This patient, who is an elderly Primigravida, in naturally likely to be quite anxious about this infection, and its overall significance to the outcome. She and her partner need to be told that Group B Streptococcal infection is most frequently responsible for severe early onset neonatal infection and contributes to significant neonatal morbidity and mortality.
Keeping her age and gestational age of the baby in mind, she should have integrated screening test to rule out Down?s syndrome.
GBS carriage is fairly prevalent and 25 % of mothers in UK are carriers. Studies refute the benefits of intrapartum Antibiotic prophylaxis to all GBS carriers due to large numbers involved for treatment along with risk of Peinicillin anaphylaxis and risks of development of resistant strains.
However patients with GBS bacteuria have been found to be high risk for developing neonatal GBS disease and should be treated with I/V penicillin immediately and also covered intrapartum with I/V Penicillin. She may be given Clindamycin if she is allergic to Penicillin. Rectal and vaginal swabs are not helpful as she should be given intrapartum prophylaxis even if swabs are negative for GBS.
The neonatologist should be informed about this so that baby is kept under increased surveillance for 12 hours even if she has received IP antibiotic prophylaxis. If neonate appears suspicious of infection, he should be covered immediately with antibiotic after the usual blood cultures are sent. Mother should be warned that postnatal antibiotic treatment does not eradicate the risk of late onset GBS disease. She may however be advised to continue breast feeding without extra risks of getting late onset GBS.
In the event of her baby getting EOGBS she should be warned about likelihood of affecting next pregnancy and the need for IP antibiotic prophylaxis in next pregnancy immaterial of GBS carriage. This risk does not exist if she gets late onset GBS disease
The couple need to be appraised about all these facts and it should be noted in her case sheet.
Posted by Sarwat F.
Group B streptococcus is a major cause of morbidity and mortality in neonates. However there is no benefit of treating asymptomatic woman in pregnancy as antenatal treatment with penicillin does not reduce colonization at the time of delivery. However if there is symptomatic urinary tract infection it needs treatment according to culture and sensitivty. It will be documented in her chart that she will need intrapartum antibiotics. Her pregnancy will be managed as planned initially. If there is any preterm rupture of membranes, it has been recommended that antibiotic prophylaxis is not recommended until labour starts. To prevent group B streptococcus transmission to neonates intrapartum antibiotics are offered if woman delivers vaginally. This is based on the assumption that bactriuria in pregnancy is risk factor for neonatal group B disease. It is associated with a high risk of neonatal disease and argument for prophylaxis becomes stronger in the presence of other risk factors like intrapartum fever, rupture of membranes greater than 18 hours, vaginal colonization of GBS. Intravenous Pencillin is given as soon as labour starts with 3 g first dose followed by 1.5 g 4 hourly. In women allergic to penicillin clindamycin 900 mg IV 8 hrly is given. There is no need to continue antibiotics after delivery. However if delivery is by caesarean section before labour starts and with intact membranes, antibiotics are not required, the risk of neonatal group B streptococcal disease is extremely low in these circumstances. After delivery baby is observed for any signs of infection. Routine cultures for GBS and antibiotic prophylaxis is not recommended. This is based on the finding that a large no of infants would need to be treated unnecessarily to prevent a single case. Routine culture in neonates is not recommended as neonates who are affected generally presents in first 12 hours long before culture results would be available. Breast feeding is not contraindicated. Woman will be counseled at each step of her management. She will also be told that antibiotic prophylaxis is not recommended in future pregnancies if GBS is an incidental finding. However if the baby develops group b disease then antibiotic prophylaxis is required as increased risk in such circumstances is due to the result of low levels of maternal antibodies.
Posted by adnan S.
Group B streptococcus is recognised as the most frequent cause of severe early onset (<7days of age )infection in the newborn infants,chrecterised by pneumonia meningitis and death in most severely affected babies.Intrapartum antibiotic prophylxis has been shown to significantly reduce the risk of early onset disease but not late onset disease.Maternal risks associated with GBS are urinary tract infection ,,chorioamnionitis ,following delivery endometritis and wound infection.
I will inform the women about GBSbacteruria ,it cause maternal anxiety ,I will explain to her that approximately 25% of mothers are likely to be GBS carriers during pregnancy .Iwill discuss intrapartum antibiotic prophylaxis prevent early onset neonatal infection.
During antenatal care at booking uss is done for dating and routine anomaly scan should be done at 18-20 weeks.Downs syndrome serum screening is done between 14 -20 weeks.If she develops urinary tract infection it should be treated with antibiotics and intrapartum antibiotics prophylaxis should also be offerd to prevent neonatal infection.
Risk of fetal infection is less with intact membranes if she is not in labour.If she is for elective ceasarean for obstetric indication Antibiotic prophylaxis to cover GBS need not be administerd .There is no present evidence to suggest sweeping of membranes or induction of labour with insertion of prostaglandin increase the rate of GBS neonatal infection.
