The effect of initial Apgar score on the birthweight-specific survival of the very low-birthweight infant

Gestational age (GA) and birthweight (BW) specific neonatal survival statistics were generated to examine the possible effect of one-minute Apgar score on outcome in very low birthweight (VLBW) infants. BW-specific and GA-specific survival is enhanced when the one-minute Apgar score is 4 or more. The route of delivery seems to matter little, although the cesarean section rate is higher for VLBW infants. The data suggest that preconceived notions about adverse outcome for this group of infants could be improved by delivery in better condition. Similarly, our approach for using BW- and GA-specific outcome, which includes condition at birth, can provide a more useful basis for comparing between different populations, allowing for some assessments to be made concerning the quality of care.     

Low 5-minute Apgar score: a population-based register study of 1 million term births.

OBJECTIVE: To determine the rate of 5-minute Apgar scores below 7 in term infants (at least 37 weeks) in Sweden during 1988-1997, evaluate the influence of obstetric risk factors on low 5-minute Apgar scores, and to study the infant prognosis regarding infant mortality, neonatal neurologic morbidity, and outcome. METHODS: Data were collected from the Swedish Medical Birth Registry 1988-1997, and the National Hospital Discharge Registry. Odds ratios (OR) and risk ratios were calculated. RESULTS: Among 1,028,705 term newborns, 7787 (0.76%) had 5-minute Apgar scores below 7. The annual rate of low Apgar scores decreased from 0.77% in 1988 to 0.63% in 1992, but thereafter increased to 0.82% in 1998. The highest OR was found for vaginal breech delivery (OR 6.7), birth weights above 5 kg (OR 6.3), and second born twins (OR 4.1). Primiparity, maternal age, smoking, post-date pregnancy, epidural analgesia, male infant gender, and being born at night, were also significant risk factors for Apgar below 7 at 5 minutes. The infant mortality rate was 48 per 1000 (OR 14.4), and the ORs were 31.4 for a diagnosis with cerebral palsy, 7.9 for epilepsy, and 9.5 for mental retardation. CONCLUSION: Several obstetric risk factors are associated with low 5-minute Apgar score in term infants. Mortality and the risk of severe neurologic morbidity are increased in these infants.     

Severe preeclampsia and the very low birth weight infant: is induction of labor harmful?

OBJECTIVE: To compare the effects of labor induction with the effects of cesarean delivery without labor on neonatal outcome in pregnancies complicated by severe preeclampsia and delivery of very low birth weight infants. METHODS: This was a retrospective study of 278 singleton, live-born infants who weighed 750-1500 g and were delivered because of severe preeclampsia between 1988 and 1997. Outcomes of infants delivered by cesarean without labor were compared with those of infants exposed to labor induction. Statistical analysis was performed using Student t test, Mann-Whitney U test, chi2 analysis, and Fisher exact test, where appropriate. Multiple logistic regression analysis was used to adjust for outcomes of interest. RESULTS: One hundred forty-five (52%) of the 278 women with severe preeclampsia who delivered infants weighing between 750 and 1500 g had labor induced and 133 (48%) delivered by cesarean without labor. Vaginal delivery was accomplished by 50 (34%) women in the induced group. Apgar scores of 3 or less at 5 minutes were more likely in the induced-labor group (6 versus 2%, P = .04), but other neonatal outcomes, including respiratory distress syndrome, grade 3 or 4 intraventricular hemorrhage, sepsis, seizures, and neonatal death, were similar in the two groups. Adjustment for birth weight and gestational age did not affect those results. Analysis of data from the induced-labor group did not reveal an effect by route of delivery on neonatal outcome. CONCLUSION: Induction of labor in cases of severe preeclampsia is not harmful to very low birth weight infants.     

Outcome of neonates with birth weights of less than 801 grams

The follow-up results of intensive care for 68 infants with birth weights less than 801 g treated at Stanford University Hospital were reviewed. The overall survival rate for these infants was 35%, but was 50% for those infants who had been successfully resuscitated in the delivery room and were admitted to the Intensive Care Nursery. Infants under 601 g in weight or less than 25 weeks gestation were more likely to die in the delivery room, but survival among those admitted to the Intensive Care Nursery did not depend on birth weight or gestational age. One-minute and 5-minute Apgar scores less than 5 and interstitial emphysema were associated with increased risk of neonatal death. Only two of 22 survivors (9%) were severely handicapped and another eight (36%) had remediable disabilities at 2 years of age. No infant developed hydrocephalus and only one infant had spasticity. We suggest that the low incidence of major handicaps among survivors encourages the vigorous resuscitation of infants weighing less than 801 g at birth, yet strategies must be developed that will minimize both prolonged dying and the cost of intensive care for nonviable infants.     

