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PubMed1998

The apgar score and its components in the preterm infant.

OBJECTIVE: The Apgar score is well-characterized in full-term infants but not in premature infants. The objective of this study was to assess the Apgar score in preterm infants with respect to the relationships between the 1- and 5-minute scores, the correlation of the Apgar score with pH and with other variables, and the relationship among the individual Apgar components. METHODOLOGY: We recorded Apgar scores at 1 and 5 minutes in a population-based cohort of preterm infants (n = 1105) with birth weight <2000 g, from three intensive care nurseries in central New Jersey. Linear correlation analysis was used to examine the relationship between 1- and 5-minute Apgar scores and between the individual components of the Apgar score. Multiple regression analysis was used to explore the relationship between various perinatal characteristics and the Apgar score, and between pH and Apgar score. Stepwise logistic regression analysis was used to assess the determinants of mortality. RESULTS: The 1-minute Apgar score median (25%, 75%) was 6(4,8) and correlated with the 5-minute score of 8(7,9) at r = .78. Slight but significant differences were seen between male (n = 557) and female (n = 508) infants in the 1-minute (6[4,8] and 7[4,8]) Apgar scores. One- and 5-minute scores of white infants (7[4,8] and 8[7,9]; n = 713) were significantly higher than those of black infants (5[3,7] and 8[6,9]; n = 280). Birth weight and gestational age were both linearly related to both Apgar scores. Low Apgar score (<3 at 1 minute and <6 at 5 minutes) was significantly associated with birth weight, gestational age and mode of delivery. Low arterial blood pH (<7.01) at birth was significantly related to low Apgar score. One hundred fifty-nine infants died; these infants were significantly smaller (983 +/- 382 vs 1462 +/- 369 g), less mature (27 vs 31 weeks), had lower arterial blood pH (7.20 +/- 0.18 vs 7.31 +/- 0.11), had lower 1- (3[2,6] vs 7[4,8]) and 5-minute Apgar scores (6[4,8] vs 8[7,9]), and a greater incidence of low Apgar score (32% vs 6%) than did survivors. CONCLUSIONS: Among the components of the Apgar score, respiratory effort, muscle tone, and reflex activity correlated well with one another; heart rate correlated less well; and color the least. Our data confirms the limited use of the Apgar score in preterm infants and demonstrates the different responses of the Apgar score's components.

Black or African American↗
PubMed1981

Apgar scores as predictors of chronic neurologic disability.

Apgar scores were recorded at one and five minutes for approximately 49,000 infants, and at ten, 15, and 20 minutes for babies who did not achieve a score of 8 or higher at five minutes. These children were followed to the age of 7 years. Low Apgar scores were risk factors for cerebral palsy, but 55% of children with later cerebral palsy had Apgar scores of 7 to 10 at one minute, and 73% scored 7 to 10 at five minutes. Of 99 children who had Apgar scores of 0 to 3 at ten, 15, or 20 minutes and survived, 12 (12%) had later cerebral palsy; 11 of the 12 were also mentally retarded (in ten, IQ less than 50) and half had seizure disorders. Eight children who survived after having very low late Apgar scores and who did not have cerebral palsy had lesser but significant disabilities. Of the children who had Apgar scores of 0 to 3 at ten minutes or later and survived, 80% were free of major handicap at early school age.

Apgar Score↗
PubMed2006

Distortion product otoacoustic emissions in term infants with a low Apgar score.

CONCLUSION: Term infants with a low Apgar score have cochlear impairment, mainly at the frequencies 1-3 kHz. Compared with infants with both a low Apgar score and hypoxic-ischaemic encephalopathy we reported before, the impairment is less severe. OBJECTIVE: To detect any peripheral impairment of cochlear origin in infants with a low Apgar score. SUBJECTS AND METHODS: Fifty-four term infants with a low Apgar score at 1 and/or 5 min but without clinical signs of hypoxic-ischaemic encephalopathy were recruited. Distortion product otoacoustic emissions (DPOAEs) were recorded with the f2 primary tone at 10 frequencies (0.5-10 kHz) on days 3-5 and 1 month after birth. RESULTS: On days 3-5 DPOAE pass rates at most frequencies tended to be decreased, and were significant lower than those in normal term controls at 1, 2, 3, 5, 6 and 10 kHz (chi2=4.49-40.31, p<0.05-0.005). The greatest difference occurred at 1 kHz; 18.5% failed the DPOAE test and this was significantly higher than in the controls (4.3%, chi2=7.65, p<0.01). At 1 month the DPOAE pass rate at most frequencies did not show any significant improvement. The overall failure rate (14.8%) did not differ significantly from that on days 3-5.

