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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.

Abdominal wall defect - Gastroschisis

All fetuses with suspected gastroschisis should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation, monitoring and delivery.

Abdominal wall defect - Omphalocele

All fetuses with a suspected omphalocele should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Amniotic band syndrome (ABS)

All patients with suspected amniotic band syndrome should be referred to a tertiary care centre, such as Mount Sinai Hopsital, for evaluation.

Cleft lip and palate

All fetuses with a suspected cleft lip and/or cleft palate should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Congenital diaphragmatic hernia (CDH)

FETOSCOPIC ENDOLUMINAL TRACHEAL OCCLUSION (FETO)

‘TOTAL’ (Tracheal Occlusion To Accelerate Lung growth) Trial

Inclusion criteria

Left-sided CDH:

  • US findings predictive of SEVERE pulmonary hypoplasia:
    • o/e LHR (observed/expected lung-to-head ratio) < 25%.
  • MRI findings predictive of SEVERE pulmonary hypoplasia:
    • o/e TFLV (Total Fetal Lung Volume) < 35%.
  • With standard postnatal management, these babies have an estimated chance of survival ≤ 30 %, and the majority require O2 therapy for ≥ 1 month after birth.
    • o/e LHR is measured at the latest at 29+5 wks
    • FETO is performed between 27+0 – 30+0 wks
    • balloon removal is scheduled after 34+0 wks
  • US findings predictive of MODERATE pulmonary hypoplasia:
    • o/e LHR 25 – 34.9 % (liver position irrelevant) OR
    • o/e LHR 35 – 44.9 % with liver in the chest
  • With standard postnatal management, estimated chance of survival ~ 50%, and 30% risk of requiring O2 therapy for ≥ 1 month after birth
    • o/e LHR is measured at the latest at 32+5 wks
    • FETO is performed between 30+0 – 32+0 wks
    • balloon removal is scheduled after 34+0 wks
  • On 2nd of May, 2019 recruitment for the MODERATE trial ended after completing recruitment of 196 cases.
  • On 10th March 2020, recruitment for the SEVERE trial was stopped prematurely by the DSMC (Data Safety & Monitoring Committee) – not for safety concerns.
  • The results of both studies have been submitted for publication, and should be available by early Spring 2021. Until the trial results are published, FETO for Moderate or Severe CDH should be discussed with one of the Ontario Fetal Centre team on a case by case basis

Right-sided CDH:

  • Were not included in the TOTAL trial
  • Can be offered FETO for US findings of o/e LHR < 45%

Exclusion criteria:

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

Practically

  • Normal microarray results, fetal echocardiogram and fetal MRI are all required prior to surgery. These may be done at the referring centre. Ideally we would like to do the MRIs at Mount Sinai at approximately 26 wks.
  • After FETO, hospitalization for at least 6 hrs may be required.
  • After discharge from hospital, patients must reside within 1 hour of Mount Sinai Hospital, until reversal of the occlusion, which is typically performed ~ 6 wks later at ~ 34-35 wks gestation.
  • Once the occlusion has been reversed, out-of-province/region patients can return to their local experienced centre for further antenatal care, delivery and neonatal management.
  • Local patients will be followed and delivered at Mount Sinai Hospital.

Congenital high airway obstruction (CHAOS)

All patients with CHAOS should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

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.

Critical aortic / pulmonary stenosis

Procedures are typically performed in carefully selected cases at a gestation which will allow optimal growth of the heart in-utero. Fetal echocardiography will be organized at the Hospital for Sick Children (SickKids). Procedures are done in the Fetal Medicine Unit at Mount Sinai Hospital and patients should prepare for 1-2 days admission as the feasibility of the procedure is critically dependent on fetal position. Post-operatively, out-of-province patients will be referred back to their local center for ongoing antenatal care and delivery. Local patients will have ongoing follow-up at Mount Sinai and SickKids hospitals.

Please refer patients via the Fetal Cardiac Program at SickKids

Duodenal or intestinal atresia

All patients with suspected duodenal or intestinal stenosis or atresia should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Fetal anaemia

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).

