In the second century AD, Soranus of Ephesus, a leading physician in Rome, described a method of assessing the health status of newborns that very much resembles today's Apgar score.1, 2 Both Soranus and Virginia Apgar recommended the evaluation of muscle tone, reflex irritability, respiratory effort and colour. Soranus, however, did not mention heart rate as prognostic factors, given that circulation had not been studied in the second century AD.1 Soranus insisted more on documentation of malformations and the pregnant woman's health and the newborn baby's maturity, whereas Apgar mentioned that prematurity and complicated pregnancy may alter scoring. While the Apgar score has been used to describe the health status of the newborn, Soranus' assessment was mainly used to determine whether the newborn is worth rearing. Since the early 1960s, an Apgar score from 0 to 3 has been defined as a low score, a score from 4‐6 as a moderately low and 7‐10 as normal or reassuring.3 Given how the score is constructed, one would expect it to describe risk in a linear manner. However, the commonly accepted belief seems to be that the outcomes should be the same for scores 7‐10, with outcomes dropping for lower scores in a step‐like manner. Yet, compared with non‐malformed term infants with an Apgar score of 10, those scoring between 7 and 9 at 1, 5 or 10minutes have higher risks of neonatal mortality, infections, asphyxia‐related complications, hypoglycaemia and respiratory distress, and these associations become substantially stronger with increasing time after birth.4 Additionally, in infants with a 5‐minute Apgar score of 10, a 10‐minute score of ≤9 is associated with a higher risk of neonatal morbidity. Consequently, infants born with lower Apgar scores within the normal range (ie with scores of 7, 8 and 9) at 1, 5 or 10minutes are also at higher risks of adverse long‐term outcomes, such as epilepsy, cerebral palsy, autism, having special needs and adverse child developmental health (compared with non‐malformed term infants with an Apgar score of 10).4-7
The score was initially developed to assess term infants during a time when neonatal mortality was very high in preterm infants. The frequency of low Apgar scores increases with decreasing gestational age, and this may reflect biological immaturity in preterm infants. However, to the extent that physiological response patterns reflected by Apgar scores in preterm infants may be a proxy for vulnerability related to immaturity, the score can also provide useful prognostic information for survival of preterm infants, even in very low birthweight neonates.8 Still, the value of Apgar score to assess the condition of the preterm infant has been questioned.3, 9 A current Policy Statement of American Academy of Pediatrics includes an overall recommendation that the Apgar score does not predict individual neonatal mortality or neurologic outcome and should not be used for that purpose,3 with no specific recommendation regarding the use of Apgar score in preterm infants.
This premise has been recently challenged in a nation‐wide Swedish study which demonstrated that Apgar scores at 5 and 10minutes after birth are closely associated with risk of neonatal mortality (deaths during the four first weeks) in preterm infants.10 Risk of neonatal mortality increases successively with decreasing Apgar score regardless of gestational age. Importantly, the absolute risks increase in neonatal mortality (ie the excess number of deaths per 100 births) by decreasing Apgar score increases with decreasing gestational age. For example, compared with infants with high Apgar scores at 5minutes (9‐10), the absolute risk increases among infants with Apgar scores of 4‐6 was 2.0% at 35‐36weeks, 4.9% at 32‐34weeks, 7.1% at 28‐31weeks, 12.0% at 25‐27weeks and 16.6% at 22‐24weeks. Even a slight increase in Apgar score from 5 to 10minutes was associated with a decrease in neonatal mortality risk.10
Together, these findings provide strong evidence for the importance of registering Apgar score in both term and preterm infants. Infants not having a full Apgar score should receive appropriate support, and efforts should be made to reduce the rate of low Apgar scores within the normal range and to strive for an Apgar score of 10 immediately after birth. Furthermore, all newborns should be assigned an Apgar score at 10minutes, regardless of their score at 1 and 5minutes. This will enable at‐risk neonates to be identified and monitored to minimise the risk of adverse outcomes. Although it is frustrating that we usually cannot pinpoint the causes of a reduced Apgar score, we need to embrace that the score is, the best available tool we have to evaluate the newborn's health in the delivery room.
