What Happens to Stillborn Babies Who Are Successfully Resuscitated?
ABSTRACT & COMMENTARY
Synopsis: Forty-two of 45 babies who were expected to be liveborn who had one minute Apgar scores of 0 were successfully resuscitated.
Source: Casalaz DM, et al. Outcome of resuscitation following unexpected apparent stillbirth. Arch Dis Child Fetal Neonatal Med 1998;78:F112-F115.
The purpose of this review article was to describe the outcome of babies born with asystole and an Apgar score of 0 at one minute (excluding known intrauterine deaths) and to determine predictors of outcome. Casalaz and colleagues retrospectively studied the outcome of 94,511 deliveries. Forty-five babies who were expected to be liveborn at more than 24 weeks gestation had an Apgar score of 0 at one minute (0.5 per 1000 births). Of these, 42 (93%) were successfully resuscitated and admitted to the neonatal intensive care unit. Twenty-six of the 42 babies successfully resuscitated (62%) survived to be discharged home. Outcome at 20 months to 8 years of age was determined by review of records or by interviewing caregivers. Sixteen (62%) of the survivors were "free of any abnormality," four (15%) had "mild-moderate" disabilities, such as hypertonicity or mild spastic hemiplegia, and six (23%) were "severely" disabled, with cerebral palsy and global dysfunction. Overall, 36% (16 of 45) of the original babies born with a one minute Apgar score of 0 survived with no abnormality, and 44% (20 of 45) survived with either no abnormality or mild-moderate disability.
Term and preterm infants had similar survival. Arterial pH within two hours of delivery was lower in those who died or survived with severe disability compared to normal survivors (median, 6.97 vs. 7.15, respectively), but there was significant overlap between the two groups.
More discriminating predictors of outcome were the presence of a heart beat at five minutes of life and the onset of seizures at less than 12 hours of life. Of 13 babies whose heartbeat was still absent at five minutes, 11 died and two survived with severe disability. Of 13 babies who had seizures recorded in the first 12 hours of life, 10 died and three survived with severe disability.
Casalaz et al conclude that "vigorous resuscitation of unexpectedly stillborn infants is clearly indicated."
COMMENT BY STEVEN PETEREC, MD, FAAP
The birth of a child who unexpectedly has no heart beat is every pediatrician's, neonatologist's and parent's worst nightmare. A difficult resuscitation ensues, and decisions must be made regarding how long to continue resuscitative efforts. If the newborn is successfully resuscitated, medical personnel must determine his or her prognosis and convey this information to the parents. This is the third article published over the last few years that helps address these issues.1,2
Like the two earlier papers, this report provides surprisingly encouraging data. Most babies born unexpectedly without a heartbeat can be successfully resuscitated in the delivery room. Of those successfully resuscitated, 48% survive with normal outcome or mild-moderate disability. (Similar rates of approximately 39% and 45% were noted in the studies by Jain et al and Yeo and Tudehope, respectively.) Reasonably good survival rates are probably due to a short period of fetal compromise prior to delivery, and subsequent, expedient, and skilled neonatal resuscitation. In almost all of the cases of successful resuscitation in the current series (39 of 42), adverse perinatal events such as a poor fetal heart rate tracing led to the presence of doctors trained in neonatal resuscitation in the delivery room. This highlights the importance of maintaining the resuscitation skills of neonatal caregivers.
Outcome data, however, must be interpreted cautiously. A major limitation of this study is that data were collected retrospectively. Detailed evaluations of survivors were not performed by Casalaz et al. Neurodevelopmental deficits may have been missed by caregivers or not recorded in the medical record. Although survivors underwent a comprehensive evaluation in Jain and associates' study, 30% were lost to follow-up. In both reports, the frequency and severity of disabilities in survivors may be significantly underestimated.
The current study also highlights the difficulties in predicting outcome. Among patients initially successfully resuscitated, few variables absolutely predict mortality or the development of severe disabilities. Early seizures may be one such variable. What to tell parents about prognosis, and when it is appropriate to withdraw support, continue to be defined.
This study does help caregivers decide how long to continue to attempt to resuscitate a baby born with no heartbeat. Outcome was uniformly poor if there was still no heartbeat at five minutes. In the study by Jain et al, of 93 attempted resuscitations, one baby without a heartbeat at five minutes survived with normal outcome and one survived with "suspect" outcome. Of 58 babies who still had no heartbeat at 10 minutes, 57 died and one survived with an abnormal outcome. Thus, for babies born with unexpected asystole, it appears appropriate to continue resuscitative efforts for five to 10 minutes, but not longer. The data clearly support the initiation of vigorous resuscitative efforts. (Dr. Peterec is Assistant Professor of Pediatrics [Neonatology] at the Children's Hospital at Yale-New Haven).