Perinatal factors influencing survival in extremely low-birthweight infants.

The majority of deaths in normally formed infants occur in extremely low birth weight infants (< 1000 g). Survival rates for these infants have improved greatly but still vary from centre to centre and accurate local outcome figures are important for counselling parents and upholding standards of care. In the Rotunda Hospital, Dublin, over the 6 year period from 1 January 1990 to 31 December 1995, there were 34 474 deliveries over 500 g birthweight. One hundred and twenty-six of these were normally formed infants between 500 g and 999 g. Our objective was to analyse the factors influencing survival in these extremely low birthweight (ELBW) infants. Overall survival in the group was 63%. The most significant factors influencing survival to 28 days were gestation and birthweight. Survival increased from 33% at 24 weeks to 100% at 28 weeks' gestation and from 29% at 500-599 g to 87% at 900-999 g birthweight. Having controlled for gestational age, none of the following variables had a significant effect on survival: year of birth; gender; multiple pregnancy; 1-minute Apgar score; maternal age; parity; use of antenatal steroids; a history of antepartum haemorrhage, pre-eclamptic toxaemia or prolonged rupture of membranes. A 5-min Apgar score > 5 increased the chance of survival by 3.97 (95% CI: 1.46- 10). Both mode of delivery and incidence of chorioamnionitis had an influence on survival which varied according to the gestational age. A larger cohort of survivors would illustrate the effect of these variables more clearly.     

Hematological profile of Korean very low birth weight infants

For very low birth weight (VLBW) infants, diagnostic and therapeutic decisions widely depend on hematological values. Although ethnic differences for hematologic parameters have been reported, few studies have been reported for Korean VLBW infants. This study aimed at defining the hematological reference values for medical research and clinical practice. Retrospectively we selected 149 infants confirmed as healthy at birth and had no medical conditions that may have affected the hematological profile. Hematological values obtained within the first 4 h after birth were classified into gestational age and we determined the influence of gender, mode of delivery, sampling site, 1-min and 5-min Apgar scores on these values. Red blood cell (RBC), hemoglobin (Hb) and hematocrit (Hct) values increased, whereas the white blood cell (WBC) and platelets decreased as the gestational age increased. In relation to the mode of delivery and the 5-min Apgar score, WBC, neutrophil, mean corpuscular volume (MCV), RBC, Hb, Hct and the platelets differed selectively. No differences in any hematological values were observed in relation to gender, sampling site, and the 1-min Apgar score. This study should be useful as a guide to the reference range of these hematological values for Korean VLBW infants.     

Perinatal risk factors related to neurologic outcomes of term newborns with asphyxia at birth: a prospective study

OBJECTIVES: The incidence of poor neurologic outcomes was studied in term newborns who had suffered severe asphyxia at birth. METHODS: Subjects were 152 newborns admitted to the NICU with a low Apgar score at 1 or 5 minutes. A 1-year prospective follow-up of neurological outcomes was carried out by a questionnaire survey concluded between April 1, 1996 and March 31, 1998. RESULTS: 1) The incidence of a poor neurologic outcome, including 15 neurologic sequelae and 6 deaths, was 13.8% among the subjects. 2) The risk of a poor outcome was increased by 13-fold in neonates with adverse neurological signs and 31-fold in those with hypoxic ischemic encephalopathy. CONCLUSION: The incidence of poor neurologic outcome was very high among term infants with low Apgar scores. These infants were 10 times to 20 times more likely to die, or to survive with permanent disabilities, than were infants without low Apgar scores.     

