title: Evaluation of Referral Pattern for Fetal Echocardiography at a Tertiary Care Center in Northern India and Its Implications.
abstract: OBJECTIVE
  To determine the referral pattern for fetal echocardiography (FE) at our tertiary referral center for pediatric cardiac care in northern India. We also aimed to determine the incidence of CHD in each group and intend to highlight the need of identifying the various risk factors and appropriate timely referral of patients for detailed evaluation.
  
  
  METHODS
  This is a prospective study including 201 consecutive patients referred for fetal echo to our center. Data collected included referral indication, gestational age, maternal age, the gravida, and the final diagnosis after detailed fetal echo. Various indications that were evaluated included maternal diabetes (pre-gestational or gestational), echogenic cardiac nodule, abnormal four chamber on ultrasound, other extra-cardiac abnormalities detected on ultrasound, and twin pregnancies or IVF conceptions. Some women had opted for fetal echo electively and they were defined as self referral.
  
  
  RESULTS
  The mean gestational age of referral was 24 ± 5 weeks. Out of these, 196 had specific referral indication while five were self referrals. The most common indication for referral was echogenic cardiac foci. CHD was diagnosed in 38 (19 %) patients. Indication that yielded the highest number of CHD cases was cardiac abnormality on USG. The mean gestational age at referral in those detected to have CHD was 27 ± 4 weeks. The commonest CHD detected was tiny VSD, while most of the complex CHD's were diagnosed in those referred for cardiac abnormality on USG.
  
  
  CONCLUSIONS
  CHD detection is highest in those referred for abnormal cardiac imaging on USG, and hence a careful assessment of fetal heart during routine prenatal screening would increase the CHD detection markedly. Nuchal translucency needs to be measured accurately and those with value greater that 99th centile should be referred for FE. Mothers with pre-gestational diabetes should have a FE prior to 20 weeks to rule out CHD. A FE scan in third trimester is indicated in diabetic females (gestational and pre-gestational) if the glycemic control is poor evidenced by HbA1c > 6 %. Timely referral is absolutely essential so that appropriate counseling of the parents can be done.
authors.affiliation: Department of Pediatric Cardiology, Fortis ESCORT Heart Institute, 5th Floor, Okhla Road, New Delhi, 110025 India.
authors.forename: Anupama
authors.initials: A
authors.lastname: Nair
authors.affiliation: Department of Pediatric Cardiology, Fortis ESCORT Heart Institute, 5th Floor, Okhla Road, New Delhi, 110025 India.
authors.forename: S
authors.initials: S
authors.lastname: Radhakrishnan
keywords: Congenital heart defects; Fetal echocardiography; Referral patterns