1. Prepared by:
DrAhmad Zharif Hussein
RSMU

2.  Streptococcus agalactiae
 Gram positive, beta hemolytic bacteria
 Colonisation
 Asymptomatic and intermittent
 Intestinal (<30% of adults)
 Vaginal (<25% of women)
 Infection
 Newborn babies
 Adults: the elderly, pregnant/postpartum women, others
with underlying disease s

3.  “Early onset” 0-6 days (~75% cases)
 90% show within 12 hours
 Usually septicaemia and pneumonia
 11% mortality, 7% morbidity
 90% preventable IV Penicillin
 “Late onset” 7-90 days (~25% cases)
 Usually meningitis and septicaemia
 8% mortality, 21% morbidity (up to 50% with meningitis)
 No current prevention: good hygiene/education
 Vaccine: future hope for both late & early onset

4. Source: Heath PT, Balfour G, Weisner AM, Efstratiou A, Lamagni TL,Tighe H et al. Group B
streptococcal disease in UK and Irish infants younger than 90 days. Lancet 2004;
363(9405):292-294.

5. Photo courtesy of Dr. Carol Baker
Baylor College of Medicine, Houston,TX

7.  US guidelines
 all women colonised with GBS at 35–37 weeks of
gestation should be offered IAP(intrapartum antibiotic
prophylaxis

8.  10% - 30% of women
 Higher proportion in African Americans and
nonsmokers
 GBS usually live in gastrointestinal tract but can spread
to the genital tract
 No symptoms or signs on examination
 Colonization comes and goes over months
 Not a sexually transmitted infectio

9.  Previous Invasive GBS baby 10 x
 GBS bacteriuria current pregnancy 4 x
 GBS found current pregnancy 3 x
 Maternal intrapartum fever (>380C) 3 x
 PROM >18 hours before birth 3 x
 Preterm labour 3 x

10.  Not recommended
 Routine bacteriological screening of all
pregnant women for antenatal GBS carriage
▪ cost-effective
 Antenatal treatment IAP is before the onset of
labour.
 screening for GBS or the administration of IAP
to women in whom GBS carriage was detected
in a previous pregnancy

11.  IAP to women with GBS bacteriuria during the
current pregnancy
 higher risk of chorioamnionitis and neonatal disease
 urinary tract infection (growth of greater than 105
cfu/ml) during pregnancy
 IAP should be offered if GBS is detected on a vaginal
swab in the current pregnancy.
 If GBS is present in a vaginal swab, it is likely that the
risk of neonatal disease is increased(risk 2.3/1000)

12.  Antibiotic prophylaxis specific for GBS is not required for
women undergoing planned caesarean section in the
absence of labour and with intact membranes.
 Immediate induction of labour and IAP should be offered
to all women with prelabour rupture of membranes at
37+0 weeks of gestation or more.

13.  If chorioamnionitis is suspected, broad-spectrum
antibiotic therapy including an agent active
against GBS should replace GBS-specific IAP and
induction of labour should be considered

14. • Intramuscular antibiotics pre-labour
• May eradicate GBS colonisation for up to 6 weeks
• Small studies & no GBS infection in control or treated
group
• Vaginal flushing with Chlorhexidine
• No evidence it reduces EOGBS infection
• Oral Antibiotics
• No evidence it reduces EOGBS infection (treats GBS
UTI)

15.  In preterm labour with intact membranes with no
other risk factors for GBS should not routinely be
offered IAP unless they are known to be colonised
with GBS
 risk of EOGBS infection is higher in preterm than
in term infants
 ORACLE trial

16.  IAP should be offered to women who are
pyrexial in labour (>38 C). should be offered
broad-spectrum antibiotics including an
antibiotic for prevention of neonatal EOGBS
disease
 IAP for women with term prelabour rupture
of membranes is unclear and NICE
recommends that it is not given, unless there
are other risk factors
 at term should be offered immediate induction of
labour or induction after 24 hours

17.  IAP should be offered to women with a
previous baby with neonatal GBS
disease(neonatal sepsis)
 Subsequent infants born to these women are
likely to be at increased risk of GBS disease

18.  IAP, benzylpenicillin should be administered
as soon as possible after the onset of labour
and given regularly until delivery.
 Clindamycin should be administered to those
women allergic to benzylpenicillin
 as soon as possible after the onset of labour
 the efficacy of IAP, the first dose should be given at
least 2 hours prior to delivery
 minimum inhibitory concentration for GBS as early as
1 hour after maternal administration
 Oral antibiotics for IAP are not recommended

19.  no evidence that intrapartum vaginal
cleansing will reduce the risk of neonatal
GBS disease