The relation of breech presentation at term tocerebral palsy

Objective To examine the relation between breech delivery and cerebral palsy, considering the influence of intrauterine growth, low Apgar score at birth, and mode of delivery.
Design Register-based, case-control study.
Population A cohort of infants with cerebral palsy born between 1979 and 1986 in east Denmark, identified by linkage of the cerebral palsy register with the national birth register. Discharge letters from births of breech infants with cerebral palsy were reviewed.
Main outcome measures Presentation, mode of delivery, gestational age, birthweight, Apgar score, type of cerebral palsy, severity of handicap.
Results Breech presentation at term was associated with a borderline significantly higher risk of cerebral palsy than vertex presentation (OR 1.56; 95% CI 0.9–2.4). Breech presentation infants more often had a lower Apgar score (< 7 at 5 minutes) and were smaller for gestational age (SGA < 2 SD) than were those with vertex presentation; infants with a low Apgar score, or who were small for gestational age, had a higher risk of cerebral palsy. After stratification by being small for gestational age the risk of cerebral palsy was not related to presentation. There were no differences between breech and vertex infants with cerebral palsy in terms of low Apgar score, being small for gestational age, mode of delivery, and severity of the handicap. Breech presentation infants were more often classified as diplegic (77.8% versus 42.3% in cephalic infants).
Conclusion The risk of cerebral palsy among term breech presentation infants does not seem to be related to mode of delivery, but is more likely linked to a higher rate of being small for gestational age in breech infants.     

The effect of placental abruption on the short-term outcome of premature infants

The purpose of this study was to analyze the effect of abruption on the outcome of preterm infants. Live-born infants of 23 to 32 weeks gestation born at Beaumont Hospital between 1995 and 1999 who suffered abruption constitute the study group. Controls were matched to cases by sex, gestational age, and birth weight. Medical records were retrospectively reviewed for confirmation of abruption, determination of abruption grade, and subsequent neonatal outcome. Univariate analysis of the grade 2 abruption group revealed statistically significant differences in time from diagnosis to delivery (p = 0.04), Apgar scores at 5 minutes (p = 0.04), and acidotic cord blood (p = 0.04) between cases and controls. However, no differences in short-term outcome were appreciated. In addition, no differences in mortality or morbidity were noted between grade 1 abruption case and control infants. We conclude that abruption is not an independent risk factor for poor outcome among infants born between 23 and 32 weeks gestation, but instead induces the preterm delivery that is the main determinant of outcome.     

Randomized management of the second nonvertex twin: vaginal delivery or cesarean section

Sixty twin deliveries after the thirty-fifth gestational week with vertex-breech and vertex-transverse presentations were managed according to a randomization protocol. Thirty-three parturient women (21 vertex-breech and 12 vertex-transverse presentations) were allocated for vaginal delivery and 27 for cesarean section (18 vertex-breech and nine vertex-transverse). Six pairs of twins in the vaginal delivery group were delivered in a different mode than requested by the protocol (two women underwent cesarean section; in four cases the second twin spontaneously changed to vertex presentation). There were no significant differences between 1- and 5-minute Apgar scores and incidence of neonatal morbidity between the second-born twins in both study groups. Firstborn twins had higher 1-minute Apgar scores than the second-born infants irrespective of route of delivery (p less than 0.05). No case of birth trauma or neonatal death was recorded. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (40.7% versus 11.1%, p less than 0.05). These results suggest that in twins with vertex-breech or vertex-transverse presentations after the thirty-fifth week of gestational age the neonatal outcome of the second twin was not significantly influenced by the route of delivery.     

Neonatal outcome following prolonged umbilical cord prolapse in preterm premature rupture of membranes

We assessed the outcome of thirteen neonates (five singletons and eight first twins) born after umbilical cord prolapse (UCP) following preterm premature rupture of membranes (PPROM) between 24 and 34 weeks of gestation. The median gestational age at PPROM was 29 weeks + 2 days. The median interval from the diagnosis of UCP to delivery was 60 and 150 minutes in singleton and twin pregnancies, respectively. The median umbilical artery pH was 7.29 [0.06]. Apgar scores ranged between four and 10 at 5 minutes after birth. All infants had a normal neurodevelopmental outcome at two years follow up.     

Hyaline membrane disease and acidosis at birth in twins.

To test the hypothesis that the increased incidence of hyaline membrane disease in second-born twins is related to acidosis at birth, umbilical arterial [H+] was measured in 26 sets of premature twins. Although overall Twin B had a lower Apgar score than Twin A, there was no difference in their [H+]. If the delivery interval was prolonged over 8 minutes then Twin B infants were more acidemic and had lower Apgar scores. Infants with hyaline membrane disease had lower Apgar scores, but were not more acidemic than infants without respiratory distress. Our data suggest that acidosis at birth is not an important factor in the development of hyaline membrane disease.     