During labour3g pencillin should be administerd as soon as possible and 1.5g four hourly until delivery.If she is allergic to pencillin clindamycin 900mg should be given intravenously eight hourly until delivery
.Neonatologist should be informed about GBSbacteruria .Postnatal antibiotic prophylxis and neonatal surveilence cultures like surface culturesor blood cultures are not recommended if there is no risk factors like prematurity intrapartum pyrexia or prolong rupture of membranes of >18 hours .
Breast feeding does not increases the risk of neonatal GBSdisease.
Posted by Sreekala S.
Neonatal Group B Streptococcal disease (caused by Steptococcus agalactiae) is the most frequent cause of early onset infection in newborn infants in the UK and has an incidence of 0.5/1000 live births. Early onset Group B Steptococcal disease usually presents within the first 72 hrs of birth with poor feeding, lethargy and temperature instability. Neonatal Meningitis, Pnemonia, septic arthritis, osteomyelitis and death are the possible complications. The mortality of GBS disease is 6% in term infants and 18% in preterm infants.
GBS bacteriuria when detected during pregnancy should be treated with appropriate antibiotics(usually penicillins) as GBS bacteriuria is associated with a higher risk of GBS disease. As the woman is 14weeks now, the penicillin group of anitibiotics can be safely be given after ruling out penicillin allergy.
Intrapartum antibiotic prophylaxis should be offered in labour to the woman after discussion as it reduces the transmission of infection from the mother to the baby during labour.It significantly reduces the early onset GBS disease but not thelate onset GBS disease. Intrapartum anbiotic propylaxis is 80% effective in preventing the early onset disease in the neonate.Benzyl Penicillin 3 grams is recommended as soon as possible in labour followed by 1.5 gram every 4 hrly until delivery. Alternatively, Clindamycin 900mg should be administered 8 hrly until delvery if she is known allergic to penicillin. To optimise the efficacy of the antibiotic prophylaxis, the first dose should be given within 2 hrs of onset of labour. It should be made clear to the mother that inspite of taking the antibiotic prophylaxis, neonatal morbidity/mortality can still be possible , but it is significantly reduced.
Although there is a significant reduction in the development of early onset GBS disease, there can be some disadvantages with its use. Firstly, severe anaphylactic reaction can occur following penicillin administration in 1/10 000 women and fatal anaphylactic reaction in 1/100 000 women . Secondly, use of antibiotics causes medicalization of labour and neonatal period which may not be acceptable to some women. Thirdly, use of antibiotics during the neonatal/perinatal period can affect the neonatal faecal flora which can interfere with development of neonatal immunity. Also, the wide spread use of antibiotics can lead to infection with resistant organisms.
There is no evidence to suggest that antenatal vaginal examination, membrane sweeping or instillation of prostaglandin gel for induction of labour increases the rate of transmission of GBS from mother to the fetus. If there is suspicion of chorioamnionitis, then she should receive broad spectrum antibiotics including an agent that can act against GBS replacing GBS specific antibiotic propylaxis.
Antibiotic prophylaxis may not be required if she has a planned caesarean section in the absence of labour with intact membranes.
Paediatrician should be available at the time of delivery to evaluate the baby at birth to look for signs/symptoms of GBS disease. The baby needs to be observed for the first 12 hours of birth as 90% of the neonates show signs of infection by then. Even if the mother received intrapartum antibiotics, if the baby shows signs/symptoms of the GBS disease, the baby should receive antibiotics. If the baby shows the signs/symptoms of the disease, blood cultures should be sent prior to starting the antibiotics. CSF cultures should be considered.
Breast feeding does not increase the risk of GBS disease and can therefore be recommended.
Postnatally, the woman should be have a discussion regarding the future pregnancies. Intrapartum prophylaxis is not recommended if she had been a GBS carrier in the previous pregnancy. But, Intrapartum antibiotic prophylaxis is recommended if the previous baby had developed GBS disease.
Posted by Vaani M.
GBS is associated with poor perinatal outcome and leads to increase in neonatal sepsis and neonatal mortality.
GBS bacteruria at 14 weeks gestation has to be treated with appropriate antibiotics usually penicillin group as it may lead to preterm delivery and poor fetal outcome.
The couple have to be explained that GBS is a common infection, a commensal in the vagina. Although if persistent through the pregnancy especially nearing labour, or with other risk factors as bacteruria as in this woman, or if the previous baby had GBS sepsis then she needs treatment again in labour.
A detailed history of previous infection, treatment of urinary tract infection should be enquired.
A repeat urine culture will be required after a course of antibiotics. Swab culture from vagina and rectum separately will be required after 36 weeks to rule out GBS carrier status in labour.
She will need antibiotic coverage in labour to prevent neonatal infection and sepsis. Vaginal delivery can be allowed unless for an obstetric indication.
If the mother is treated the chances of neonatal infection occuring is minimal. The neonate needs to be observed for 24 hours for signs of infections, fever, irritability, poor feeding and antibiotic treatment may be necessary if there are signs of infection although the chances are remote.
Appopriate counselling for the couple to explain the nature of illness and the successful cure will help releive their anxiety and understand the plan of management.
