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 123 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.Conclusion 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.

Fetal Echocardiography Characteristics in a Tertiary Center

“…The average gestational week in the first evaluation was 24±4.2 in our study. In other studies, fetal echocardiography was performed in similar gestational weeks (7,8). The most common reason for admission to our clinic was the suspicion of CHD in accordance with the literature (7,8).…”

Referral Pattern for Fetal Echocardiography Over 10 Years in a Single Fetal Imaging Centre from Southern India

“…The most frequent maternal risk indication was diabetes mellitus, similar to the observation from Northern India [3]. In a retrospective study, Roman et al [6] demonstrated that poor glycemic control (Hb A1c [ 8.5%) in early pregnancy is associated with an increased risk of CHD in offspring.…”

“…However, the average gestation at referral was above 22 weeks in both groups which could be due to socio-economic or demographic factors, such as availability or accessibility of fetal imaging centres. A similar study on FE referral pattern from northern India also mean gestation at referral as 24 ± 5 weeks [3]. Addressing the factors for the delay may make the referral time more appropriate for Indian scenario as the legal limit for termination for pregnancy is 20 weeks.…”

Determining the factors causing delayed referral for fetal echocardiography at a tertiary care hospital

“…Moreover, a low percentage of referrals were associated with chromosomal defects and extracardiac anomalies [18]. Contrary to the aforementioned studies, Nair and Radhakrishnan [19] described echogenic cardiac foci as the most prevalent indication of referral. In our study, CHD was found in 24 (12%) cases.…”

“…In our study, CHD was found in 24 (12%) cases. However, Pike et al [17] and Nair and Radhakrishnan [19] reported a comparatively higher percentage of fetal cardiac anomalies, i.e., 22.5% and 19%, respectively [18], [19].…”