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The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort

https://doi.org/10.1016/j.ajog.2006.10.877Get rights and content

Objective

The purpose of this study was to investigate the outcomes of infants who had Apgar scores of zero at 10 minutes and were resuscitated successfully.

Study Design

The literature was reviewed systematically to identify the outcomes of cases; in addition, the perinatal database at the John Radcliffe Hospital, Oxford, was used to identify similar cases. Eligible infants were identified through hospital records, and outcomes of all infants with an Apgar score of zero at 10 minutes, who were born between January 1991 and December 2004, were reviewed.

Results

Eighty-five cases were identified from the literature. With the Oxford database, 9 of 83,065 infants (0.12/1000 births) met our study criteria. Six of the 9 infants died before leaving hospital. One infant with severe quadriparesis and microcephaly died at 11 months of age. One infant at follow-up examination at 5 years had severe spastic quadriparesis with severe global delay. One infant with grade 2 hypoxic-ischemic encephalopathy, who was born with severe anemia that was corrected promptly at birth, had mild disability at follow-up examination at 2 years. Thus, death or severe disability occurred in 8 of 9 infants. Combining the results of metaanalysis of published data with our results of 94 infants, 88 infants (94%) either died or were handicapped severely; 2 infants (2%) were handicapped moderately, and 1 infant (1%) was handicapped mildly. For 3 infants (3%), the long-term outcome could not be determined.

Conclusion

The outcome of infants with an Apgar score of zero at 10 minutes is almost universally poor.

Section snippets

Methods

We searched Medline (1966-April 2005) for publications that had examined the association between low Apgar scores and neonatal outcome. The MeSH headings used were Apgar score, resuscitation, and cardiopulmonary resuscitation; the text key words searched for were Apgar, resuscitation, ten minutes, and 10 minutes. From the abstracts that were identified, we studied the eligible articles and their reference lists. Only articles that provided the outcomes of infants with an Apgar score of zero at

Results

Our literature search identified 33 studies. After we screened abstracts, we read 25 papers that were found to be relevant to this study. Eighteen papers were excluded because the outcomes of infants with an Apgar score of zero at 10 minutes could not be determined from the data. This left 7 studies in which the outcomes of infants with an Apgar score of zero at 10 minutes were known. The results of these studies combined with our results are shown in Table 1. Of the 94 infants, 88 infants

Comment

We present the unique combination of a systematic review of the literature and a prospective cohort study. Our purpose was to evaluate the outcomes of infants who were resuscitated successfully after an Apgar score of zero at 10 minutes. This issue is of great relevance to all caregivers who are involved in intrapartum care. The evidence for prolonged resuscitation has been based mainly on experimental work from the 1960s on fetal lambs.13 This showed that terminal apnea occurred 20 minutes

Acknowledgments

We thank Ms Elaine Garrett (librarian at the Royal College of Obstetricians and Gynaecologists) and Dr Mona Zaki for help in the literature search; Dr Kenny McCormack (Consultant Neonatologist), who was involved in designing the study; and Mr Lawrence Impey (Consultant in Obstetrics and Fetal Medicine) for advice in the preparation of the article.

References (14)

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    In this subgroup of newborns with severe depression at birth, both survival and survival without moderate-to-severe impairment have been reported. Among 105 such infants reported in the literature with Apgar scores 0 or 1 who were successfully resuscitated, were treated with therapeutic hypothermia, and were assessed after discharge, 20% of all infants survived without moderate-to-severe NDI, and 37% of the survivors did not have moderate or severe NDI.107,109–112,116,117 The evidence supporting this recommendation is of very low certainty.

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Cite this article as: Harrington DJ, Redman CW, Moulden M, Greenwood CE. The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort. Am J Obstet Gynecol 2007:196:463.e1-463.e5.

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