Five-Minute Apgar Scores and Its Prognostic Value: A Multinational Cohort Study
The Apgar score was originally developed to standardise the assessment of term-born infants' clinical condition at 1 min of life. However, accumulating research shows that the judgement at 5 and 10 min has better predictive value for in-hospital mortality and severe neurologic and non-neurologic morbidities in term-born infants. In very preterm (VPT) infants <32 weeks' gestation, low 5-min Apgar scores have been consistently associated with increased risk of mortality, but results on associations with morbidity are contradictory. The authors from a multinational research collaboration concluded that low Apgar scores were associated with increased risk for severe brain injury in preterm infants 24–28weeks but not in a graded manner. The longer-term prognostic value was called into question in extremely preterm infants.
Key aims of the present study were to describe variations in 5- min Apgar scores <7 among VPT infants across European countries, to assess associations with adverse neonatal outcomes and to test whether these associations differ by country-level variations in low Apgar score prevalence.
itwasaProspective observational population-based cohort study. In total, 7900 liveborn VPT infants from the EPICE-SHIPS study were included. Associations between 5-min Apgar scores<7 and adverse neonatal outcomes were estimated with adjustments for perinatal characteristics. We tested for interactions by country-level prevalence of an Apgar score<7, grouped into low (14%–16%), medium (19%–22%) and high (28%–40%).
20.2% of infants had 5-min Apgar score <7 with rates of 14%–40% across countries. A score <7 increased risks of in hospital mortality, intraventricular haemorrhage (IVH), cystic periventricular leukomalacia (cPVL), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD) and length of hospital stay (LHS), but not necrotising enterocolitis or late-onset infection (LOI). No interactions with country group were detected for mortality, cPVL and ROP, while associations with IVH, BPD and LHS were restricted to countries with lower prevalence of scores <7.
In a multinational cohort of VPT infants using data abstracted following a common, standardised protocol, study provide novel results on the association of 5-min Apgar score severe outcomes. Three findings advance the scientific knowledge about the prognostic value of the 5-min Apgar score in this high-risk population. First, the proportion of VPT infants with 5-min Apgar scores <7 varies largely between European countries. Second, there is a clinically relevant association of low 5-min Apgar scores with most adverse neonatal outcomes. This is reassuring as the Apgar score is the first clinical assessment to judge the vitality of VPT infants after birth. The importance arises from the fact that the score guides clinical treatment decisions for stabilisation measures and resuscitation worldwide, although concerns of its suitability have been raised by researchers and leading medical societies. Lastly, the variations in strength of associations between adverse outcomes and low 5-min Apgar score by country suggest the need for context-specific validation of the Apgar score and risk thresholds. While mortality was not impacted by country variations in 5-min Apgar scores, this was present for severe IVH. The latter finding is of relevance for the long-term outcome of VPT infants, as severe IVH constitutes one of the most devastating acute morbidities with high impact on the psychomotor outcome.
Early prediction of adverse outcomes remains an unmet need in research on VPT infants and clinical care. Easy-to-use bedside tests are required that can guide prompt decisions as well as risk stratification. The 5-min Apgar score has remained a standard assessment tool for more than 70 years despite the advances in clinical care and medical knowledge. One of the reasons is its easy applicability. Study results and others argue for its suitability to predict adverse neonatal outcomes after VPT birth. However, associations are too weak and variability is too high to base treatment decisions exclusively on the 5-min Apgar score. Multivariable models, combining the 5-min Apgar score with additional items including medical interventions after delivery and the new features of artificial intelligence, show promise, as established for other disease entities like sepsis. This will hopefully lead to an easy-to-handle tool with high accuracy as established for BPD and ROP risk calculators. Overall, results encourage initiatives to standardise Apgar scoring within a European guideline and video tutorials.
Study results indicate that low 5-min Apgar scores <7 are associated with an unfavourable short-term outcome in VPT infants. The variations in Apgar scores between the countries underscore the importance of not only focusing on baseline risks, management and outcomes, but also considering the interaction with country in routine clinical care and research.
Source: Harald Ehrhardt, Soodabeh Behboodi, Rolf F. Maier; BJOG: An International Journal of Obstetrics & Gynaecology, 2025; 0:1–11 https://doi.org/10.1111/1471-0528.18291
