Portal de Periódicos da CAPES

The legacy of Virginia Apgar

2020; Elsevier BV; Volume: 124; Issue: 3 Linguagem: Inglês

10.1016/j.bja.2019.12.017

1471-6771

Carlos Rogério Degrandi Oliveira,

Cardiac, Anesthesia and Surgical Outcomes

Editor—The Apgar scale is used to assess newborn babies worldwide. This eponym is well known by obstetricians, paediatricians, and anaesthesiologists. Six decades since its publication, this work of Virginia Apgar (1909–1974), is still in routine use today. A 1933 graduate of Columbia University College of Physicians & Surgeons in New York City, Dr Apgar was determined to be a surgeon. Having won a scholarship, she completed her studies with great success. However, the chair of surgery, Allen Whipple, persuaded her not to train in surgery. He saw in Apgar the energy, intelligence, and ability needed to make contributions in a new speciality. Her mentor's arguments were convincing. In January 1937, Apgar went to Madison, WI, USA as a visitor to the anaesthesiology department of Ralph Waters, considered at that time the most important training centre in the USA.1González-Cordero G. Garza-Hinojosa G. Apgar Virginia Una anestesióloga fuera de serie.Anestesia en México. 2004; 16: 32-39Google Scholar In 1938, she returned to Columbia University Presbyterian Hospital where she was appointed Director of the Anesthesiology Division of the Department of Surgery, being the first woman to assume this position at a US university. Apgar was especially interested in the development of obstetric anaesthesia and neonatal resuscitation. At that time, maternal mortality was very high. Her greatest concern was the prevalence of acidotic, hypoxaemic, premature, and malformed newborns.2Finster M. Wood M. The Apgar score has survived the test of time.Anesthesiology. 2005; 102: 855-857Crossref PubMed Scopus (154) Google Scholar The initial idea of an evaluation method came about in 1949 at Columbia over coffee, when a medical student commented on the need for a method to evaluate the newborn. Apgar took the nearest piece of paper and wrote a draft of what would become her score. In 1953, Apgar published the method of evaluating the five signals: heart rate, breathing effort, reflex irritability, muscle tone, and skin colour. A score of 2, 1, or 0 was assigned to each sign 60 s after delivery.3Apgar V. A proposal for a new method of evaluation of the newborn infant.Anesth Analg. 1953; 32: 260-267Crossref PubMed Scopus (1328) Google Scholar In 1962, two paediatricians, Butterfield and Covey, published the APGAR epigram to facilitate memorisation and teaching of the five signs.4Butterfield J. Covey M.J. Practical epigram of the Apgar score (letter).JAMA. 1962; 181: 353Crossref Scopus (13) Google Scholar Apgar also predicted that her scoring system would be useful for comparing results from different obstetric practices, methods of maternal pain relief, and various neonatal resuscitation techniques used at the time. The resuscitation of the child was very misunderstood, and many bizarre methods such as alternating immersion in cold and hot water, rectal dilatation, and oxygen insufflation of the stomach were used.3Apgar V. A proposal for a new method of evaluation of the newborn infant.Anesth Analg. 1953; 32: 260-267Crossref PubMed Scopus (1328) Google Scholar Her first observations showed that some anaesthetic agents used at the time, such as meperidine and cyclopropane, easily crossed the placental barrier and depressed the child. Newborns delivered by Caesarean section under spinal anaesthesia had better scores compared with those born to mothers undergoing general anaesthesia. Among the children studied, those with a score of 2 or lower had a 14% mortality; from 3 to 7, 1.1%; and those who scored from 8 to 10 had a mortality rate of only 0.13%. Children born by natural childbirth with cephalic presentation had the highest score, an average of 8.4.5Apgar V. Holaday D.A. James L.S. Weisbrot I.M. Berrien C. Evaluation of the newborn infant-second report.JAMA. 1958; 168: 1985-1988Crossref PubMed Scopus (190) Google Scholar At a time when the birth rate was very high after World War II, studies of newborns by Apgar proved of great interest. A study published in 1964 involving 17 221 infants found that the Apgar score, especially when carried out 5 min after birth, was a strong predictor of neonatal survival.6Drage J.S. Kennedy C. Schwarts B.K. The Apgar score as an index of neonatal mortality.Obstet Gynecol. 1964; 24: 222PubMed Google Scholar The same correlation was found in an analysis of more than 150 000 deliveries.7Casey B.M. McIntire D.D. Leveno K.J. The continuing value of the Apgar score for the assessment of newborn infants.N Engl J Med. 2001; 344: 467-471Crossref PubMed Scopus (583) Google Scholar Apgar received several distinctions during her life. She was the first woman on the Executive Committee of the American Society of Anesthetists, later the ASA, acting as Treasurer. In 1949, she was appointed professor of anaesthesiology, being the first woman with a teaching position at Columbia University College of Physicians & Surgeons. Apgar then earned her master's degree in public health and became a professor in the department of genetics at Johns Hopkins University School of Public Health. In 1961, she became the first woman to receive the Distinguished Service Award, the highest honour of the ASA. In 1973, Apgar wrote the book Is My Baby All Right, a guide for parents about newborn care. In 1994 the US Postal Service issued a postage stamp from the Great Americans series in her honour (Fig. 1). It was an appropriate recognition, as Apgar had a fantastic professional career and was a dedicated stamp collector. In the 21st century, the 5-min score remains an easy method for assessing resuscitation effectiveness and even the vitality of the newborn.8Papile L.A. The Apgar score in the 21st century (editorial).N Engl J Med. 2001; 344: 519-520Crossref PubMed Scopus (73) Google Scholar Apgar held a prestigious position, and gained great respect in a male-dominated society. Partly because of her pioneering efforts, anaesthesiology has become a desirable vocation for women. She overcame several constraints that limited her original ambitions, yet took advantage of the opportunities available to create one of the most exceptional careers of any anaesthesiologist to date. The author declares that they have no conflict of interest.