Low Apgar Scores Predict Poor Outcomes in Premature Infants

TOPLINE:

A 5-minute Apgar score < 7 was significantly associated with increased risks for in-hospital mortality, severe intraventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and prolonged hospital stay among infants born very preterm (VPT).

METHODOLOGY:

• Researchers conducted a prospective population-based cohort study of liveborn infants born VPT from the EPICE-SHIPS cohort.
• This study included 7900 liveborn infants born VPT between 22 + 0 and 31 + 6 weeks of gestation across 19 regions in 11 European countries.
• Data on maternal and perinatal characteristics, management, and neonatal outcomes were collected from patient records.
• Adjusted associations between 5-minute Apgar scores < 7 and adverse neonatal outcomes were analysed; researchers tested for interactions by the country-level prevalence of an Apgar score < 7, categorised as low (14%-16%), medium (19%-22%), and high (28%-40%) groups.
• Outcomes included in-hospital mortality, severe IVH (> grade 2), cystic periventricular leukomalacia (cPVL), necrotising enterocolitis, late-onset infection, ROP (≥ stage 3), BPD (moderate/severe), and prolonged hospital stay.

TAKEAWAY:

• A 5-minute Apgar score < 7 was observed in 20.2% of infants born VPT, varying widely across countries from 14% to 40%.
• A low Apgar score (< 7) was strongly associated with a higher risk for in-hospital mortality than a high Apgar score (≥ 7; 35.7% vs 6.9%; adjusted relative risk [RR], 2.24; 95% CI, 1.95-2.58), with consistent risk observed across all country groups.
• A low Apgar score was associated with increased risks for severe IVH (RR, 1.61; 95% CI, 1.33-1.96), ROP (RR, 1.41; 95% CI, 1.09-1.82), cPVL (RR, 1.40; 95% CI, 1.00-1.96), BPD (RR, 1.35; 95% CI, 1.20-1.51), and prolonged hospital stay (RR, 1.44; 95% CI, 1.26-1.63).
• Associations with IVH, BPD, and prolonged hospital stay were stronger among countries with a lower prevalence of low Apgar scores (test of interaction P = .04 for IVH, P = .09 for BPD, and P = .43 for prolonged hospital stay).

IN PRACTICE:

“[Low Apgar scores’] interactions with adverse outcomes demand caution when using the Apgar score in prognostic models for clinical care and research without local validation,” the authors wrote.

SOURCE:

This study was led by Harald Ehrhardt, MD, Department of Pediatrics and Adolescent Medicine, University Medical Centre Ulm, Ulm, Germany. It was published online on July 15, 2025, in BJOG: An International Journal of Obstetrics & Gynaecology.

LIMITATIONS:

The study’s data were collected in 2011-2012, and clinical practices may have evolved since then. Variations in how Apgar scores were assigned across different centres, the lack of data on postnatal resuscitation efforts, and a mostly White European cohort may have limited generalisability.

DISCLOSURES:

This work was supported by the European Union’s (EU’s) Seventh Framework Programme and the EU’s Horizon 2020 research and innovation programme. Some authors reported receiving funding from the EU and Swedish Foundation related to the study, and others reported receiving unrelated grants and serving unpaid roles in paediatric organisations and advisory boards.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.