中文翻译：
从Soranus得分到Apgar得分
公元二世纪，罗马的一位主要医师以弗所·索拉努斯（Serranus of Ephesus）描述了一种评估新生儿健康状况的方法，该方法与当今的Apgar评分非常相似。1，2 Soranus和Virginia Apgar均建议评估肌肉张力，反射性易怒性，呼吸强度和肤色。然而，考虑到公元二世纪还没有研究过血液循环，Soranus并未将心律作为预后因素。1个Soranus坚持要更多地记录畸形，孕妇的健康状况以及新生婴儿的发育，而Apgar提到早产和复杂的怀孕可能会改变评分。虽然Apgar评分已用于描述新生儿的健康状况，但Soranus的评估主要用于确定新生儿是否值得饲养。 自1960年代初以来，Apgar得分从0到3被定义为低分，从4-6到中等或较低的得分被定义为7-10，这是正常或令人放心的。3鉴于分数的构造方式，人们期望它以线性方式描述风险。但是，普遍接受的信念似乎是，分数7-10的结果应该相同，分数较低的结果以逐步的方式下降。然而，与Apgar评分为10的非畸形足月婴儿相比，在1、5或10分钟时得分在7到9之间的婴儿有更高的新生儿死亡，感染，窒息相关并发症，低血糖和呼吸窘迫的风险，并且这些出生后的时间越长，关联性就越强。4此外，在5分钟Apgar评分为10的婴儿中，10分钟评分≤9与新生儿患病的风险较高相关。因此，在1、5或10分钟时，Apgar分数在正常范围内（即7、8和9）的婴儿出生时，其长期不良后果的风险也较高，例如癫痫，脑瘫，自闭症，有特殊需要并不利于儿童发育健康（与Apgar评分为10的非畸形足月婴儿相比）。4-7 最初开发该分数是为了评估早产儿新生儿死亡率很高时的足月儿。Apgar评分低的频率随着胎龄的降低而增加，这可能反映了早产儿的生物学不成熟。但是，就早产儿Apgar评分所反映的生理反应模式可能是与不成熟相关的脆弱性的代表而言，即使在极低出生体重的新生儿中，该评分也可以为早产儿的生存提供有用的预后信息。8尽管如此，用于评估早产儿状况的Apgar评分的价值还是受到质疑。3、9美国儿科学会目前的政策声明包括一项总体建议，即Apgar评分不能预测个体新生儿死亡率或神经系统结局，因此不应用于此目的3，但没有关于在早产儿中使用Apgar评分的具体建议。 最近在瑞典进行的一项全国性研究对这一前提提出了挑战，该研究表明，出生后5分钟和10分钟的Apgar评分与早产儿新生儿死亡的风险（头四个星期内的死亡）密切相关。10无论胎龄如何，随着Apgar评分的降低，新生儿死亡的风险会随之增加。重要的是，随着Apgar分数的降低，随着胎龄的降低，新生儿死亡的绝对风险（即每100例死亡中的过多死亡）会增加。例如，与5分钟Apgar评分较高的婴儿（9-10）相比，Apgar评分4-6婴儿的绝对风险增加在35-36周为2.0％，在32-34周为4.9％，为7.1 28-31周时为％，25-27周时为12.0％，22-24周时为16.6％。Apgar评分从5分钟到10分钟的轻微增加与新生儿死亡风险的降低有关。10 总之，这些发现为足月和早产儿注册Apgar评分的重要性提供了有力的证据。Apgar分数未达到满分的婴儿应获得适当的支持，并应努力将Apgar分数低的比率降低至正常范围，并在出生后立即将Apgar分数降至10。此外，无论新生儿在1分钟和5分钟时的得分如何，均应在10分钟时为其分配Apgar得分。这将使高危新生儿得以识别和监测，以最大程度地降低不良后果的风险。尽管令人沮丧的是我们通常无法查明Apgar评分降低的原因，但我们需要接受的是，评分是我们评估分娩室新生儿健康的最佳可用工具。
