 Then, of course, we have intrinsic lung lesions where we have C-pans or congenital pulmonary arrhythmia malformation. We have bronchopulmonary sequestration and we have hybrid lesions and very often it becomes difficult to differentiate one from the other. Now, overall, if you look at an ecogenic and acidic masses, the incidence is about one in 3000. Now, C-pans typically is actually, they feel it's a hamad award, it's a mesenchymal sort of changes coming up within the lung. Usually it is unilateral but it can affect either any lobe or the entire lung or multiple lobes, as we've seen subsequently. So, it's one of the most common congenital lung lesions, almost 75% of all lung lesions and it is a hamad otomatous lesion supposed to be. And the pathology basically is that there is an overgrowth of mesenchymal tissue because of seizure of the bronchial growth at a very early stage with an insert happening before 16 or 17 weeks of gestation. And one of the hallmarks of C-pans is that there's a communication with the proximal air base, though of course this communication may be abnormal. And of course, the diagnostic feature of the C-pans is that the blood flow for C-pans comes from the pulmonary artery and the venous drainage also is from the pulmonary veins. So whenever we see masses like this, here for example, it's filling up entire one of the lung and it's very important to look at the blood flow. But this is an old classification which was based on histopathology. A lot of people have given it up but overall I still feel that it's a good way of describing these lesions. It's a good way of prognostic getting lesions and therefore you can still use it. So typically type one is multiple large cysts, usually more than 5 centimeters. Type two are multiple small cysts less than 5 and type three are microsys or they are solid cystic lesions, typically less than 5 millimeters. So that's an example of a type one C-pamp, type two C-pamp and that's an example of a type three C-pamp. So a lot of people don't believe in this classification but I still feel that it's a good way of describing these lesions. So type three are usually solid, uniform depogenic or they can be very, very tiny microsys. Now sometimes the C-pamps, the other pathology which we see is pulmonary sequestration. Now here typically the lesions could be small. They are very often close to the diaphragm. They are very often sort of triangular in shape and the diagnostic thing is of course a blood flow coming from a cystic vessel like the aorta. So these are solid-leconium lesions. They are thought to be of a pleural duration and the difference is that there is no communication with the bronchial treat. And here again we can have a large sort of sequestration but the and the blood flow is coming from the aorta. So very often as I said they are located very close to the diaphragm. They could be infrared diaphragmatic also. Most of the time they are unilateral. They could be bilateral and the blood flow is very, very important. And of course very often what we have are hybrid lesions where we have a lot of sequestration and C-pamp coming together. And actually on ultrasound it is very difficult to differentiate between the different types of lesions very often. Now so very often we see them as supra diaphragmatic, infrared diaphragmatic but just so we have one case where ideally we felt it is supra diaphragmatic. Fortunately when the baby was born on scan we felt it is infrared diaphragmatic but on surgery it actually turned out to be intra-diaphragmatic sequestration which is a very, very rare thing to happen. So look out, so it's a very important thing here is to look out for the blood flow whether it's coming from the pulmonary vessels or whether it is coming from the aorta and nowadays of course with good machines that is very easy to do. So with sequestration we can have other anomalies like diaphragmatic hernia, vertebral anomalies, congenital diseases, pulmonary atroplasia of course, colonic duplication etc. And therefore a thorough search is very often required. So as I said that very often almost sometimes 50% of these lesions should be hybrid and it is very difficult to differentiate between this type. So typically most of these lesions they increase till about 24 weeks or 26 weeks where they reach a peak around that time and then gradually decrease. That's very important and all of them do that and therefore very often the composition is not a very, very important issue. So we all know that what we look out for whenever there is C-PAN or thymine sequestration is the presence of hydrops. So once you see hydrops then of course we are worried about the outcome and typically when you see progressive hydrops coming up in the second trimester then of course the prognosis may be bad or in some cases once there is an hydrops then we should or may think of doing an intervention as well. So when you counsel the patient this is very important in C-PAN there is no significant association with chromosomal abnormality syndrome so it's reassuring and less than 20% develop hydrops. So C-PAN no hydrops very good survival rate and almost 50% resolve antiretally with hydrops the mortality goes up significantly to 19 to 95% and some of them we might have to intervene in neutral. So just some examples this year 2020 we had this lady who had a game on 1st October that was a small issue for C-PAN we followed up she came from a long distance and she came directly in December and the entire region has totally disappeared. This is another lady she had a very large region in fact it was occupying the entire lung and someone somehow suggested a termination