RAMB Maio/Junho 2015

9 / 108

Correlation between Apgar score and hipoxic- ischemic encephalopathy
Rev Assoc Med B ras 2015; 61(3):193 193
CORRESPONDENCE
Correlation between Apgar score and hipoxic-ischemic encephalopathy
Correlação entre escore de Apgar e encefalopatia hipóxico-isquêmica
José M. R. Perez1
1PM.D., Coordinator, Centro Internacional de Neurodesenvolvimento Neonatal (CINN), Secretary at the Sociedade Iberoamericana de Neonatologia (Siben). São Paulo, SP, Brazil.
After the publication of articles such as those of Salustiano
et al.1 and Ehrenstein et al.,2 demonstrating the strong as-
sociation between low Apgar score (<7) at 5 minutes and
the incidence of hypoxic-ischemic encephalopathy (HIE)
leading to cerebral palsy; and also on account of our expe-
rience in the management of patients withHIE, as published
by Perez et al.,3 and our experience in noting the difficulty
in diagnosing this condition in the countries of Latin Amer-
ica, as reported by the Ibero-American Society of Neonatol-
ogy (Siben), we decided to put into debate a proposal for
monitoring of newborns presenting perinatal asphyxia.
As we can see in these studies1,2 the incidence of HIE
is much higher than the already published in Latin Amer-
ican studies. This can be partly explained by population
differences, but also for the association between low Ap-
gar and HIE. In our specialty, it is relatively common to
find centers that keep newborns with low Apgar score at
1 or 5 minutes, but who recover at 10 minutes, in the nurs-
ery, without monitoring their neurological progress more
thoroughly, missing the opportunity for early diagnosis
of HIE. In our previously cited study,3 we made a change
in the routine assessment of our newborns with Apgar
score 5 or less at any time of evaluation (1’-5’-10’) by im-
plementing an additional clinical assessment using the
Sarnat neurological score at 10 minutes after birth and
hourly thereafter within the first six hours of life, a criti-
cal period for decision-making, regarding deployment of
therapeutic hypothermia. This should be done in all new-
borns even when there is recovery according to Apgar
score, because the hypoxic ischemic injury might already
have triggered the inflammatory process that may result
in HIE. As a result of this strategy, we had an incidence
of neurological sequelae of 11.5% (3 cases in 26 newborns
with moderate to severe HIE; 1 with mild cerebral palsy,
1 with moderate cerebral palsy and 1 with hearing defi-
cit; no severe cerebral palsy), which is very low in our con-
text for patients with HIE.
One of the main difficulties encountered initially to
implement this routine was training to use the said score.
Both the medical and nursing staffs were not familiar
with the scale, which, unfortunately, is common in most
Latin American countries. Too often we find centers that
do not use any neurological grading scale to evaluate new-
borns, and the question remains as to how they will be
able to identify cases of HIE disease. In our study, we
chose to print the Sarnat score and put it on the wall in
places that included the delivery room and the interme-
diate care and intensive care units, and to prepare a spe-
cific training for doctors and nurses on the score.
Today, as the formation of therapeutic hypothermia
centers in Latin America is encouraged, we emphasize the
need to adapt the training of newborn care teams toward
proper diagnosis, without which the efficacy of any ther-
apy is compromised.
References
1. Salustiano EMA, Campos JADB, Ibidi SM, Ruano R, Zugaib M. Low Apgar
score at 5 minutes in a low risk population: maternal and obstetrical factors
and postnatal outcomes. Rev Assoc Med Bras. 2012; 58(5):587-93.
2. Ehrenstein V, Pedersen L, Grijota M, Nielsen GL, Rothman KJ, Toft H.
Association of Apgar score at five minutes with long-term neurologic disability
and cognitive function in a prevalence study of Danish conscripts. BMC
Pregnancy Childbirth. 2009; 9:14.
3. Perez JMR, Golombek S, Sola A, Alpan G. A novel device for the treatment
of neonatal hypoxic encephalopathy with hypothermia: neonatal laminar
flow unit. Acta Paediatrica. In press.