James A. McGregor, MDCM

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Preterm birth (short gestation, PTB, < 37weeks) and low birth (LBW,  <1500grms) continue as the commonest cause of excess perinatal morbidity,  mortality and excess birth related costs and medical malpractice liabilities  worldwide. Reproductive tract infection and subsequent inflammation are now  recognized as common and preventable causes of short gestation and biologic  immaturity at birth. Bacterial vaginosis (BV) is the best studied of  microbe-mediated infections or conditions causing preterm birth. Current  evidence supports these "optimizing principles" for effectively reducing risks  of infection induced adverse pregnancy effects:

Timing: Early identification and elimination/suppression of  	abnormal reproductive tract or genitourinary microflora is essential.  	Studies show that increased risks or preterm birth as well as first and  	second trimester causes and other adverse effects are associated with  	screening and positive identification of bacterial vaginosis and abnormal  	microflora early in pregnancy. Early treatment with elimination and/or  	suppression of reproductive tract infection is associated with greatest  	reduction of adverse effects.

Infection and inflammation of lower and upper reproductive tract  	tissues are the primary pathophysiologic processes adversely affecting  	pregnancy. Treatments must provide for elimination/suppression of  	microorganism with in both upper uterine and trophoblast and lower  	reproductive tract tissues. Use of macrolides or clindamycin eliminates or  	suppresses most intrauterine microbes.

Optimize antimicrobial choices: Choose antimicrobials  	which posses 1) antivirulence activities and 2) anti-inflammatory activities  	and are 3) concentrated within infected cells, macrolides, lincosamides.

Combined effects, eliminate prevalent sexually  	transmitted infections (STIs)

Improved pregnancy outcomes are optimized when trichomoniasis, gonorrhea, and  chlamydia as well as UTI/asymptomatic bacteruria are identified and treated with  appropriate treatment of partners (TOPs)and tests of cure (TOC).

Conclusion: Bacterial vaginosis and other common reproductive tract microbial  conditions should be 1) routinely identified, 2) treated with antimicrobials  most likely to eliminate/suppress intrauterine microflora and 3) which have  potentially important adjunctive advantages (antivirulence factor,  anti-inflammatory, intracellular concentration and 4) which are established safe  and effective in controlled trials. Selected populations appear to benefit from  empiric antimicrobial therapy aimed at prevalent reproductive tract infections  and at prevention or early treatment of intrauterine infection (chorioamnionitis,  CAM or placentitis).

Both care providers and families can now improve pregnancy care with  intelligent use of updated information about common genital tract infection.  Future discussions will discuss optimized care of mothers to be who are actually  having preterm labor.

Articles

Evidence-based Ways to Prevent Prematurity Caused by Infection Including Bacterial Vaginosis (BV) and Sexually Transmitted Infections (STIs)

Evidence-based Ways to Prevent Prematurity Caused by Infection

Group B strep (GBS) can definitely infect babies before birth,  yet there is not an official name designated for GBS disease when it causes  babies to be miscarried or stillborn. To further awareness and prevention of GBS  disease in all stages of a baby’s development, Group B Strep International is  giving a name to GBS disease acquired before birth: Prenatal-onset Group B Strep  (POGBS) Disease. 
 
 Most medical literature mentions only two types of GBS disease: early-onset and  late-onset. The majority of known GBS infections in newborns occurs in the first  week of life. These GBS infections are designated as early-onset GBS (EOGBS)  disease. So far the primary focus of GBS disease prevention has been treating  GBS positive women during labor so that their babies do not become infected  during passage through the birth canal. Currently both the United States and  Canada have active prevention guidelines in place to test all pregnant women at  35-37 weeks of pregnancy and, if positive, treat them with IV antibiotics during  labor. These guidelines have been very successful in reducing the rate of  early-onset infection by more than half from 0.7 cases per 1000 live births in  the U.S. in 1997 to 0.32 cases per 1000 live births in the U.S. in 2004.

 
 
 Currently the secondary focus of GBS disease prevention is late-onset GBS (LOGBS)  disease which occurs in infants over 1 week of age usually up to the first  three, but sometimes even six months of life. LOGBS can be caused by sources  other than the mother, including hospital personnel. Prevention consists mainly  of promoting thorough hand washing prior to anyone handling the baby and  breastfeeding to give the baby important antibodies. Recognizing symptoms of GBS  infection can result in better outcomes for the baby if prompt medical treatment  is initiated. 
 