Apgar Score↗
PubMed1986

Correlation of the one-minute Apgar score and umbilical cord acid-base status.

The one-minute Apgar score has proven useful by ensuring rapid assessment of the neonate, but is often poorly correlated with other indicators of intrauterine well-being. Since fetal asphyxia is directly associated with neonatal acidosis, a low Apgar score in the face of normal pH and base deficit does not indicate an asphyxiated infant. In a study to ascertain the feasibility of combining umbilical artery pH with the one-minute Apgar score for neonatal assessment, umbilical artery pH and Apgar scores were obtained on 212 singleton pregnancies. When the Apgar score was less than 7, more than half (60%) of the neonates had a normal umbilical artery pH. Fifty-one percent of this group had had intubation and nasopharyngeal suctioning, procedures known to be associated with lowered Apgar scores. When reviewing the umbilical artery gas values and base deficit in those neonates with a pH less than 7.20, we found that of the eight patients with an Apgar score of 7 or greater, seven (87.5%) were classified as having metabolic acidosis, with only one having respiratory acidosis. In the neonates with Apgar scores of less than 7, approximately two thirds had blood gas values compatible with metabolic acidosis, while the others displayed respiratory acidosis. We recommend, therefore, that neonates with a one-minute Apgar score less than 7 have umbilical artery pH determinations to confirm the presence or absence of acidosis. We also recommend that when the pH is less than 7.20, a complete set of gas values be evaluated with that specimen. This information offers more precise confirmation of the diagnosis of fetal distress and neonatal asphyxia, both for treatment and more reliable follow-up data, as well as for medicolegal purposes.

Acid-Base Equilibrium↗
PubMed2006

Apgar scores and long-term risk of epilepsy.

BACKGROUND: Low Apgar scores are associated with high risk of neonatal death, cerebral palsy, and mental retardation, but the association between Apgar scores and long-term risk of epilepsy remains unresolved. METHODS: We carried out a population-based cohort study of 1,538,732 live newborns in Denmark between 1 January 1978 and 31 December 2002 by using national registers. The Apgar scores at 1 or 5 minutes were recorded by midwives following standardized procedures. We obtained information on epilepsy by linking the cohort with the National Hospital Register. Cohort members were followed from birth until onset of epilepsy, death, emigration, or 31 December 2002, whichever came first. RESULTS: The incidence rate of epilepsy increased consistently with decreasing Apgar scores. The incidence rate of epilepsy was 628 per 100,000 person-years for those with 5-minute Apgar scores of 1 to 3 and 86 per 100,000 person-years for those with a score of 10; the resulting incidence rate ratio was 7.1 (95% confidence interval = 5.8-8.8). The incidence rate ratios of epilepsy associated with low Apgar scores were particularly high in early childhood but remained high into adulthood. The association did not change after excluding children with cerebral palsy, congenital malformations, or a parental history of epilepsy. CONCLUSIONS: Neonates with a suboptimal Apgar score have a higher risk of epilepsy that lasts into adult life. These findings suggest that prenatal or perinatal factors play a larger role in the etiology of epilepsy than has previously been recognized.

Adult↗
PubMedDate not supplied

The relation between Apgar score and subsequent developmental functioning.

A randomly selected sample of 252 infants aged 5--18 months was evaluated through medical and developmental examinations. Developmental achievement scores and factors such as management of delivery and fetal distress were studied in relation to Apgar scores. Low-Apgar-score infants aged 5--8 months achieved consistently lower scores on all developmental fields. High-Apgar-score infants at younger and older ages did not differ on their achievement scores. Low Apgar score was much more frequent in infants delivered by vacuum extraction than in those delivered spontaneously, with forceps or by cesarian section. The frequency of low Apgar score was higher when fetal distress occurred.

Apgar Score↗
PubMedDate not supplied

Trends in neonatal outcome with low Apgar scores.

Trends in incidence and neonatal outcome following low Apgar scores (1 min Apgar score < 6) were prospectively studied during the years (1981, 1983, 1986 and 1988. The incidence of birth asphyxia was 7.6% of live births during the study period; it was 5.8% in 1981, increased to highest of 8.9% in 1986 with slight reduction to 7.2% in 1988. Birth weight distribution of asphyxiated babies and 1 min Apgar score < 3 (severe asphyxia) remained unchanged. A significant decline in neonatal mortality with asphyxia was noted from 46.0% to 28.4% during 1981 and 1988 respectively. Aetiological factors for asphyxia could be identified in nearly 90% of infants during 1988, and all but 2 of 12 factors studied registered significant differences from control non-asphyxiated group.