Neonatal Outcome and Its Relationship with Maternal Age

The relationship between maternal age and neonatal outcome was examined in 22,689 pregnancies using various determinants of neonatal well-being which included evidence of fetal distress, birth-weight, Apgar scores, the necessity for admission to the neonatal unit and other indicators of neonatal morbidity. Differences in the incidence of congenital malformations and perinatal mortality were also studied. There was a trend towards more frequent fetal heart monitoring, lower birth-weight and a higher rate of neonatal unit admission for infants delivered by younger women. There was also a significant increase in the Caesarean section rate with advancing maternal age. Maternal age had no effect, however, on the incidence of fetal distress, Apgar score, the development of respiratory disease, the need for intubation and ventilation nor on subsequent neonatal central nervous system complications. There was also no association between maternal age and either perinatal mortality or the incidence of congenital malformations. The favourable outcome in teenagers in this study may have been influenced by the extremely low pregnancy rate amongst young adolescents in Hong Kong, but a similar outcome in the mature age women was likely to have reflected the recognition of risk and its appropriate management.     

Fused eyelids in the extremely premature infant: multivariate analysis of survival and outcome.

The presence of fused eyelids at birth in the extremely low birthweight infant (less than 1000 gm) is often regarded by physicians as an indication of nonviability. This is especially true for the pediatrician who does not have routine exposure to extremely premature infants and may use the presence of fused eyelids to influence the level of resuscitation afforded the infant in the first crucial minutes following birth. Unfortunately, there are scant data in the literature to guide general pediatricians with regard to this issue. The purpose of this study was to examine, with the aid of multivariate statistical analysis, the survival and combined outcome score in extremely premature infants with and without fused eyelids. The combined outcome was a composite of several outcome variables (intraventricular hemorrhage, bronchopulmonary dysplesia, and retinopathy of prematurity); survival was defined employing the standard definition of neonatal survival, that is, alive at 28 days post natal age. Combined outcome and survival were analyzed with regard to several independent variables (birthweight, gestational age, and 5-minute Apgar scores, mode of delivery, race, sex, and maternal age). A regression analysis was performed to determine the effect of the independent variables on the combined outcome. A separate multivariate logistic regression analysis was employed to determine the effect of the same independent variables on neonatal survival.(ABSTRACT TRUNCATED AT 250 WORDS)     

The relationship of Apgar scores, gestational age, and birthweight to survival of low-birthweight infants

While Apgar scores provide a valid prediction of mortality in term infants (primarily reflecting asphyxia), intervening variables in premature newborns complicate interpretation. Physiologic states normal to preterm infants (such as, decreased muscle tone) can depress scores but may not influence survival significantly. Therefore the relationship between Apgar scores and survival in term and preterm infants differs. Because of the paucity of studies on preterm infants, we tested Apgar scores, as well as birthweight and gestational age, as outcome predictors in 748 low-birthweight infants (500-1800 gm). Our purpose was to assess the relationship between 1- and 5-minute Apgar scores and survival, and to evaluate all combinations of the four variables as outcome predictors. Univariate analysis showed a significant relationship between each of the four variables and survival; however, no single variable accounted for more than 32% of the variance in outcome, thus no single factor could be invoked as the major determinant of survival. Logistic regression analyses demonstrated the interrelationships of the four variables to survival. While both Apgar scores were related to survival, independent of the effects of birthweight and gestational age, they were slightly less predictive than either of these variables alone. However, when 1- and 5-minute Apgar scores were combined with gestational age, the predictive value was slightly better than any of the four variables alone or in other possible combinations.     

Maternal hematological status and risk of low birth weight and preterm delivery in Nepal

BACKGROUND: Our aim was to investigate associations between maternal characteristics, with emphasis on hematological status, and risk of low birth weight and preterm delivery among pregnant Nepali women. METHODS: In a case-control study, 1400 pregnant women attending Patan Hospital, Kathmandu, Nepal for antenatal care and delivery in the period 1994 to 1996 were included. Women with twin pregnancies (n=15) and those delivering infants with congenital malformations (n=13) were excluded from the study. Maternal characteristics including hematocrit values were recorded at the first antenatal visit. Main outcome measures included birth weight, gestation at delivery, Apgar score, mode of delivery, and perinatal death. Linear and logistic regression models were used to analyze data. RESULTS: Severe anemia (hematocrit < or =24%) was associated with a significantly increased risk of low birth weight (<2500 g) and preterm delivery (<37 weeks gestation). High hematocrit values (> or =40%) did not increase the risk of low birth weight or preterm delivery. The risk of low Apgar score or operative deliveries was significantly increased in women with severe anemia in the first trimester. Teenagers, women with short height or low body mass index, and those belonging to the ethnic group Brahmins, had significantly higher risks of delivering low birth weight infants. CONCLUSIONS: Severe maternal anemia, particularly in the first trimester, was significantly associated with adverse pregnancy outcome. Low maternal age, height or body mass index also increased the risk of low birth weight. Improvements in the nutritional status of young Nepali women could contribute to improved health among their infants.     

