Referrals

This section is intended for physicians looking to refer patients to the Ontario Fetal Centre.

Thank you for your interest in referring your patient to the Ontario Fetal Centre. Our dedicated team of experts is committed to providing excellent, innovative, comprehensive and compassionate care to patients and their families, from prenatal diagnosis, to fetal intervention and post-natal support.

The Ontario Fetal Centre is the largest and most advanced fetal therapy centre in Canada, specializing in the cutting-edge treatment of complex fetal conditions. We are grateful to you for trusting us with the care of your patient, and look forward to collaborating with you in the ongoing management of her pregnancy.

Your patient’s first visit with the OFC will involve a comprehensive intake appointment. A personalized care plan will be established, and a detailed consult letter outlining any planned investigations, procedures, follow-up appointments, anticipated location and mode of delivery, and postnatal care plans will be sent to the attention of the referring physician within two business days. All documentation from any subsequent visits will be sent to the attention of the referring physician as well.

To refer a patient please review the referral criterion per condition below. If your patient meets the eligibility criteria for referral, please download the form and fax to the OFC. Please ensure that you attach all requisite information along with the referral. This includes, but is not limited to laboratory test results, ultrasound, echocardiography, genetic screening or diagnosis results and MRI reports.

Phone: 416-586-4800 x 7756
Fax: 416-586-3216

Referral criteria by condition

For more information on any of these conditions, please visit the Conditions we Treat page.

Spina Bifida

Surgical criteria:

  • Open fetal spina bifida with upper level of the bony defect between T1 and S1
  • Chiari II malformation.

Exclusion criteria:

  • Associated genetic anomalies or major anatomic anomalies.
  • Significant maternal comorbidities precluding safe surgery or anesthesia
  • Maternal BMI >40 kg/m².
  • Abnormal placentation.
  • Cervix <20mm or history of spontaneous preterm birth.
  • History of classical uterine incision.
  • Severe kyphosis (to be evaluated on individual basis).

Practically:

Surgery is typically performed between 23 and 26 weeks gestational age. Normal microarray results are required prior to surgery. Fetal MRI and echocardiography will be organized at The Hospital for Sick Children (SickKids). Early referral is preferred to allow for comprehensive work-up and multidisciplinary planning. Inpatient admission is required for more than one week. After discharge, patients will be requested to stay within one hour of Mount Sinai Hospital for the first 3-4 weeks after surgery but will then be referred back to their local centre familiar with postnatal spina bifida management for further management and delivery. Local patients will be followed and delivered at Mount Sinai Hospital.

Congenital diaphragmatic hernia

Surgical criteria:

  • Moderate or severe pulmonary hypoplasia (i.e. observed/expected lung-to-head ratio <35% when liver is ‘down’, or <45% when liver is ‘up’ for left-sided lesions. O/E LHR <45% for right-sided lesions).
  • For left-sided lesions: willing to participate in randomized trial.

Exclusion criteria:

  • Associated genetic anomalies or major anatomic anomalies.
  • Cervix <15mm.
  • Multifetal pregnancy.

Practically:

FETO is performed between 28 and 30 weeks’ gestation for severe pulmonary hypoplasia or between 30-32 weeks’ gestation for moderate pulmonary  hypoplasia. Normal microarray results, fetal echocardiogram and fetal MRI are all required prior to surgery. These may be organized by the referring centre. Inpatient hospitalization for approximately 24 hours is required. After discharge from hospital, patients must reside within one hour of Mount Sinai Hospital until reversal of the occlusion, which is typically performed around 35 weeks’ gestation. Out-of-province patients will be referred back to their local centre familiar with postnatal diaphragmatic hernia management for further antenatal management and delivery once the occlusion has been reversed. Local patients will be followed and delivered at Mount Sinai Hospital.

Congenital pulmonary airways malformation (CPAM) and/or severe pleural effusions

Surgical criteria:

Severe unilateral or bilateral pleural effusions or large macrocystic lung lesions causing significant mediastinal shift and hydrops.

Exclusion criteria:

Associated severe genetic or anatomic anomalies. Hydrops is not an exclusion criterion.

Practically:

Urgent referral is required in the presence of hydrops. An echocardiography can be done locally or at The Hospital for Sick Children (SickKids). Genetic testing will be offered at the time of the procedure. These procedures typically require a 24-hour hospitalization. In the presence of hydrops, surveillance for mirror syndrome is warranted. Postoperatively, out-of-province patients will be referred back to their local centre for further antenatal care and delivery. Local patients will be followed further at Mount Sinai Hospital and SickKids.