Apgar Score↗
PubMed2001

The continuing value of the Apgar score for the assessment of newborn infants.

BACKGROUND: The 10-point Apgar score has been used to assess the condition and prognosis of newborn infants throughout the world for almost 50 years. Some investigators have proposed that measurement of pH in umbilical-artery blood is a more objective method of assessing newborn infants. METHODS: We carried out a retrospective cohort analysis of 151,891 live-born singleton infants without malformations who were delivered at 26 weeks of gestation or later at an inner-city public hospital between January 1988 and December 1998. Paired Apgar scores and umbilical-artery blood pH values were determined for 145,627 infants to assess which test best predicted neonatal death during the first 28 days after birth. RESULTS: For 13,399 infants born before term (at 26 to 36 weeks of gestation), the neonatal mortality rate was 315 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 5 per 1000 for infants with five-minute Apgar scores of 7 to 10. For 132,228 infants born at term (37 weeks of gestation or later), the mortality rate was 244 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 0.2 per 1000 for infants with five-minute Apgar scores of 7 to 10. The risk of neonatal death in term infants with five-minute Apgar scores of 0 to 3 (relative risk, 1460; 95 percent confidence interval, 835 to 2555) was eight times the risk in term infants with umbilical-artery blood pH values of 7.0 or less (180; 95 percent confidence interval, 97 to 334). CONCLUSIONS: The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago.

Apgar Score↗
PubMed1994

Outcome in relation to Apgar score in term neonates.

Sixty four asphyxiated term babies (Apgar score of 6 or less at 5 minutes) and 90 non-asphyxiated term babies (controls) were studied. Of these, 40 cases and 48 controls could be followed up. Mortality and neurodevelopmental outcome were studied in both the cases and controls. Mortality and poor neurodevelopmental outcome correlated inversely with the Apgar scores at 5 and 10 minutes. The outcome of babies with low 5 minute Apgar scores was significantly better than those with the same scores at 10 minutes. Symptomatic neonates when compared to asymptomatic neonates with same Apgar score showed significantly poorer outcome. Babies with Apgar scores of 6 at 5 or 10 minutes behaved like the controls both in terms of mortality and neurodevelopmental outcome.

Apgar Score↗
PubMed2006

Interobserver variability of the 5-minute Apgar score.

OBJECTIVES: To assess interobserver variability of Apgar scores assigned with video recordings of neonatal resuscitation (AS(video)) and compare the scores assigned by observers of videos to the Apgar score given by staff attending the delivery (AS(del)). STUDY DESIGN: Ten-second clips of 30 newborns taken at 5 minutes were shown to observers. Infants were 23 to 40 weeks' gestation, received varying degrees of resuscitation, and were monitored with pulse oximetry. Forty-two observers (neonatal/obstetric medical/nursing staff) scored infants' respiratory effort, muscle tone, reflex irritability, and color. The value for heart rate was assigned from the oximeter, which was masked in all clips. All 42 AS(video) and the AS(del) were represented graphically for each infant. Interobserver reliability was assessed by use of a variance components model. RESULTS: AS(video) varied widely between observers. Variability was large for all 4 elements of the score observers assigned and was seen irrespective of the infant's level of illness. AS(del) was greater than AS(video) in most cases, on average by 2.4 points. There was no evidence that the level of discrepancy was substantially different between groupings of staff. CONCLUSION: The Apgar score has poor interobserver reliability. More objective and precise measures of newborns' condition are required.

Apgar Score↗
PubMed1988

The value of Apgar scores in predicting developmental outcome at age five.

Although Apgar scores as indicators of physiologic depression in newborns appeared to have limited value in predicting developmental outcome, they remain attractive indicators of risk status because they are obtained routinely in this country. Unfortunately, most follow-up studies of the relationship between Apgar scores and outcome have been generally of short duration. Thus the long-term predictive value of Apgar scores is not completely known. In this study 111 otherwise normal full-term infants with 5 minute Apgar scores of less than 7 were enrolled prospectively in a follow-up program. Approximately 13% died (2) or had significant developmental disabilities (12) identified by 30 months of age. Sixty-seven percent of the children with these poor outcomes had a history of neonatal seizures. The remainder received an extensive developmental evaluation at age 5. The mean performance on psychoeducational tests of children without a history of neonatal seizures did not differ from that of a comparison group, whereas the mean of children who experienced neonatal seizures was significantly lower. Thus, low Apgar scores warrant developmental surveillance during the early years of life but, if unaccompanied by neonatal seizures, do not appear to predict more subtle developmental dysfunction evident at school entry age. However, seizures remain an ominous sign for significant early and late developmental sequelae.

