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In-utero transfer, too difficult? A prospective survey of “missed” in-utero transfers

Presented at the Neonatal Society 2009 Autumn Meeting (programme).

Gale CR1, Hay A2, Chauhan H2, Khan R3, Ratnavel N1 (introduced by Dr S Kempley )

1 Neonatal Transport Team, 2nd floor, David Hughes Building, The Royal London Hospital, Whitechapel Road, London, E1 1BB, UK
2 Emergency Bed Service, London Ambulance Service NHS Trust, 220 Waterloo Road, London, SE1 8SD, UK
3 Department of Obstetrics and Gynaecology, The Royal London Hospital, Whitechapel Road, London, E1 1BB, UK

Background: In cases of preterm labour in-utero transfer is associated with better neonatal outcomes than postnatal transfer(1-2), and is consequently recommended whenever possible. Since the establishment of a neonatal transport team (NTS) in London to simplify postnatal transfers, in-utero transfers have declined, with a simultaneous rise in postnatal transfers(3). Anecdotal reports suggest arranging in-utero transfer is difficult and time consuming, and as a result potential opportunities are missed.

Aims: To determine the incidence of “missed” in-utero transfers in London. To determine reasons for “missed” in-utero transfers.

Design: Potential cases were defined as follows: post-natal transfers following passage of >12 hours between maternal admission and delivery, infant <29 weeks gestation, infant transferred for reasons of prematurity to higher level unit within 24 hours of birth. Following appropriate Caldicott Guardian and information governance approval a prospective questionnaire-based study assessed clinical, organisational and administrative reasons in-utero transfer did not occur. “Missed” transfers were defined as cases where there was no clinical contra-indication to in-utero transfer. In collaboration with the Emergency Bed Service, data on total in-utero requests within the London area was collected.

Results: Over the 5-month study period NTS carried out 600 postnatal transfers, 66 (11%) on infants <29 weeks gestation, <24 hours old. Within this preterm group 12 (18%) met our criteria as “missed” in-utero transfers. “Missed” cases had been present for a median of 36 hours (IQR 13-60) prior to delivery. An average of 7 units (SD 3) had been contacted, requiring on average 220 minutes (SD 128) of clinical time. Maternal condition changed during attempted in-utero transfer, making in-utero transfer inappropriate, in all “missed” cases. A neonatal cot was identified in 5 (41.7%) cases, with subsequent maternal bed being identified in 1 case (8.3%). Over the study period EBS received 404 requests for in-utero transfer, 228 resulted in successful in-utero transfers (56%), median EBS involvement time 183 minutes (IQR 135.5-369.5).

Conclusion: “Missed” in-utero transfers make up a significant proportion of emergency preterm post-natal transfers carried out by the London NTS. Significant clinical time is involved in arranging unsuccessful in-utero transfer. A dedicated, centralised in-utero planning service would save clinical time and may reduce missed in-utero transfers, with consequent beneficial effects on neonatal outcome.

1. Towers CV, Bonebrake R, Padilla G, Rumney P. The effect of transport on the rate of severe intraventricular hemorrhage in very low birth weight infants. Obstet Gynecol. 2000 Feb;95(2):291-5
2. Harris TR, Isaman J, Giles HR. Improved neonatal survival through maternal transport. Obstet Gynecol. 1978 Sep;52(3):294-300
3. Kempley ST, Baki Y, Hayter G, Ratnavel N, Cavazzoni E, Reyes T. Effect of a centralised transfer service on characteristics of inter-hospital neonatal transfers. Arch Dis Child Fetal Neonatal Ed. 2007 May;92(3):F185-8

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