 However, a baby can definitely succumb to GBS infections long before the  bacteria are transmitted during delivery. Since this is not yet a recognized  disease it is unknown how many babies have been miscarried or stillborn due to  GBS. Pathology testing is not mandatory and not even always suggested to the  mother. At minimum, placental culturing may tell the cause of death. This is  important especially since having a baby infected by GBS puts a mother at higher  risk for subsequent babies being infected by GBS.

Perhaps the reason that prenatal-onset GBS disease has not been officially  recognized is that the general medical opinion considers GBS-caused miscarriages  and stillbirths to be rare occurrences. However, among GBS awareness groups,  there are far too many parents who have had their baby’s autopsy or placental  testing report cite GBS as the cause of death for prenatal-onset GBS disease to  continue being regarded as rare.
 
 Fortunately there are at least four main courses of action to help prevent  prenatal-onset GBS disease:

Increase awareness among care providers, pregnant women, and their  	families as to how invasive procedures can cause GBS to cross even intact  	amniotic membranes. 

The August 16, 2002 CDC MMWR specifically states  	that GBS can cross intact amniotic membranes.

 
 	
 	GBS germs can travel or be transported into the womb by digital exams even  	early in pregnancy. GBS microorganisms have special attractant molecules  	that can take hold of genital tract tissues. These microorganisms also have  	special molecules that can dissolve through the mucus plug.

 GBS  	can then penetrate membranes and infect the baby or damage the placenta

  	which eventually results in miscarriage or early pregnancy stillbirth. Later  	in pregnancy, GBS may be introduced to the baby during routine cervical  	checks and other invasive procedures such as intrauterine fetal monitoring,  	application of cervical ripening medications, and “membrane stripping”  	sometimes known as “membrane sweeping.” 
 	
 	The benefits of invasive procedures may outweigh the risks, but other times  	invasive procedures are merely used for convenience or as part of routine  	examinations. Perineal and vaginal ultrasounds offer an alternative to  	digital examination.
 	
 	Membrane stripping can introduce infection

 although there is a  	debate about whether or not it is directly related to a higher incidence of  	GBS infection. However, it has been proven via dye tests that small  	particles can ascend through the cervix. Case studies of dead or very sick  	babies at birth point to a direct correlation. Common sense alone dictates  	that if a gloved hand or instrument is moved through the lower third of the  	vagina (where GBS usually colonizes) and then up into the cervix that GBS or  	other bacteria can be moved closer to where the baby can be harmed. A recent  	legal case examines the potential for litigation regarding membrane  	stripping.

Ensure prompt attention to vaginal and urinary tract infections  	during pregnancy. 

Even though health care providers do not widely  	recognize GBS vaginitis, GBS can cause yellow or green discharge as well as  	vaginal burning and/or irritation. These symptoms may be mistaken for a  	yeast infection or bacterial vaginosis. Vaginal and bladder infections  	caused by GBS have been linked to preterm births and can indicate a heavy  	amount of GBS colonization that can potentially harm the baby.


 	
 	Pregnant women should be promptly evaluated and treated appropriately for  	any symptoms of vaginitis. “Tests of cure” should be routine. Extreme  	caution should be used regarding any invasive procedures in a woman  	experiencing symptoms of vaginitis. 
  

Periodic urine cultures for GBS should be performed during pregnancy.

  	The presence of GBS bacteriuria in any concentration in a pregnant woman is  	a marker for heavy genital tract colonization and possibly absent maternal  	immunity which can put the baby at greater risk. These women do not need  	vaginal and rectal screening at 35-37 weeks. 
 	
 	The CDC recommends that women with any quantity of GBS bacteriuria during  	pregnancy should receive intrapartum chemoprophylaxis. The CDC also  	recommends that women with urinary tract infections, both symptomatic and  	asymptomatic, receive appropriate treatment at time of diagnosis according  	to the current standard of care for UTI’s in pregnancy.

 In  	addition to intrapartum chemoprophylaxis, parent-based groups advocate  	treatment at time of diagnosis as well as a recheck for any quantity of  	bacteriuria to further protect the baby. ACOG recommends that a urine  	culture be performed at the first prenatal visit as well as in the third  	trimester (28-40 weeks.