Ponderal Index: A Better Definition of the ''At Risk'' Group With Intrauterine Growth Problems than Birth-weight for Gestational Age in Term Infants

A study was undertaken at Nepean Hospital, Penrith to compare the outcome of pregnancies with growth retarded infants; 2,508 consecutive births were analyzed between August 1, 1989 and April 30, 1990. A comparison of outcome was made between infants whose birth-weight for gestational age was below the tenth percentile and infants who had a low ponderal index from 37 weeks' gestation. The Caesarean section delivery and fetal distress rates were significantly higher for infants with a low ponderal index than for infants with a low birth-weight. Ponderal index appears to be a better measure of infants with intrauterine growth problems than birth-weight percentiles.     

Assessment of placental function by estimation of testosterone in plasma after an intravenous injection of dehydroepiandrosterone sulphate (DHAS)

The response of plasma testosterone to an intravenous injection of 50 mg dehydroepiandrosterone sulphate (DHAS) was measured in 22 pregnant women. In 15 women with uncomplicated pregnancies a rapid and steep increase of plasma testosterone was observed, most women having their maximum testosterone value recorded as soon as 5 minutes after the injection. Three women with preeclampsia had delayed maximum values. They delivered infants of low birth-weight or with low Apgar scores. One woman with pre-eclampsia had a normal response and gave birth to a healthy infant of normal birth-weight. Out of 3 women with intrauterine growth retardation (IUGR) 2 had an abnormal and 1 a normal response. It is concluded that the plasma response of testosterone to an injection of DHAS is a reflection of placental function.     

Is There a Lower Limit for Birth-weight/Gestational Age and Antenatal Steroid Therapy?

The aim of this study was to determine if there is a lower limit for birth-weight/gestational age below which antenatal steroid therapy may not improve fetal survival. The association between antenatal steroid therapy and survival to 2 years of age was assessed in 2 cohorts of children of birth-weight below 800 g or of gestational ages below 27 weeks. Antenatal steroid therapy was associated with significantly higher survival rates in infants of birth-weight 500-599 g and 700-799 g, and at gestational ages of 25 and 26 weeks. There were few survivors before 25 weeks and none below 500 g birth-weight. After adjustment for extraneous prognostic variables, antenatal steroid therapy was associated overall with approximately a doubling of the survival rates of infants of birth-weight 500-799 g, and of gestational ages 24-26 weeks. In the absence of maternal contraindications, if the goal is to deliver a surviving infant, this study suggests that the obstetrician may assist the survival chances of the tiniest and most immature infants by treating the mother with steroids before birth, with no apparent lower limit of birth-weight or gestational age.     

Diagnosis of birth asphyxia on the basis of fetal pH, Apgar score, and newborn cerebral dysfunction

Imprecise diagnosis of birth asphyxia coupled with uncertainties about causal factors for neurologic abnormalities in the newborn have greatly fueled the current litigation crisis in obstetrics. Our goal was to more precisely define birth asphyxia based on fetal condition as measured by umbilical artery blood pH, Apgar scores, and neurologic condition of newborns. We selected for study 2738 patients with singleton pregnancies with cephalic presentations who were delivered of infants at term to avoid complications such as prematurity, which may affect infant outcome independent of birth condition. The basis for study of these particular patients were defined criteria for high risk and an indicated arterial cord pH value. A total of five infants demonstrated cerebral dysfunction as evidenced by seizures during the neonatal period. Infection was linked to seizures in three of these infants; one infant had neonatal asphyxia and only one infant's clinical course could be attributed solely to birth events (uterine rupture). Stratification of umbilical artery blood pH values, Apgar scores, and combinations of these dependent variables in relation to newborn clinical outcomes revealed that infants must be severely depressed at delivery before birth asphyxia can be reliably diagnosed. Such depression includes Apgar scores less than or equal to 3 at 1 and 5 minutes plus umbilical artery pH values less than 7.00.