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, intra-partum care and neonatal support.

The Ontario Fetal Centre is the largest and most advanced fetal therapy centre in Canada, specializing in the cutting-edge treatment for 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 health care practitioner within 2 business days. Relevant documentation from subsequent visits will also be sent to the attention of the referring health care practitioner.

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.

Congenital diaphragmatic hernia (CDH)

Inclusion criteria

  • Moderate or severe pulmonary hypoplasia (i.e. observed/expected lung-to-head ratio (o/e LHR) <35% when liver is ‘down’, or <45% when liver is ‘up’ for left-sided lesions.).
  • Left-sided CDH: must be willing to participate in a randomized trial (TOTAL), as treatment is currently only offered as part of the trial.
  • Right-sided CDH: can be offered FETO outside the TOTAL trial for o/e LHR < 45%

Exclusion criteria

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

Practically

FETO is performed between 28-30 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. Once the occlusion has been reversed, out-of-province patients will be referred back to their local centre experienced with postnatal CDH management for further antenatal care and delivery. Local patients will be followed and delivered at Mount Sinai Hospital.

Congenital pulmonary airways malformation (CPAM)

Inclusion 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. Fetal echocardiography can be done locally or arranged here at SickKids. Genetic testing will be offered at the time of the procedure. These procedures may require a 24-hour hospitalization. In the presence of hydrops, surveillance for “mirror” syndrome is warranted. Post-operatively, out-of-province patients will be referred back to their local centre for ongoing antenatal care and delivery. Local patients will be followed further at Mount Sinai Hospital and SickKids.

Fetal anaemia

Inclusion criteria

  • Fetal anaemia 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 (MoM).

Practically

Interventions are typically performed as outpatient procedures. Repeated procedures may be necessary (every 2-3 weeks). Post-operatively, out-of-province or distant patients will be referred back to their local care provider for ongoing 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.

Fetal and neonatal alloimmune thrombocytopenia

Inclusion criteria

  • Confirmed maternal platelet antibodies with or without a history of a previously-affected pregnancy.
  • Incompatible platelet phenotype in partner.
  • History of F/NAIT in a female sibling

Practically

IVIG administration can usually 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 usually planned at Mount Sinai Hospital.

Lower urinary tract obstruction (LUTO)

Inclusion 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

Fetal vesicocentesis (bladder drainage) and genetic testing will be offered at Mount Sinai Hospital. Shunt or cystoscopy procedures may require 24 hours of hospitalization. Post-operatively, out-of-province patients will be referred back to their local care provider for ongoing antenatal care and delivery. Local patients will be followed further at Mount Sinai Hospital and The Hospital for Sick Children (SickKids).

Twin anaemia polycythaemia sequence (TAPS)

Inclusion criteria

  • Divergent MCA PSV (middle cerebral artery peak systolic velocities) in monochorionic twins, typically one > 1.5 MoM and the other < 0.8 MoM, often in the absence of significant amniotic fluid discordance.

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 ongoing care, ultrasound follow-up and delivery.

Twin-reversed arterial perfusion (TRAP)

Inclusion 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

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 in an attempt to prevent the 30% spontaneous loss rate that occurs between 12-16 weeks.

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.

Twin-twin transfusion syndrome (TTTS)

Inclusion 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.

Sacrococcygeal teratomas (SCT)

Inclusion Criteria

Large solid SCTs (> 5 cm) or those 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 (RFA) or interstitial laser procedures typically require 24 hours hospitalization, whereas open fetal surgery will require hospitalization for at least 1 week. In the presence of hydrops, monitoring for “mirror” syndrome is required. Post-operatively, out-of-province patients will be referred back to their local provider for ongoing antenatal care and delivery. Local patients will be followed and delivered at Mount Sinai Hospital.

Selective intrauterine growth restriction (sIUGR)

Inclusion 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, the 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.

Spina bifida

Inclusion 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/m.
  • Abnormal placentation.
  • Cervix <20mm or history of spontaneous preterm birth.
  • History of classical uterine incision or hysterotomy
  • Severe fetal kyphosis (>30°).

Practically

  • Early referral is necessary to allow for comprehensive work-up, multidisciplinary counselling and planning.
  • Surgery is performed between 23 and 25 weeks gestation.
  • Normal karyotype or microarray results are required prior to surgery.
  • Fetal MRI and echocardiography will be organized at SickKids.
  • After fetal myelomeningocele (fMMC) surgery, patients will remain in the hospital for at least one week.
  • After discharge, patients will be required to stay within one hour of Mount Sinai for the first 3-4 weeks after surgery but will then be referred back to their local centre familiar with the management of spina bifida postnatally, for further ongoing care and delivery.
  • Local patients will be followed and delivered at Mount Sinai Hospital.