|ORIGINAL RESEARCH REPORT
|Year : 2018 | Volume
| Issue : 1 | Page : 18-21
Hypoxic-ischemic encephalopathy and the Apgar scoring system: The experience in a resource-limited setting
Ibrahim Aliyu1, Teslim O Lawal2, Ben Onankpa3
1 Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria
3 Department of Paediatrics, Usman Danfodiyo University, Sokoto, Nigeria
|Date of Web Publication||23-Feb-2018|
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University Kano, Kano
Source of Support: None, Conflict of Interest: None
Introduction: Virginia Apgar developed the Apgar scoring which has shown relevance in assessing the general well-being of the newborn at delivery and also determining the response and effectiveness of resuscitation. This includes the 1st, 5th, and even the 10th and 20th min scores. However, the first and fifth scores have been severally used in defining perinatal asphyxia. This study, therefore, seeks to assess the performance of Apgar scoring in a resource-limited setting in determining hypoxic-ischemic encephalopathy (HIE). Materials and Methods: This was a retrospective study. The medical records of 142 admitted newborns with a diagnosis of perinatal asphyxia were reviewed over a 1-year period. Results: There were 86 males and 56 females with perinatal asphyxia and a male-to-female ratio of 1.5:1. Most cases had a 1 min Apgar score in the range of 4–5 (62.0%), whereas using the 5th min Apgar score, majority of the cases had scores of 6 and more. Sixty-five cases (45.8%) had HIE, whereas Stage 1 HIE was the most recorded form of encephalopathy. The 1st min Apgar scoring showed that most cases with a score of 4–5 had Stage 1 HIE, whereas all the nine cases with Stage 3 HIE had a score of 0–3 (Fisher's exact test = 132.074; P = 0.00); furthermore, most cases with Stage 1 HIE had a 5 min score of 6 and above, but all the cases with Stage 3 HIE had a score between 4 and 5 (Fisher's exact test = 49.024; P = 0.00). Conclusion: The Apgar score still remains an important tool in neonatal resuscitation and monitoring; asphyxiated neonates need to be actively and effectively resuscitated.
Keywords: Apgar score, birth asphyxia, hypoxic-ischemic encephalopathy, resource-limited setting
|How to cite this article:|
Aliyu I, Lawal TO, Onankpa B. Hypoxic-ischemic encephalopathy and the Apgar scoring system: The experience in a resource-limited setting. J Clin Sci 2018;15:18-21
|How to cite this URL:|
Aliyu I, Lawal TO, Onankpa B. Hypoxic-ischemic encephalopathy and the Apgar scoring system: The experience in a resource-limited setting. J Clin Sci [serial online] 2018 [cited 2018 Aug 14];15:18-21. Available from: http://www.jcsjournal.org/text.asp?2018/15/1/18/226035
| Introduction|| |
The Apgar score was developed by Virginia Apgar in the year 1952, to assess the well-being of newborn at birth; therefore, identifying those who need attention and immediate resuscitation. It consists basically of observation of five physical parameters with a score of 0–2 assigned to each. These scores are determined in the 1st and 5th min of life. However, it has been modified over the years with the 10th min and 20th min Apgar scorings included. To avoid ambiguity, several regulatory bodies such as the International Liaison Committee on Resuscitation recommends that the duration of Apgar scoring should be limited to the 10th min in the absence of any sign of life; afterward, resuscitation should be called off. Till date, controversy still persists on the scope of its utilization, while some researchers believe that it could predict long time neurologic outcome,, others hold contrary opinion.,, Furthermore, the isolated use of the Apgar score for defining perinatal asphyxia has been discontinued over the years in developed countries. Therefore, the American Academy of Pediatrics and the American College of Obstetrics and Gynecology definition stipulate that other evidences of hypoxemia such as acidemia, encephalopathy, and multiorgan dysfunction should be present before the diagnosis could be made. Some of these guidelines are often difficult to implement in some resource-constraint settings, for instance, blood gas analysis. The pertinent question then will be done we suspend the diagnosis of perinatal asphyxia in such settings? The resounding answer will be a no. The bottom line of perinatal asphyxia is the presence of hypoxic-ischemic encephalopathy (HIE). Therefore, this study seeks to determine how efficient and effective is the 1st and/or 5th min Apgar scoring in defining and classifying birth asphyxia and also comparing its score with the clinical manifestation of HIE using the Sarnat-Sarnat classification.
| Materials and Methods|| |
This was a retrospective study of inborn neonates admitted into the Special Care Baby Unit of our health facility with a diagnosis of birth asphyxia from January 1, 2012, to December 31, 2013. Their medical records were reviewed, and information on bio-data including sex, weight, gestational age, and information on Apgar score and clinical features diagnostic of HIE were extracted and entered into the study pro forma. Newborns with Apgar scores <7 at 1st min were included in the study; furthermore, only those scored by health personnel well trained in neonatal resuscitation were included in the study. In our institution, pediatricians attend deliveries of high-risk pregnancies, cesarean sections, and complicated labors; and they ascribe the Apgar score; however, the obstetricians and trained obstetric nurses score in noncomplicated deliveries. Files with incomplete records and nondocumented Apgar scoring were excluded in the data analysis. Infants <34 (completed) weeks' gestation were also excluded from the study.