Lower urinary tract obstruction

Surgical criteria:

  • Lower urinary tract obstruction with normal fetal kidney function on fetal urine testing.
  • Severe oligohydramnios or anhydramnios.

Exclusion criteria:

  • Associated major genetic or anatomic anomalies
  • Poor fetal kidney function.

Practically:

Procedures will typically be done at less than 16 weeks’ gestational age. Fetal vesicocentesis and genetic testing will be offered at Mount Sinai Hospital. These procedures typically require approximately 24 hours of hospitalization. Postoperatively, out-of-province patients will be referred back to their local care provider for further antenatal care and delivery. Local patients will be followed further at Mount Sinai Hospital and The Hospital for Sick Children (SickKids).

Twin-twin transfusion syndrome

Surgical criteria:

  • Monochorionic/diamniotic multiple pregnancy.
  • Severe polyhydramnios with deepest vertical fluid pocket in recipient twin >8cm prior to 20 weeks gestation and >10cm after 20 weeks.
  • Oligohydramios in the donor twin with deepest vertical fluid pocket < 2cm

Practically:

Twin-twin transfusion may develop acutely so please refer urgently. Inpatient admission is approximately 24 hours. Patients will usually be asked to return for one follow-up appointment with the OFC within 48-72 hours after their surgery, but will then be referred back to their local care provider for further follow-up and delivery.

Twin-reversed arterial perfusion

Surgical criteria:

Monochorionic multiple pregnancy with twin reversed arterial perfusion sequence prior to 20 weeks gestation. Intervention after 22 weeks gestation will only be offered in the presence of signs of high-output cardiac failure in the pump-twin or a very large acardiac fetus.

Practically:

Please refer as soon as diagnosis is made (ideally in first trimester). Participation in TRAPIST-trial will be offered. Hospitalization is typically required for 24 hours. Patients will be referred back to their local care provider for further follow-up and delivery.

Research

Patients seen before 14 weeks gestation will be offered participation in the TRAPIST-trial, which randomizes between early (12-14 weeks) and later (16-19 weeks) intervention (clinicaltrials.gov NCT02621645) in an attempt to prevent the 30 per cent spontaneous loss rate that occurs between 12 and 16 weeks.

Other complications in monochorionic twin pregnancies

Surgical criteria:

Monochorionic multiple pregnancy with severe fetal anomalies or severe selective intrauterine growth restriction with a moribund smaller fetus (reversed end-diastolic flow in umbilical artery, abnormal flow in ductus venosus, arrest of growth, oligohydramnios or anhydramnios, or empty bladder).

Practically:

Patient eligibility, surgical feasibility, timing of surgery and surgical technique will be determined on a case-by-case basis. Hospitalization is typically less than 24 hours. Patients will be referred back to their local provider for further follow-up and delivery.

Fetal Anemia

Surgical criteria:

  • Fetal anemia due to red blood cell alloimmunization (confirmed red blood cell antibodies; incompatible red blood cell phenotype in partner) or Parvovirus B19 infection (Parvovirus IgM positive)
  • Middle cerebral artery peak systolic velocity >1.5 multiples of the median.

Practically:

Interventions are typically performed as outpatient procedures. Repeated procedures may be necessary (every 2-3 weeks). Postoperatively, out-of-province patients will be referred back to their local care provider for further antenatal care and delivery. Local patients will have shared care between the referring centre and Mount Sinai Hospital. Delivery will be planned at Mount Sinai Hospital.

Large sacrococcygeal teratomas / placental chorioangiomas

Surgical criteria:

Large solid sacrococcygeal teratomas or placental chorioangiomas resulting in cardiac failure and hydrops prior to 30 weeks’ gestation.

Practically:

Refer if signs of hydrops or high output cardiac failure present. The timing and type of procedure will be individualized based on patient presentation. Radio-frequency ablation procedures typically require 24 hours of hospitalization. In the presence of hydrops, monitoring for mirror-syndrome is required. Postoperatively, out-of-province patients will be referred back to their local provider for further antenatal care and delivery. Local patients will be followed and delivered at Mount Sinai Hospital.

Fetal and neonatal alloimmune thrombocytopenia

Surgical criteria:

  • Confirmed maternal platelet antibodies with or without a history of a previously-affected pregnancy.
  • Incompatible platelet phenotype in partner.

Practically:

IVIG administration can often be administered locally and on an outpatient basis, in shared care with Mount Sinai Hospital. Fetal blood sampling at 28 and 36 weeks may be recommended. Local patients will have shared care between the referring centre and Mount Sinai Hospital. Delivery will be planned at Mount Sinai Hospital.