Apgar Score↗
PubMed2004

Association between low Apgar score and neonatal cholestasis.

AIM: To investigate the association between low Apgar score and the development of cholestasis. METHODS: Seventy-seven cholestatic infants, all referred to our tertiary centre and born between 1987 and 1996 were studied. Twenty-eight patients had biliary atresia (BA), 36 had various intrahepatic disorders and for 13 patients the aetiology of the cholestasis was unknown. Data on gestational age, mode of delivery, Apgar score and birthweight for the cholestatic infants and 1,118,270 control subjects born during the same time period were obtained from the Swedish Medical Birth Registry. If the Apgar score of the cholestatic patient was <7 at 1 min and/or <9 at 5 min and/or <9 at 10 min of age the available medical records were reviewed for signs of neonatal distress. RESULTS: Five cholestatic patients, all of them premature, fulfilled the Apgar criteria. For two of them the low Apgar score and need for immediate resuscitation were explained by major surgical problems. The other three patients, two with biliary atresia (BA) and one with Alagille syndrome, had clinical signs of neonatal distress. The incidence of low Apgar score in BA patients was 7% and in cholestatic patients without known aetiology 0%, neither figure differing significantly from that of the of the control group (2.6%). CONCLUSION: Low Apgar score is not more common in any of the cholestatic groups than in the general Swedish population of newborns. We suggest that aetiological associations other than low Apgar score need to be considered in infants with cholestasis of unknown cause.

Apgar Score↗
PubMed1988

The inaccuracy of Apgar scoring.

A short Apgar quiz was prepared with eight descriptive neonatal cases. The quiz was completed by 223 health professionals caring for newborns. Pediatricians and pediatric housestaff, the most accurate scorers, assigned the correct score only 68% of the time. Nurses from community hospitals were only 24% accurate. Improper scoring limits the usefulness of the Apgar score in comparing neonates within and between hospitals.

Apgar Score↗
PubMed2000

Antecedents and neonatal consequences of low Apgar scores in preterm newborns: a population study.

BACKGROUND: To examine the antenatal and early neonatal correlates of low Apgar scores (<3 and <6 at 1 and 5 minutes) in preterm newborns (23-34 weeks' gestation). OBJECTIVE: The use of Apgar scoring for premature newborns remains widespread, despite controversy regarding its reliability as a measure of morbidity and mortality in the neonatal period. DESIGN: A cohort of 852 preterm newborns born during a 34-month period between 1984 and 1987 was studied. Newborns were stratified into 2 groups by gestational age (23-28 weeks and 29-34 weeks), and data were analyzed, controlling for gestational age in single weeks. SETTING: Two academic and 1 community hospital, which together accounted for 83% of all preterm births in a tri-county area of central New Jersey during the study period. PATIENTS: All premature newborns (birth weight <2000 g and gestational age <35 weeks) born in the participating hospitals during the study period were evaluated. MAIN OUTCOME MEASURES: Antecedents included maternal illness during pregnancy, maternal complications of labor and delivery, and fetal heart rate abnormalities during labor and delivery. Consequences included delivery room resuscitation, abnormal physical findings, diagnoses, and therapeutic interventions in the first 6 to 8 hours of life. RESULTS: Premature newborns with low Apgar scores received more cardiopulmonary resuscitation in the delivery room and in the first 6 to 8 hours of neonatal intensive care. Mortality was significantly increased among newborns with low Apgar scores (54% vs. 26% in the 23- to 28-week stratum, 30% vs 6% in the 29- to 34-week stratum). Newborns with low Apgar scores in the 29- to 34-week stratum more often required intubation, positive pressure ventilation, and umbilical vessel catheterization. Newborns with low Apgar scores had higher rates of bradycardia, pneumothoraces, acidosis, and increased oxygen requirement during the first 6 to 8 hours of life. Maternal illness, complications of labor and delivery;, and fetal heart rate decelerations did not correlate with subsequent Apgar scores of newborns. The presence of severe bradycardia (<90/min) and fetal heart rate accelerations correlated with low Apgar scores in the 29- to 34-week group. CONCLUSION: Low Apgar scores are associated with increased neonatal morbidity and mortality in preterm newborns. Antenatal maternal history, and pregnancy complications are not clearly associated with low Apgar scores. Therefore, the Apgar score is a useful tool in assessing neonatal short-term prognosis and the need for intensive care among preterm newborns.