The Apgar score is interpreted as normal (reassuring) if the score is 7–10, 6 is a fairly low score, 4–5 is low, whereas 0–3 is very/critical low in the term infant and late-preterm (near-term) infant., Perinatal asphyxia had been previously defined based on the Apgar scoring alone. therefore, the 5th min Apgar score of <7 and the 1st min Apgar score of <7 have been variedly used to define perinatal asphyxia. The severity of perinatal asphyxia was classified as mild, if the Apgar score is 6, moderate perinatal asphyxia is Apgar score of 4–5, whereas a score of 0–3 is severe perinatal asphyxia. We, therefore, compared how effective was the 1st or the 5th min Apgar in determining newborns who subsequently develop HIE. HIE was classified using the Sarnat and Sarnat criteria.
Data obtained were entered in a computer and were analyzed using Statistical Package for the Social Sciences version 16 (SPSS Inc., Chicago, Illinois, USA). Quantitative variable was summarized as a mean and standard deviation, whereas qualitative variables were summarized in percentages. The Fisher's exact test and one-sample Chi-square binomial tests were adopted as the tests of significance and P < 0.05 was adjudged statistically significant.
| Results|| |
There were 1600 recorded deliveries and 142 neonates fulfilled the criteria for inclusion in the study; 86 males and 56 females with a male-to-female ratio of 1.5:1. There were 30 (21.1%) preterms and 112 (78.9%) term infants. The birth weight ranged from 1.9 kg to 4.00 kg with a mean of 2.6 + 0.5 Kg. They were all appropriate for their gestational age.
[Table 1] described the 1st and 5th min Apgar scores and the frequency of HIE of the cases. It showed that most of the cases had a 1 min Apgar score in the range of 4–5 (62.0%); using the 5th min Apgar score, majority of the cases had scores of 6 and more. Sixty-five (45.8%) of the subjects had HIE; Stage 1 HIE was the most recorded form of encephalopathy.
|Table 1: The Apgar scores distribution and hypoxic-ischemic encephalopathy staging among the study group|
Click here to view
[Table 2] compared the Apgar scores of the 1st and 5th min with the clinical stages of HIE: the 1st min Apgar scores showed that 22 of the newborns with a score of 4–5 had Stage 1 HIE, whereas all the nine cases with Stage 3 HIE had a score of 0–3 (Fisher's exact test = 132.074; P = 0.00); furthermore, most cases with Stage 1 HIE had a 5th min score of 6 and above; however, none had a score of 0–3, but all the cases with Stage 3 HIE had a score between 4 and 5 (Fisher's exact test = 49.024; P = 0.00).
|Table 2: Comparing the Apgar scores with the hypoxic-ischemic encephalopathy staging status|
Click here to view
| Discussion|| |
The Apgar scoring has been applied variedly in different settings. While some use the 1st min Apgar score in defining perinatal asphyxia, majority use the 5th min Apgar score., Therefore, this may account for the varied prevalence, and severity of perinatal asphyxia reported in several studies.,,
In the 1st min Apgar score, about 62.0% of the subjects were moderately asphyxiated with only 9.9% being mildly asphyxiated; this improved significantly (P = 0.001) with no documented score of 0–3 at the 5th min Apgar score and the score of 6–7 increased to 26.8% signifying the relevance of Apgar scoring in monitoring of resuscitation.,
Our findings showed that a low 1st and 5th min Apgar score was associated with the clinical features of HIE in 45.8% of the cases, whereas the rest had no clinical manifestations of HIE. Therefore, newborns who had critically low 1st min Apgar scores were more likely to develop severe forms of HIE (Stages 2 and 3); however, most of those whose 1st min Apgar scores were in the moderate range (4–5) and the 5th min scores of 4–5 and 6, respectively, mostly had Stage 1 HIE.
While efforts are made in improving the health-care system by making available basic health services, the Apgar scoring should remain a guide in determining the physiologic state of the newborn at birth and also monitoring the effectiveness of resuscitation. Although the diagnosis is based on both clinical and laboratory parameters, absence of facilities for cord blood ABG should not deter us from making a diagnosis of perinatal asphyxia in our setting.
Home deliveries common are in most resource-limited settings; and the community-based neonatal care programs which are aimed at improving the survival of newborns, especially in rural settings has significantly improved neonatal morbidity and mortality outcomes. In the traditional practice, absence or a weak cry at delivery has been associated with perinatal asphyxia. While this may relate with some of the characteristics of the Apgar score, there is a need of educating health-care providers on the ease and usefulness of applying the Apgar scoring system in their routine delivery and newborn assessment protocol. With constant practice, training, and retraining, consistency in scoring may be achieved. Even in tertiary centers, there are also concerns of interobserver variability in Apgar scoring; O'Donnell et al. reported significant interobserver differences in the Apgar scores of up to 2.4 points among staffs involved in newborn resuscitation; however, retraining and use of simulations can significantly improve the reliability of the Apgar score. Nadler et al. reported a significant correlation between reported Apgar scores by clinicians participating in simulation exercise and that of experts who designed the program.
| Conclusion|| |
The Apgar score still remains an important tool in newborn assessment and monitoring the progress of resuscitation in a resource-poor setting. Both the first and 5th min Apgar scores showed a good correlation with clinical features of severe forms of HIE.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg 1953;32:260-7.