and she came to us it looked like a hybrid region there was some blood flow coming from the aorta so we reassured her and we said okay we will follow it up there were no signs of hydrops there was no hydromias and we followed it up subsequently it went on reducing in size and on 3rd time I said totally disappeared the child was born we did a CT scan after that and there was no region the child was lost in traumatic. So now some measurements we do very often in practice there are newer measurements which have also come up but this is a good way of sort of prognostic getting so what we do is we do the C-PAN volume and then we take a ratio with that circumference and we come we derive what is known as a CVR and again these are very easily available on the net these calculators so if the CVR of course is low it's a good thing if it is large more than 1.6 then we need to keep a close of watch so if you have a CVR of more than 1.6 and you see large cysts in the malformation this is these are the feet I would require a very close follow up and subsequently may potentially develop hydrox or you might have to intervene so typically that's a figure which is good enough for counseling some people like to take volume of the lung and compare it with a weight and this is also can be done so what we are worried about in C-PAN and large concomitant sequestration is the development of hydrox with societies coming up so most of the literature says that even if you have a media relationship that doesn't change prognosis even if you have mild moderate hydrownia that doesn't change prognosis but once you have hydrox that is the accumulation of fluid in other places in the body that is when things you need to worry or when you have such large cysts like this which are filling up the entire lung again we need to keep prognosis we need to counsel them about potential potential coming up often hydrox so you have an example at 29-30 weeks this is last year we had a CVR of 1.2 which is little unusual because by usually by 29-30 weeks we start seeing them regressing so we said okay there was more hydrox so we said okay we'll watch but after 1 or 2 weeks the CVR increased further reached almost 1.6 so we gave them steroids because very often with steroids we can see a reduced reduction in the size of a C-PAN but it continued to increase and before hydrox could set in we thought we will put a shunt from this cyst to the amniotic fluid but the patient had come from a long distance and it was difficult to get the shunt immediately so what we did is we aspirated the larger cysts or the macro cysts and fortunately a good number of them were communicating so after aspirating 2 cysts the size of the lesion actually decreased in front of our eyes and subsequently followed up on follow up at 26 and 37 weeks the CVR which had gone to 1.6 dropped to 1.2 or even 0.6 so this child was born in Thane and subsequently a CT scan was done which showed a small region and because the child was little symptomatic they did a surgery but subsequently the child has done significantly very well and is almost I think one year now so we can also put of course shunts from large cysts into the amniotic fluid if you have an acupuncture that hydrox is developing very often if you are doing an intervention procedure you do not know whether the cysts are communicating or not communicating if they are communicating it's good for us you know so what has been suggested is that once you puncture the cyst you can put some contrast, ultrasound contrast like definitely your son on you and then see whether the cysts are communicating if they are communicating then our intervention procedures can become good so if you have large macro cysts then there is an option of doing operation or putting up shunts but if you have micro cysts or solid lesions then again then people have done laser ablations or people have done also perfidious sclerotherapy honestly I have not done anything in solid lesions so far what about secretation again no infusion very good survival and almost 50% resolved but a good number of them would require spastic tommy after birth but any diffusion again the prognosis is bad so if there is a permanent secretation with infusion then it is advised that we drain the fluid or put a shunt from the pleural cavity into the amniotic fluid and burn the fetal vessel with laser or with an RFA and this is supposed to have a very good effect and that's I've taken it from one of the journals where they have done a laser for the fetal vessel so this of course benefits the fetus significantly in those which are who are developing hydrops and as the lesions is supposed to regress now very very important message here is that even if you see the lesion regressing in the third trimester this does not match the actual regression because a good number of these lesions become isoequic in late pregnancy it might be difficult for you to pick up and therefore it is very important to investigate after birth so there are two schools of thought some people like to do a CT scan in almost all patients and in some periodic surgeons would like to do it only if the fetus or the newborn is symptomatic so I would say if the newborn is symptomatic then definitely one should do a CT scan because you are not going to see it easily on XNA or you are not going to see it on ultrasound neither after the baby is gone so another very important thing is that when you cancel almost about 10% of C-pamps can potentially develop pleuro pulmonary blastomers so this also has to be kept in mind when you do the counseling to the patients this is of course in C-pamps and not so in sequestration