Comparative Prognostic Value of Combined versus Conventional Apgar Scores for Neonatal Outcomes: A Prospective Cohort Study

Objective: To compare the predictive performance of the combined Apgar score versus the conventional Apgar score in forecasting adverse clinical outcomes among hospitalized neonates in a tertiary care setting. Methods: This prospective cohort study, conducted from April to October 2023 at Imam Khomeini and Sina Hospitals in Ahvaz, Iran, enrolled 637 neonates requiring hospitalization. Both conventional and combined Apgar scores were recorded at 1, 5, and 10 minutes post-birth by trained neonatologists following standardized protocols. The combined Apgar score integrated gestational age adjustments and resuscitative interventions, while the conventional score assessed five physiological parameters. Primary outcomes included mortality, need for mechanical ventilation, length of hospital stay, seizures, and blood product infusions. Predictive performance was evaluated using Receiver Operating Characteristic (ROC) curve analysis, with an Area Under the Curve (AUC) of greater than 0.75 as the threshold for acceptable sensitivity. Multivariable logistic regression was adjusted for confounders, including gestational age and birth weight. Results: Among the 637 neonates enrolled (64% male and 36% female; gestational age, 23–42 weeks; birth weight, 500–5060 g), 193 were born preterm. The combined Apgar score demonstrated significantly higher sensitivity and specificity than the conventional score in predicting mortality (n = 99), mechanical ventilation (n = 166), seizures (n = 51), blood product infusions (n = 139), and prolonged hospital stays (all AUC > 0.75, p < 0.0001). Significant negative correlations were observed between Apgar scores and adverse outcomes, with the combined score showing stronger prognostic accuracy, particularly in preterm infants. Conclusion: The combined Apgar score, by incorporating gestational age and intervention data, offers superior predictive accuracy for neonatal morbidity and mortality compared to the conventional method. Its adoption in clinical practice could enhance early identification of high-risk neonates, optimize resource allocation, and improve outcomes, particularly in preterm and high-risk populations. Multicenter studies with long-term follow-up are warranted to validate and extend these findings.