All fetal echocardiograms performed at our institution between January 1,1986, and June 1, 1991, were reviewed. The echocardiogram referral indication and results were verified for all women studied. Historic risk factors under consideration were pregestational diabetes, anticonvulsant or lithium ingestion in the first trimester, and a family history of congenital heart disease. Women with historic risk factors who had either a fetal abnormality on antenatal sonography or a known aneuploid fetus prior to the fetal echocardiograph were excluded. Of the 994 women who had a fetal echocardiogram performed during this study period, 486 (48.9%) were evaluated solely on the basis of a historic risk factor. Four of the 486 women (0.8%) were diagnosed as having a significant fetal structural cardiac malformation. Two of the four fetuses succumbed to obstetric complications. The remaining two infants were delivered at term and are doing well after postnatal cardiac surgery. In this select group of women with risk factors but no recognized fetal abnormality, the incidence of significant cardiac lesions was low. Although indications for fetal echocardiography must be evaluated on an individual basis, our data do not support a recommendation for the routine use of fetal echocardiography as a screening test in all women with historic risk factors. © 1994, by Thieme Medical Publishers, Inc. All rights reserved.