 Hello everyone. My topic is prenatal ultrasonographic detection of saprocoxidyl teratoma, a case rip. Myself, Dr. Shivani Damadi, I am junior resident at Government Medical College, Mirage. Saprocoxidyl teratoma is a rare tumor that arises from embryonic germ cells. It is the most common congenital tumor in fetus and neonates, with an incidence of 1 in 35,000-40,000 live birds. There is recognized female predilection with male to female ratio of 1 is to 4. Sacrocoxidyl teratoma arises from embryonic germ cells that are normally present in sacrocoxidyl region. They are thought to arise from tautipotent cells from the node of hensin at the anterior aspect of the coccyx by about a second to third weeks of gestation. Thus, the tumor is composed of all three germ cells, i.e. ectoderm, mesoderm and endoderm. At prenatal ultrason, majority of these tumors are seen solid or mixed cystic and solid, external caudal mass. High fit and mortality is seen due to complications such as high output heart failure resulting from arteriovenous communication, with subsequent polyhydrominus and hydropes. I am presenting you a case of 22 years old primigravida with 5 weeks of eminoria came to the obstetive opedic for routine examination at our institution. On general examination, her BP was 110 by 70 mmHg, pulse rate was 80 to BPM and there was no pallor or ictus. On clinical examination, respiratory or cardiovascular system was normal. Her abdomen examination showed a relaxed uterus of 15 to 20 weeks. Blood investigations revealed complete blood count, blood sugar level, liver function tests, kidney function tests within normal limits. She was advised by second trimester prenatal ultrasonography as a part of routine investigation. Her previous prenatal ultrasonograms detected no abnormalities. There was no history of consent union's marriage and no history of animalist babies in both side of the families. A two-dimensional ultrasound examination was performed in our institution on Philips affinity 50 ultrasonography equipment, which revealed a single life pregnancy of 20 weeks, 5 days, with fetus presenting a 21 by 29 by 23 mm solid cystic mass seen arising below the lower end of sacrocoxygen region, extending as exophytic mass externality. On color Doppler, there was internal flow within the solid component. The mass was predominantly external with minimum pre-sacral component. Tricuspid regurgitation was noted with structurally normal heart. Middle cerebral artery peak sister-early velocity was 0.86 mm. No ultrasonographic evidence of fetal anemia was present. Both lateral ventricles appeared normal. No evidence of intracranial lesion was identified. Vertibular spine and spinal canal appeared normal. She was concerned for termination of pregnancy to avoid the complications. After the termination of pregnancy in the prenatal ultrasonographic diagnosis, type 1 ascending was confirmed clinically. This is the figure 1, which is societal section on ultrasound showing a solid cystic tumor mass arising from sacrocoxygen region of fetus suggestive of sacrocoxygen teratum. Figure 2 shows societal section on ultrasound showing intrapelvic, which is shown by a white arrow, and extrapelvic shown by a red arrow, sacrocoxygen mass. Figure 3 is societal section ultrasound image with Doppler showing internal vascularity of the mass. Figure 4 and 5 are the gross specimens of male fetus with type 1 ascity confirming the findings of ultrasonography. Sacrocoxyl teratoma is an extra gonadal germ cell tumor that develops in the fetal and neonatal periods. Sacrocoxygen teratoma is a type 1 germ cell tumor in which only teratoma and gyoza tumors arise from the extra gonadal sites. It is believed to originate through epigenetic reprogramming of early primordial germ cells migrating from the yolk sac to the gonadal regions. These cells fail to migrate important from the control of embryonic inductors differentiate into various tissues which are aberrant to sacrocoxygen region and thus gives rise to sacrocoxygen teratoma. The association of sacrocoxygen teratoma with the common location of sacrocoxygen region is thought to be due to the large number of pluripotential cells which are usually found in the corded regions of the embryo closely associated with the distal sacrum and corpus. SCTs are either benign which are matured or malignant which are immature composed of embryonic elements. Mature teratomas are more common in both neonates that is 68% and older children that is 73%. According to Hickey and Latin there is a definite propensity for the sacrocoxygen teratoma to undergo malignant change usually after four months of life but apparently infrequently after childhood. It cannot be foretold clinically which teratoma has malignant potentials. Classification of sacrocoxygen teratoma. The SCTs will be subdivided and classified according to their location. Type 1 tumors predominantly external sacrocoxygen with only a minima pre sacral component. Type 2 are tumors presenting externally but with a significant intrapelvic extension. Type 3 are the tumors where apparent externally but the predominant mass was pelvic and extended into the abdomen. Type 4 are the pre sacral with no external presentation. On imaging findings, it is crucial to make an early prenatal diagnosis of SCT since mortality is inversely related to the gestational age at the time of diagnosis. Later, the diagnosis is made versus the prognosis. It is possible to determine the localization and size of SCT along the degree of involvement of intrapelvic structures with sonograph. The teratomas exhibit three sonographic patterns. Mixers of cystic and solid components in equal proportions, predominantly solid with few scattered unecoic areas and unilocular cystic masks. The sonographic appearance of the SCT can vary as it depends on multiple components of the tumor like calcification, cystic component, necrosis and intratumoral hemorrhage. The increased ekogenicity with post-acoustic shadowing can signify the dystrophic calcification in the areas of hemorrhage or rudimentary fragments of maldeveloped bones. Now, we will come to the differential diagnosis. Despite the fact that the prenatal diagnosis could be done with certainty, the major sonographic differential diagnosis should include anterior or posterior meningomyelosis, conjoined twins, especially in large tumors, hemangioma and neuroectrodermal cysts. Cystic sacrocoxial teratomas detected at prenatal ultrasound may be confused with meningomyelosis. However, meningocytes are usually seen superior to the level of sacrocoxial region and the septations are uncommon in cystic mass as it is often seen with teratoma. In sacrocoxial teratomas, sacrum is usually intact although dystrophic changes might be present. Also, there is a rare possibility that meningocytes and teratoma may coexist. A dumbbell shift sacrocoxial teratoma may be mistaken for a hemangioma or an hypoma. In such a dilemma, imaging studies either CT or MRI imaging help to define the deep extent of the region and help suggest the true diagnosis. In the case of a pre-sacral mass, if it is purely cystic lesion, the differential diagnosis should include a rectal duplication cyst and anterior meningocytes. However, unlike teratomas, these cystic masses are usually not multiloculated and do not contain fright or calcification. Neuroplastoma should be the primary consideration if the mass is solid. Large teratomas has a high perinatal mortality pertaining to high output heart failure resulting from arteriovenous communication with subsequent polyhydroaminous and hydropes. Additional secondary issues that need to be considered are the amount of intrapelvic tumour with bladder obstruction, hydronephrosis, urinary dilatation and tumour rupture. Gastrointestinal obstruction may also occur due to pelvic compression by the tumour. Prenataly-diagnosed sacrocoxygeal teratoma have a total perinatal mortality of 54% which is due to pregnancy termination, intrautrient death and neotatal death. Now, coming to treatment and prognosis. To monitor the fetal growth and tumour size and to assess for the development of hydropes, serial antinatal sonography should be utilised. Volume reduction amniocentesis and tocolysis may be required to treat symptomatic polyhydroaminous and prevent pre-tum delivery. However, surgical excision includes of oxygectomy with additional chemotherapy is the mainstay for marignan tumours. Sacrocoxygeal and pharyngeal teratomas are not thought to be inherited in Mendelian or polygenic passion. It is therefore important to reassure patients that they are not at increased risk of bearing another child with these lesions. Thank you.