Outcome of Resuscitation Following Unexpected Apparent Stillbirth

Abstract

There are few data to inform a decision to resuscitate babies who are unexpectedly stillborn. The outcome for 42 successfully resuscitated stillborn children, of whom 62% survived to be discharged home, is reported. Of the survivors, a poor outcome with severe disability was found in 23% (including one postneonatal death), equivocal outcome was found in 15% (two mild hypertonia; two with mild hemiplegia and no associated other disability) and 62% were free of any impairment at follow up 20 months to 8 years later. In 39 (93%) fetal problems had been identified and the resuscitation team was present at delivery. Poor outcome was associated with late return of heart beat, delayed respirations, neonatal acidaemia and early onset of seizures. Of the unexpected apparent stillbirths successfully resuscitated, 52% died or survived severely disabled, 10% had an equivocal outcome, but 36% survived apparently intact. Therefore, vigorous resuscitation is clearly indicated in these circumstances. (Arch Dis Child Fetal Neonatal Ed 1998;78:F112-F115)

Improving infant outcome with a 10 min Apgar of 0: Table 1

“…Twenty-one per cent survived with intelligence quotients between 77 and 99 as measured on the Wechsler Preschool and Primary Scale of Intelligence III, with normal visuospatial and attention, executive function and without cerebral palsy at 6–7 years of age 10. Conversely, Sarkar et al has reported uniformly poor outcome in a group of term infants with asystole at 10 min treated with hypothermia, consistent with previous case series which took place prior to the investigational use of therapeutic hypothermia 2 5 11 12. The objective of this report was to review the recent outcome of infants ≥35 weeks gestation without an apparent HR at 10 min of life despite intensive resuscitation treated both with therapeutic hypothermia and standard care.…”

“…Notably, there is a paucity of data regarding term and near-term infants with an Apgar of 0 at 10 min of life. The few case series cited in the 2000 and 2005 Neonatal Resuscitation Guidelines justifying discontinuation of resuscitation at 10 min are small, include both term and preterm infants and took place between 1982 and 1999 2 5 11. Thus, Jain et al 5 reported on the largest series of 58 term and preterm infants with an Apgar of 0 at ≥ 10 min, with death occurring in all infants except one survivor who was subsequently diagnosed with cerebral palsy.…”

“…An absent heart rate (HR) at birth may reflect an intrapartum stillbirth or a state of severe and prolonged secondary apnoea which may only be reversed with effective positive pressure ventilation and in some cases more intensive resuscitation 1. Even with the recovery of spontaneous circulation, there is a high likelihood of cerebral hypoperfusion with subsequent brain injury or death 2 3…”

“…The rationale behind suggesting 15 min appears unclear, as the recommendation went on further to state that survival without severe disability was unlikely after 10 min of asystole. Small case series were cited which included both term and preterm apparently stillborn infants, all of whom suffered death or disability 2 5 6. The guidelines in 2005 advised that discontinuation may be warranted if there were no signs of life after 10 min of adequate resuscitation 7.…”

Use and Efficacy of Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room

“…1,2 This often results in injury to the brain and other organ systems. Prolonged intensive resuscitation is strongly associated with increased mortality and poor neurologic outcomes, [3][4][5][6] emphasizing the need to optimize the neonatal resuscitation regimen.…”