Selective Fetal Echocardiogram Referral Program for Pregnancies Affected by Pregestational Diabetes

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OBJECTIVES: Fetal echocardiography (FE) is universally recommended for pregnancies affected by pregestational diabetes. We hypothesized that in an experienced center, the use of a selective FE referral policy detects congenital heart disease (CHD) without missing clinically relevant defects. METHODS: This was a retrospective cohort study of pregnancies complicated by type 1 or 2 diabetes that underwent detailed obstetric ultrasound and delivered at a tertiary care center between July 2018 and July 2023. The primary outcome was clinically significant prenatal CHD detection, defined as CHD that may require intervention within a year of life, with a secondary outcome of all CHD detection. Detailed obstetric ultrasounds with expanded cardiac views were performed by maternal fetal medicine (MFM) sonographers, with interpretation by MFM physicians or specialized radiologists in fetal imaging. FE was ordered for other AIUM FE screening indications, suboptimal, or abnormal cardiac views. All neonates underwent standard CHD screening prior to discharge by physical exam. RESULTS: Among 604 eligible pregnancies, 10 (1.7%) clinically significant CHD were diagnosed, with 56 (9.3%) total CHD in neonates. All cases of clinically significant CHD were detected prenatally, even in those with an A1C >9.0. For all minor CHD, 30 cases (53.5%) were not identified prenatally and were only identified postnatally. The postnatally detected lesions all were clinically insignificant. With selective referral, 166 (27.5%) pregnancies underwent FE, representing a significant reduction in FE performed. CONCLUSION: In a tertiary center with expanded cardiac imaging protocols, selective FE referral substantially reduced FE utilization while effectively identifying all clinically significant CHD in pregnancies with pregestational diabetes.

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