) Testing urine more frequently may be  	prudent.
  

Consider treating GBS positive women with intramuscular benzathine  	penicillin G in the late third trimester. (Alternatives for this treatment  	for penicillin allergic women are not yet reported.) 

Although this  	strategy is not currently a CDC or ACOG recommendation, two studies have  	shown that treating GBS positive women with 4.8 million units of  	intramuscular benzathine penicillin G eradicates or significantly reduces  	their GBS colonization at delivery when given in the late third trimester.

  	This treatment appears to be effective for at least 4 weeks after injection.

  	Another more recent study using 2.4 million units of intramuscular  	benzathine penicillin G suspension (Bicillin L-A) in the late third  	trimester showed a smaller yet still significant decrease in the rate of GBS  	colonization upon admission to labor and delivery.


 	
 	Two of the studies noted in their conclusions that their respective  	treatments may be useful as a supplement for women who are at risk for not  	receiving the appropriate amount of intrapartum antibiotic prophylaxis  	against GBS.

Current protocol actively addresses early-onset prevention. However,  prevention of prenatal-onset GBS and recognition of symptoms of GBS infection in  babies once born can further reduce the effects of GBS disease in babies before  and after birth. For symptoms including fever, lethargy, and any kind of  distress in the baby, please visit 

 http://www.groupbstrepinternational.org/brochure.html

. GBS information is  available in both English and Spanish.

Group B Strep International (GBSI) is an organization formed to promote awareness and prevention of Group B Strep disease worldwide. To further these efforts GBSI is sponsoring International Group B Strep Awareness Month in July as an official observance on the 2007 National Health Observance Calendar.

  in the fight against GBS disease before and after birth.

Your comments and feedback are appreciated. Please feel free to e-mail us at 

This article is for informational purposes only and does not constitute medical advice.

Active Bacterial Core Surveillance (ABC’s) Report Emerging Infections Program Network group B streptococcus, 1997 and 2004, Centers for Disease Control and Prevention.

Morbidity and Mortality Weekly Report, Prevention of Perinatal Group B Streptococcal Disease Revised Guideline from CDC, Centers for Disease Control and Prevention, Vol. 51, No. RR-11. August 16, 2002.

“Group B Strep: A Patient/Provider Approach for Optimizing Care.”

    4. Kurt Benirschke and Peter Kauffman, “Pathology of the Human Placenta, Third Edition."

“Cervical Manipulations Linked to Perinatal Sepsis: Consider GBS-specific Chemoprophylaxis (Eight Case Reports).”

    6. Cohen, Arnold W., MD, Goldberg, Jay, MD, MSCP, 

“Membrane Sweeping and GBS: A litigious combination?”

 OBG Management, Sept. 2006, Vol. 18, No. 9.

    7. McGregor, James A., MD, “Infection and prematurity: the evidence is in,” Medical Tribune Opinion, Feb. 6, 1997.

    8. Antimicrobial therapy for obstetric patients. ACOG educational bulletin no. 245. Washington, D.C.: American College of Obstetricians and Gynecologists, March 1998;245:8-10.

    9. Bland ML, Vermillion ST, Soper DE, “Late third-trimester treatment of rectovaginal group B streptococci with benzathine penicillin G.” Am J Obstet Gynecol. 2000 Aug;183(2):372-6.

    10. Weeks JW, Myers Sr, Lasher L, Goldsmith J, Watkins C, Gall SA., “Persistence of penicillin G benzathine in pregnant group B streptococcus carriers.” Obstet Gynecol. 1997 Aug;90(2):240-3.

    11. Pinette MG, Thayer K, Wax JR, Blackstone J, Cartin A., “Efficacy of intramuscular penicillin in the eradication of group B streptococcal colonization at delivery.” Matern Fetal Neonatal Med. 2005 May;17(5):333-5.

Prenatal-onset Group B Strep (POGBS) Disease: Giving a Name to Group B Strep DiseaseAcquired before Birth and Four Courses of Action to Help in Its Prevention

Author | James A. McGregor, MDCM

Articles

Evidence-based Ways to Prevent Prematurity Caused by Infection

Prenatal-onset Group B Strep (POGBS) Disease