Apgar Score↗
PubMed1983

Correlation of the one-minute Apgar score and the pH value of umbilical arterial blood.

The one-minute Apgar score, proven useful for rapid assessment of the neonate, is often poorly correlated with other indicators of intrauterine well-being. Fetal asphyxia is directly associated with neonatal acidosis. A low Apgar score in the face of normal pH and base deficit does not, therefore, indicate an asphyxiated infant. We performed a study at Vanderbilt University Hospital to ascertain the feasibility of combining the pH value of umbilical arterial blood with the one-minute Apgar score for neonatal assessment. The pH values and Apgar scores were obtained on 172 singleton neonates. When the Apgar score was less than 7, over one half (56%) of the neonates had a normal pH value. Of this group 46% had undergone intubation and nasopharyngeal suctioning, procedures known to be associated with lowered Apgar scores. We recommend, therefore, that neonates with a one-minute Apgar score of less than 7 be further evaluated with umbilical arterial blood gas studies to ascertain the presence of acidosis and to differentiate between metabolic and respiratory acidosis. More precise confirmation of the diagnosis of fetal distress and neonatal asphyxia, for both treatment and medicolegal purposes, is possible with this information.

Apgar Score↗
PubMed1988

Apgar scores and umbilical cord arterial pH in the breech neonate.

Apgar scores and umbilical cord arterial pH measurements of 449 singleton breech deliveries are compared retrospectively to those of 1425 singleton vertex neonates. In the vaginal deliveries the Apgar scores and umbilical arterial pH were higher for the vertex neonates. There were no differences in either Apgar scores or umbilical arterial pH between the breech and vertex neonates delivered by cesarean section. Whereas Apgar scores in the less than 1000 g and greater than or equal to 2500 g weight groups were lower in the breech neonates delivered vaginally compared to cesarean section, umbilical arterial pH measurements were similar. The data suggest that liberal use of cesarean section may improve the Apgar scores but will probably not appreciably improve the acid-base status of the breech neonate.

Apgar Score↗
PubMed1989

Predictive value of Apgar scores for developmental outcome in premature infants.

For more than two decades, Apgar scores have been used to predict developmental outcome in newborns. However, most studies have used full-term babies for their data base, and the predictive value of Apgar scores for low birthweight infants has remained unclear. This study was designed to provide a data base for premature infants, demonstrating to what degree Apgar scores predict developmental outcome. We tested Apgar scores alone and in combination with two other easily quantified variables, birthweight and gestational age, as predictors of risk for 256 infants weighing less than 1800 gm at birth. Although significant correlations existed between Apgar scores and Bayley Mental and Psychomotor Developmental Indices, multiple regression analyses demonstrated that these relationships were not significant independent of birthweight and gestational age. That is, after controlling for birthweight and gestational age, Apgar scores did not predict morbidity in low birthweight infants and should not be used to provide a developmental prognosis.

Apgar Score↗
PubMedDate not supplied

[Evaluation of umbilical cord pH and its relationship with Apgar score in term newborn infants].

The value of the Apgar score as an index of birth asphyxia has been recently questioned. The purpose of the present study is to evaluate the relationship between cord blood pH and Apgar score in term newborn infants.A cross-sectional study involving 76 term newborn infants was performed from March through September 1995 at the Obstetric Unit of Hospital de Clínicas de Porto Alegre. The blood samples were obtained from umbilical cord artery and vein at the moment of delivery. Infants were divided in three different groups according to the Apgar score: Group A (n=60): >or=7 at one and five minutes; Group B (n=13): < 7 at one minute and >or=7 at five minutes; Group C (n=3): < 7 at one and five minutes. The frequency of acidemia in Group A was 18.3% (11 newborn infants) considering arterial pH < 7.20 and 5% considering arterial pH or= 7.20 and nine (56.2%) had arterial pH > 7.10. None of the newborn infants in Group C had arterial pH > 7.10. The sensitivity and specificity values for Apgar score less than 7 at one minute for detection of fetal acidemia were, respectively, 54.1% and 94.1%. This study confirms a poor correlation between Apgar score and umbilical blood cord pH, even in a term newborn, and emphasizes the importance of obtaining umbilical cord pH to consider the diagnosis of perinatal asphyxia.

English Abstract↗