Images in Fetal Medicine
Fetal Diagn Ther 2009;26:170–172
DOI: 10.1159/000255169
Prenatal Diagnosis and Management of a
Fetal Intra-Abdominal Teratoma:
A Case Report and Review of the Literature
N. Wagner a K.O. Kagan a S.W. Warmann b H. Abele a I. Tekesin a
Departments of a Obstetrics and Gynaecology and b Paediatric Surgery, University of Tübingen, Tübingen, Germany
Key Words
Prenatal ⴢ Teratoma ⴢ Tumor ⴢ Abdomen
Abstract
We report on a case of a large intra-abdominal teratoma di-
agnosed antenatally and managed successfully after birth.
Intra-abdominal teratomas are rare in prenatal life. Ultra-
sound examination shows a heterogenic tumor with cystic
and solid components. After postpartum surgical removal,
the prognosis is generally good.
Copyright © 2009 S. Karger AG, Basel
Case Report
A 35-year old gravida 3 para 2 was referred to our fetal medi-
cine unit at 29 weeks of gestation due to an unclear mass in the
fetal abdomen.
Ultrasound and MRI showed a heterogenic intra-abdominal
mass with liquid and solid parts of about 7 ! 6 ! 7 cm in size,
which almost filled the whole intra-abdominal cavity (fig. 1). The
intra-abdominal organs appeared to be normal but displaced.
Catecholamines and their metabolites in the amniotic fluid were
within the normal range and excluded a neuroendocrine origin.
AFP was increased, thus a teratoma was suspected. Serial ultra-
sound examinations demonstrated an increase in size of the tu-
mor to 9 ! 9 ! 9 cm and consecutive polyhydramnios presum-
ably due to external compression of the upper gastrointestinal
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Received: July 28, 2009
Accepted after revision: August 16, 2009
Published online: November 2, 2009
tract. The baby boy was born by cesarean section at 35 weeks of
gestation with a birth weight of 2,780 g and good vital signs. A
postpartum MRI examination also confirmed the suspicion of a
teratoma (fig. 2). Laparatomy in the following week showed a be-
nign teratoma with solid and liquid parts and a plain surface
(fig. 3). Complete surgical resection was possible. Two years after,
the infant is well without any signs of recurrence of the tumor.
Discussion
Fetal tumors are rare in prenatal life [1]. As there is no
widely accepted classification of fetal tumors, antenatally
diagnosed masses are characterized by their origin, their
sonographic morphology and the presumptive histologi-
cal diagnosis [1]. As shown in a series of 84 fetal tumors
by Kamil et al. [1], only 19% of the masses were found in
the abdomen and only 17% were classified as teratomas.
These were mainly found in the face, neck and sacrococ-
cygeal region. In their study, none of the 16 abdominal
tumors were teratomas. Half of them were cysts, mainly
of ovarian and mesenterical origin, and the other half
were liver hemangiomas.
Prenatal suspicion of a teratoma is based on the local-
ization and the sonographic morphology of the tumor.
Generally, teratomas appear as large, heterogeneous
masses with cystic spaces and occasional calcifications as
described by Asai et al. [2]. About one third of these cas-
Dr. K.O. Kagan
Calwer Strasse 7
DE–72076 Tübingen (Germany)
Tel. +49 7071 298 407, Fax +49 7071 295 619, E-Mail kokagan @ gmx.de
Fig. 1. Sonographic image of the intra-ab-
dominal teratoma.
Fig. 2. Postnatal MRI of the intra-abdominal teratoma.
es are complicated by polyhydramnios. This may be due
to arteriovenous shunts inside the tumor as well as exter-
nal compression of the upper gastrointestinal tract. The
presence of arteriovenous shunts may also cause high
output cardiac failure and fetal hydrops. Associated con-
genital anomalies are present in about 20% of cases.
Isaacs et al. [3] reported on 534 fetuses and neonates
with teratomas. Of those, 42% were diagnosed prenatally
and the remaining 58% at birth. In 40% of the cases, the
teratomas were localized in the sacrococcygeal area fol-
lowed by intracranial (13.3%), cervical (13.1%), oro- and
nasopharyngeal (8%) and cardiac (7.5%) teratomas. In
only 14 cases (2.6%) were the teratomas localized in the
Prenatal Diagnosis and Management of a
Fetal Intra-Abdominal Teratoma
Color version available online
1
Fig. 3. Histological examination of the intra-abdominal teratoma
with epithelial (1), neuronal (2) and mesenchymal (3) layers.
abdomen and in none of these cases were they detected
antenatally. All of the 14 abdominal teratomas were be-
nign.
Rao et al. [4] reviewed the clinical course of 33 neo-
nates with teratomas within a period of 45 years. The tu-
mor was malignant in only 2 of these cases (6%): one was
found in the sacrococcygeal region and the other in the
abdomen.
In view of the postnatal management, the appropriate
therapy consists of complete surgical resection of the tu-
mor. Isaacs et al. [3] showed that in all 14 neonates with
abdominal teratomas, complete removal was possible
and all neonates survived the surgery. In 2 cases (14%)
Fetal Diagn Ther 2009;26:170–172 171
they observed recurrence of the teratoma. This was about
three times higher than the recurrence rate of all perina-
tal teratomas. It should be noted, however, that the num-
ber of infants in this group was small.
Bernbeck et al. [5] from the German MAKEI Study
Group demonstrated that incomplete removal of the ter-
atoma is an important risk factor for recurrence. As an
alternative to surgical treatment, a platinum-based com-
bination chemotherapy can be offered. However, it should
be reserved for those infants with advanced malignant
germ cell disease [5]. After successful treatment, close fol-
low-up examinations and measurement of serum ␣-feto-
protein is recommended.
Prenatal management involves interdisciplinary coun-
seling of the parents together with the neonatologists and
the pediatric surgeons. Depending on the size, the local-
ization of the tumor and secondary complications, termi-
nation of pregnancy should also be offered. If the preg-
nancy proceeds, symptomatic therapy of the polyhy-
dramnios may be necessary to avoid preterm birth. In
utero treatment by open surgery or laser is only reported
in a few cases [6].
Unless the teratoma is small or located internally, ce-
sarean section is the mode of delivery to reduce the risk
of dystocia, tumor rupture and exsanguination. In those
rare cases where upper respiratory airway obstruction is
suspected, an ex utero intrapartum (EXIT) procedure
may be appropriate [7]. The timing of delivery has to be
chosen with respect to the fetal status, maturity of the fe-
tus and tumor growth during pregnancy [5].
Acknowledgement
We are grateful to PD Dr. Schaefer (Department of Radiology)
and Dr. Haen (Department of Pathology) for the MRI and the
histological images.

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172 Fetal Diagn Ther 2009;26:170–172 Wagner/Kagan/Warmann/Abele/Tekesin

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