Group B Strep: A Patient/Provider Approach for Optimizing Care
Group B Strep: A Patient/Provider Approach for Optimizing Care
Although Group B Streptococcus was first described over one hundred years ago, GBS began becoming noticed as a leading cause of infection and death in newborns only in 1961. According to the CDC, roughly 1 to 3 babies out of every 1,000 children born in the United States suffers invasive Group B Strep disease, mostly in the first week of life. This is when Group B Strep is most common, and it is among the most common causes of newborn infections. The signs of newborn infections include sepsis (or, bacteria in the blood), pneumonia (or, Group B Strep in the lungs), and meningitis (or, germs in the baby's brain and brain coverings). These infections are more common if the baby is born too soon before its due date, if the baby is an African-American, or if there is evidence of placental or baby infection before birth. GBS can cause devastating effects for babies, mothers, and their families. At this point in time, GBS infections are not completely preventable, but I believe that there are many strategies that we as healthcare providers can adopt to optimize our patients' care regarding Group B Strep during pregnancy and around the time of birth. Patient-friendly literature is available through the CDC, the American College of Obstetrics and Gynecology, the Group B Strep Association, and the Jesse Cause. Patients need to be informed to optimize their own healthcare, as well as that of their babies. It is especially important for parents to be able to identify the symptoms of early and late onset Group B Strep once they've taken the baby home from the hospital.
Doctors and nurses now know how to quickly treat Group B Strep, and deaths rates have been lowered to less than 1 in 10 infected newborns. Among the many surviving children, there are risks of long-lasting and sometimes life-long impairments caused by blindness, deafness, cerebral palsy, and developmental delays. Obviously, we need to improve prevention strategies as well as treatments for Group B Strep and other infections, which are most damaging during pregnancy and at birth. We now know that GBS causes other problems in mothers and babies, besides so-called early onset sepsis, which occurs in the first week of life. Like other germs including E-coli, also from the gut or the GI tract, GBS causes pregnancy loss even in early gestation. In one research paper, GBS was the most common identifiable cause of stillbirth.
The are many important facts about GBS carriage and infection. The presence of identifiable amounts of GBS varies from 1 in 20 women, to 1 in 3 pregnant women. Less than 5% of mothers, or 1 in 20, are so heavily colonized that Group B Strep can be cultured from the mother's urine. Later, at the time of birth, about one-half of babies born vaginally can be colonized with GBS as they pass through the birth canal, and these babies can be infected by Group B Strep. Overall, about 1 in 200 exposed children can be infected. Those that are most commonly infected include preterm babies, babies of diabetic mothers, and babies of mothers who've had a previous baby with Group B Streptococcal disease.
We also know that when mothers are so heavily colonized that they have Group B Strep in their urine, the risk of preterm birth and rupture of the protective bag of water surrounding the baby can be doubled. One study in Denmark showed that the risks of prematurity and premature rupture of this bag was reduced by penicillin treatment with continued follow-up, and retreatment if necessary.
The manner in which Group B Strep germs invade the womb is also becoming better understood. These microorganisms have special attractant molecules that can take hold of genital tract tissues. Many Group B Strep germs also make special molecules that can dissolve through the cervix, or the mucin between the vagina and the cervix. Many of these germs also make toxins, which can damage the baby and the placenta before birth. Both the mother and the baby have powerful defenses against Group B Strep, but these can be overwhelmed by too many germs or not enough defensive factors - such as antibodies themselves - that can specifically attack Group B Strep and other germs. Uterine or womb contractions can move infectious fluids from the vagina up inside the womb.
Effective strategies used to prevent Group B Strep infections in the baby and mother are recommended by the Centers for Disease Control and Prevention, as well as professional obstetrical and pediatric societies. These strategies can prevent over 80% of baby infections in the first week of life. In 1995, the CDC issued guidelines to treat women during labor and around the time of birth.
Care providers can use either culture-based or risk-based strategies to give antibiotics prophylactically, most commonly penicillin during labor and delivery. Briefly, mothers who are shown to be culture positive in the vagina or the rectum are treated with antibiotics prophylactically during labor. Alternatively, care providers can choose to give antibiotics during labor and delivery when it's complicated by prematurity, rupture of the membranes for over eighteen hours, or whenever there is fever present. Other circumstances that require antibiotic treatment include preterm labor for premature ruptured membranes occurring before the mother's due date, or if the mother had a prior child with GBS infection. If a woman has a C-section, we would still recommend antibiotics if indicated by her culture or risk factors.
The CDC has shown that hospitals that have official policies to prevent Group B Strep infections do much better than other hospitals in stopping GBS disease in newborns. I agree with the CDC and suggest that each and every provider of birth services adopt these preventive guidelines. It is true that giving antibiotics to target against GBS increases the amount of antibiotics used, which may or may not lead to antibiotic resistance, and that rare mothers may indeed have serious reactions if they are allergic to penicillin. However, the overall benefits of giving recommended antibiotics and labor targeted at GBS saves many, many more babies' lives.
Since GBS is not passed through breast milk, patients should be advised that breast-feeding can give the baby important antibodies and other factors to help protect the baby from infection. Additionally, routine hand washing is always advised in handling any newborn to reduce the number of germs.
Researchers continue to search for better methods of preventing Group B Strep infection and disease. A vaccine is already being tested which can be given to susceptible mothers during pregnancy, or even before pregnancy. Some physicians give a shot of penicillin to babies who are born to mothers who have not received the recommended antibiotic treatment, or when the antibiotics weren't given for an adequate amount of time. Research has been done showing that both labor contractions and manual or digital examinations by care providers can actually move infectious vaginal fluid through the mouth of the womb. Perineal or vaginal ultrasound appears to be a safer alternative to manual or digital cervical examinations, especially once the bag of water has been ruptured.
In the event of miscarriage or stillbirth, pathology sampling and testing is a non-invasive procedure that should be encouraged in every case to provide parents with valuable closure and knowledge for future pregnancies. GBS disease can be avoided in some cases by culturing more frequently than the present recommendations, earlier in pregnancy, and then treating with oral antibiotics as appropriate. Any symptoms of vaginitis or yeast infections should be taken seriously. Diagnosis should be made specifically, and the infection should be treated. An appropriate birth plan, which can be individualized, should be made for all our GBS affected patients. These birth plans should take into consideration short labors and long distances to hospitals. Patients need to be informed as to the minimum time required for antibiotics to be effective, as well.
Proper communication between obstetrics and pediatrics is also necessary with regard to maternal risk factors affecting newborn babies. GBS can affect patients, the babies, of course, and their families at any time during pregnancy, as well as the first few months after birth, even after an apparently healthy labor and delivery. As healthcare providers, we need to stay informed as to the latest research on Group B Strep in order to optimize the care of each of our patients. For additional information and research updates, please refer to the American College of Obstetrics and Gynecology, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics."
GBS can cause devastating effects for babies, mothers, and their families. At this point in time, GBS infections are not completely preventable, but I believe that there are many strategies that we as healthcare providers can adopt to optimize our patients' care regarding Group B Strep during pregnancy and around the time of birth. Patient-friendly literature is available through the CDC, the American College of Obstetrics and Gynecology, the Group B Strep Association, and the Jesse Cause. Patients need to be informed to optimize their own healthcare, as well as that of their babies. It is especially important for parents to be able to identify the symptoms of early and late onset Group B Strep once they've taken the baby home from the hospital.