20.  Universal screening of pregnant women for GBS at 35-37 weeks
gestational age(only in US)
 Intrapartum antibiotic prophylaxis for:
 GBS positive screening test
 GBS colonization status unknown with
 Delivery <37 weeks
 Temperature during labor >100.4˚ F (>38.0˚ C)
 Rupture of membranes >18 hours
 Previous infant with GBS disease
 GBS in the mother’s urine during current pregnancy
 Penicillin preferred drug for IAP
 Ampicillin acceptable alternative
 Cefazolin preferred for penicillin-allergic at low risk of
anaphylaxis

21.  Colonization with GBS during a previous pregnancy
•
 GBS bacteriuria during a previous pregnancy
•
 Negative vaginal and rectal GBS screening test during the
current pregnancy
•
 Cesarean delivery performed before labor onset on a woman
with intact amniotic membranes
•
•

22.  In a UK study of invasive GBS disease,
 89% of early-onset cases were identified on day 1.
 Most cases (65–67%) have one or more risk factors
prior to or during labour.
 A significant number will also have had signs of fetal
distress, an emergency delivery and low Apgar scores.
 The majority of early-onset cases in these studies
presented with
▪ sepsis (79.4%),
▪ 11.8% had meningitis,
▪ 7.8% had pneumonia and
▪ 1% focal infection

23.  Well infants at risk of EOGBS should be
observed for the first 12–24 hours after birth
with regular assessments of general
wellbeing, feeding, heart rate, respiratory rate
and temperature
 great majority of infants (89–94%) who develop
EOGBS infection develop signs within the first 24
hours after birth
 the majority of such infants (65–67%) will have had
one or more ‘conventional’ risk factors evident in or
before labour.

24.  Postnatal antibiotic prophylaxis is not recommended
for asymptomatic term infants without known
antenatal risk factors.
 Infants with clinical signs of EOGBS should be
treated promptly with appropriate antibiotics

25.  For a well infant whose mother has had a previous
infant with GBS disease, either clinical evaluation
after birth and observation for around 24 hours
are necessary, or blood cultures need to be
obtained and the infant treated with
benzylpenicillin until the culture results are
available.

26.  It is not necessary to perform routine surface
cultures or blood cultures on well infants
 no evidence to discourage breastfeeding

27. • grunting;
• lethargy;
• irritability;
• poor feeding;
• very high or low heart rate;
• low blood pressure;
• low blood sugar;
• abnormal (high or low) temperature; and
• abnormal (fast or slow) breathing rates with
blueness of the skin due to lack of oxygen
(cyanosis).

28. Typical signs of late onset
GBS infection
• fever;
• poor feeding and/or vomiting;
• impaired consciousness;
• fever, which may include the hands and
feet feeling cold, and/or diarrhoea;
• refusing feeds or vomiting;
• shrill or moaning cry or whimpering;
• dislike of being handled, fretful;
• tense or bulging fontanelle (soft spot on
the head);

29. • involuntary body stiffening or jerking
movements;
• floppy body;
• blank, staring or trance-like expression;
• abnormally drowsy, difficult to wake or
withdrawn;
• altered breathing patterns;
• turns away from bright lights; and
• pale and/or blotchy skin.

32. The
Recommendations
MMWR,Vol 59
(RR-10)

33. www.gbss.org.
uk

34.  25/g4p3 @ 39/52 ANC 1.Hx of neonatal sepsis
in previous pregnancy secondary to GBS
 But current pregnancy no HVS taken
 Pt came with c/o contraction pain,LL @
28/7/2013 FM good
 DOA 29/7/2013
 Ve os 2 cm cx 2cm st -12 MI clear liquor seen
vx no cord no placent
UR mx??

35.  27 g2p1 @ 38/52 (SOD)scan correspond to
date(correspond to edd)
 unbooked unscreened
 c/o contraction pain.LL @ 25/4/2013 @
0640am,FM good
 DOA 25/4/2013 1200am
 Ve os 4 cm cx 0.5 cm st -1 MI clear liquor
seen.vx
 Ur Mx?

36.  27 g1p0 @ 28 week clo contraction pain and
LL @25/6/2013 0800am, FM good,diagnosis
PPROM.DOA:26/6/2013
 Ve os 1 cm cx 2 cm st -2 MI clear liquor seen
 Contraction 2;10
 Ur management?

37.  CDC -Overview of CDC Prevention
Guidelines, 2010
▪ National Center for Immunization and Respiratory
Diseases
Division of Bacterial Diseases
 Green top guideline no 36
 Prevention of early neonatal group B
streptococcus
http://www.gbss.org.uk/epetitio

38.  Thank you