Apgar V. The newborn (Apgar) scoring system. Reflections and advice. Pediatr Clin North Am 1966;13:645-50.
American Academy of Pediatrics, Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists and Committee on Obstetric Practice. The Apgar score. Pediatrics 2006;117:1444-7.
Apgar V, Holaday DA, James LS, Weisbrot IM, Berrien C. Evaluation of the newborn infant; second report. J Am Med Assoc 1958;168:1985-8.
International Liaison Committee on Resuscitation. The international liaison committee on resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Neonatal resuscitation. Pediatrics 2006;117:e978-88.
Behnke M, Eyler FD, Carter RL, Hardt NS, Cruz AC, Resnick MB, et al.
Predictive value of Apgar scores for developmental outcome in premature infants. Am J Perinatol 1989;6:18-21.
Laptook AR, Shanharan S, Ambalavanan N, Carlo WA, McDonald SA, Higgins RD, et al
. Prediction of early childhood outcome of term infants using Apgar scores at 10 minutes following hypoxic-ischemic encephalopathy. Pediatrics 2009;124:1619. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821195
. [Last accessed on 2016 Feb 20].
Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics 1981;68:36-44.
Moster D, Lie RT, Irgens LM, Bjerkedal T, Markestad T. The association of Apgar score with subsequent death and cerebral palsy: A population-based study in term infants. J Pediatr 2001;138:798-803.
Thorngren-Jerneck K, Herbst A. Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol 2006;108:1499-505.
Use and abuse of the Apgar score. Committee on Fetus and Newborn, American Academy of Pediatrics, and Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Pediatrics 1996;98:141-2.
Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol 1976;33:696-705.
Executive summary: Neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy. Obstet Gynecol 2014;123:896-901.
Holton T. What are Apgar Scores, and Why are They Important? Available from: http://www.holtonlaw.com
. [Last accessed on 2016 Dec 12].
Ibe BC. Birth asphyxia and Apgar scoring: A review. Niger Med Pract 1990;20:111-3.
Olowu JA, Azubuike JC. Assessment and care of the newborn infant. In: Azubuike JC, Nkanginieme KEO, editors. Paediatrics and child health in a tropical region. First edition; African Educational Series. Owerri, Nigeria 1999. p. 38-43.
West BA, Opara PI. Perinatal asphyxia in a specialist hospital in Port Harcourt, Nigeria. Niger J Paediatr 2013;40:206-10.
IIah BG, Aminu MS, Musa A, Adelakun MB, Adeniji AO, Kolawole T. Prevalence and risk factors for perinatal asphyxia as seen at a specialist hospital in Gusau, Nigeria. Sub-Saharan Afr J Med 2015;2:64-9.
Ekure EN, Ezeaka VC, Iroha E, Egri-Okwaji M. Prospective audit of perinatal mortality among inborn babies in a tertiary health center in Lagos, Nigeria. Niger J Clin Pract 2011;14:88-94.
] [Full text]
Mukhtar-Yola M, Iliyasu Z. A review of neonatal morbidity and mortality in Aminu Kano teaching hospital, Northern Nigeria. Trop Doct 2007;37:130-2.
Ugwu GI, Abedi HO, Ugwu EN. Incidence of birth asphyxia as seen in central hospital and GN children's clinic both in Warri Niger Delta of Nigeria: An eight year retrospective review. Glob J Health Sci 2012;4:140-6.
Lopriore E, van Burk GF, Walther FJ, de Beaufort AJ. Correct use of the Apgar score for resuscitated and intubated newborn babies: Questionnaire study. BMJ 2004;329:143-4.
Jain L, Ferre C, Vidyasagar D, Nath S, Sheftel D. Cardiopulmonary resuscitation of apparently stillborn infants: Survival and long-term outcome. J Pediatr 1991;118:778-82.
Gogia S, Ramji S, Gupta P, Gera T, Shah D, Mathew JL, et al.
Community based newborn care: A systematic review and metaanalysis of evidence: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr 2011;48:537-46.
Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois. Pediatrics 2001;107:648-55.
O'Donnell CP, Kamlin CO, Davis PG, Carlin JB, Morley CJ. Interobserver variability of the 5 minute Apgar score. J Pediatr 2006;149:486-9.
Nadler I, Liley HG, Sanderson PM. Clinicians can accurately assign Apgar scores to video recordings of simulated neonatal resuscitations. Simul Healthc 2010;5:204-12.
[Table 1], [Table 2]