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Endgames Case Review

A baby with low Apgar scores at birth

BMJ 2016; 352 doi: (Published 03 February 2016) Cite this as: BMJ 2016;352:i479
  1. Sagarika Ray, consultant neonatologist
  1. Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Telford TF1 6TF, UK
  1. Correspondence to: S Ray sagarika.ray{at}

A baby girl, weighing 3510 g (50th centile), was born at 41+1 weeks’ gestation. The mother had presented in labour and initial assessment identified placental abruption and breech presentation. At emergency caesarean, the infant was found to be in the abdominal cavity after maternal uterine rupture. At initial assessment the baby was floppy and pale, with no respiratory effort and an inaudible heart rate. She was intubated at 45 seconds and a heart rate of 70 beats/min was first heard at 1 minute; this subsequently improved.

At 10 minutes of age, she remained ventilated and Apgar scores were 2 at 1 minute, 4 at 5 minutes, 4 at 10 minutes. Venous cord gas showed pH 6.6, partial pressure of carbon dioxide 20.1 kPa, base excess −25 mmol/L, bicarbonate 15.5 mmol/L. Passive cooling was started by switching off the resuscitaire’s overhead warmer.

On admission to the neonatal unit, ventilator settings were on a time cycled pressure limited mode of pressure control-assist control (PC-AC), peak inspiratory pressure 16, peak expiratory pressure 5, inspiratory time 0.4 seconds, fractional index of oxygen 0.25, ventilator rate 40 breaths/min (all breaths delivered by the ventilator owing to lack of regular spontaneous breaths by the infant). Observations included: temperature 34.8°C (axilla) and 34.4°C (rectal), heart rate 179 beats/min, respiratory rate 60 breaths/min, non-invasive blood pressure 70/30 mm Hg (mean 44), oxygen saturations 97%. Clinical examination showed generalised hypotonia with some limb movements in response to handling and no obvious clinical seizure activity at the time of admission.


  1. What is the most likely diagnosis?

  2. What further management is needed at this stage?

  3. What other relevant investigation is useful at this stage?

  4. What are the prognostic indicators?

  5. What are the long term outcomes of this condition?


1. What is the most likely diagnosis?

Short answer

Hypoxic ischaemic encephalopathy (HIE).


The diagnosis of HIE is based on the Apgar …

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