highlights the importance of early diagnosis and timely management of ectopic pregnancy due to its association with rare phenomena such as lithopedion formation within the broad ligament. Low socioeconomic status, illiteracy, lack of proper surveillance, and negligence in obtaining necessary treatment on time were the main contributing factors. Ensuring regular antenatal check-ups, developing a proper surveillance system to monitor such populations, and increasing public health awareness can easily prevent this condition.

Ethical approval

Not required for this study.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

All the authors were involved in manuscript preparation, review of literature, and final approval of the manuscript. S.A.: Conceptualization; Data curation; Writing – original draft; Writing – review & editing; Methodology; Software; Visualization. M.B.: Conceptualization; Project Administration; Data curation; Writing – review & editing; Resources. F.I.C., M.Z.: Project Administration; N.S.,T.A.: Resources; Data Curation H.J.,Z.N.; Visualization, Data curation. All authors read and approved the final manuscript.

Conflicts of interest disclosure

The authors have no conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Shafi Ahmed.

Provenance and peer review

Not commissioned; externally peer reviewed.

Data availability statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.