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 (F/NAIT)

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

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.

Fetal Arrhythmia

Please refer your patient as soon as the diagnosis of a fetal arrhythmia is suspected. Mothers may be admitted to the antenatal ward at Mount Sinai for monitoring at the start of treatment (typically for less than one week). Regular fetal echocardiographic follow-up will be organized. Local patients will be delivered at Mount Sinai to facilitate postnatal assessment at SickKids hospital. Click here for referral to the fetal cardiac program at SickKids. To date, none of the medications used treat supraventricular tachycardia (SVT), including atrial flutter (AF) in-utero have been evaluated in a randomized controlled clinical trial (RCT). In the absence of such evidence, there is no consensus as to the optimal treatment. The Fetal Atrial Flutter and Supraventricular Tachycardia (FAST) Therapy Trial is a prospective international multi-center trial designed to address this knowledge gap and to guide future fetal AF & SVT therapy. It is funded by the Canadian Institutes of Health Research (CIHR) and the principal investigator is Dr. Edgar Jaeggi at SickKids hospital, a key member of the OFC team.

Referral criteria

  • Fetal tachyarrhythmia >170 100% of time or >180 for 10% of an observation time of 30 minutes or longer.

Exclusion criteria

  • maternal contra-indication to anti-arrhythmic treatment
  • high maternal creatinine
  • low maternal serum potassium
  • low calcium levels

Fetal hydrops

All patients with fetal hydrops should be urgently referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Fetal / Intrauterine growth restriction (FGR / IUGR)

Patients with suspected IUGR should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Fetal neck masses

All patients with a fetal neck mass should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Hypoplastic left heart syndrome with intact or restrictive atrial septum

Fetal echocardiography will be organized at the Hospital for Sick Children (SickKids). Procedures are done in the Fetal Medicine Unit at Mount Sinai Hospital. Post-operatively, out-of-province patients will be referred back to their local centre with experience in managing high-risk cardiac conditions for ongoing antenatal care and birth. Local patients will have ongoing follow-up at Mount Sinai and SickKids hospitals. 

Please refer patients via the Fetal Cardiac Program at SickKids.

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).

Placental chorangiomas

Criteria

  • Large placental chorangiomas (>5 cm diameter) or those resulting in cardiac failure and hydrops.

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. 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.

Placental insufficiency

All patients with suspected placental insufficiency should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation. Antenatal care and monitoring will be shared with the referring physician as appropriate.

Placenta praevia

All patients with suspected placenta praevia should be referred to a tertiary care centre, such as Mount Sinai Hospital, for evaluation.

Transposition of the great arteries with intact atrial septum

Fetal echocardiography will be organized at the Hospital for Sick Children (SickKids). Procedures are done in the Fetal Medicine Unit at Mount Sinai Hospital. Post-operatively, out-of-province patients will be referred back to their local center for ongoing antenatal care and delivery. Local patients will have ongoing follow-up at Mount Sinai and SickKids hospitals.

Please refer patients via the Fetal Cardiac Program at SickKids.

Twin anaemia polycythaemia sequence (TAPS)

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.

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)

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.

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)

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

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)

Criteria

Large solid SCTs (> 5 cm) or those resulting in cardiac failure and hydrops prior to 30 weeks’ gestation.

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)

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).

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

  • Singleton pregnancy
  • Maternal age ≥ 18 yrs
  • Open fetal spina bifida with upper level of the bony defect between T1 and S1
  • Chiari II malformation.
  • Normal karyotype. Normal CMA (chromosomal microarray) is also recommended.

Exclusion criteria

  • Associated genetic or major anatomical anomalies.
  • Significant maternal co-morbidities, precluding safe surgery or anesthesia
  • Maternal BMI >40 kg/m.
  • Maternal: Insulin-dependent pre-gestational diabetes
  • Abnormal placentation (praevia, abruption,
  • Cervix <20mm or cervical cerclage or history of spontaneous preterm birth (<36+0 wks).
  • History of classical uterine incision or hysterotomy or uterine anomaly
  • 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.