Group B Streptococcus in

Pregnancy and Newborn

Dr. Chandani Pandey

2nd year resident
Department of obstetrics and gynecology
 Group B Streptococcus
• Gram positive, beta hemolytic bacteria

• Common colonizer of human gastrointestinal and

genitourinary tracts

• Recognized as causing disease in humans in the 1930s

• Causes serious disease in young infants, pregnant women and

older adults

• Emerged as most common cause of sepsis and meningitis in

Epidemiology

• 0.12 per 1000 live births (range 0.11 to 0.14 per 1000 births)

• Upper genital tract infection accounted for approximately one-half of

cases.

• Isolated bacteremia occurred in one-third of cases.

• One-half of the maternal GBS infections led to fetal death, neonatal

infections, neonatal death or pregnancy loss.
 GBS Maternal Colonization
• Primary reservoir - gastrointestinal source

• Vaginal and cervical contamination – from GI source

• Can be considered as STI as GBS recovered from urethra of 45- 63%

male of female carrier

• 10 – 30 % of pregnant women

• Transient , intermittent, chronic

 GBS Maternal Colonization
• Higher proportion in African Americans

• Colonization rate does not vary with gestational age

• Once colonized – increased risk of colonization in subsequent

pregnancy

• Mostly asymptomatic
Neonatal colonization
• Vertical transmission
• horizontal transmission
• Higher transmission rates - when women are persistently culture
positive carriers or when women are heavily colonized
• The most important determinant of susceptibility - maternal
antibodies directed against the capsular polysaccharide antigens of
GBS.
MATERNAL RISK
 Urinary tract infection
• Asymptomatic bacteriuria
• Cystitis
• Pyelonephritis
• The risk of adverse outcome - decreased with antibiotic treatment of
asymptomatic bacteriuria.
Asymptomatic bacteriuria
• 7 to 30 %

• A marker for heavy genital colonization with GBS

• Associated with increased risk of upper genital tract infection and

postpartum endometritis.

• Identified by screening urine cultures

Asymptomatic bacteriuria

• Threshold of ≥10*5 CFU per mL - significant bacteriuria

• Treatment of asymptomatic bacteriuria - decreased rates of adverse

pregnancy outcomes.
Cystitis
• Urinary frequency, urgency, and dysuria without fever.

• Diagnosis - positive urine culture

• Should receive intrapartum chemoprophylaxis at the time of delivery

to prevent neonatal infection.
Pyelonephritis
• 10 % of cases

• Fever, urinary symptoms, nausea/vomiting, flank pain, and/or

costovertebral angle tenderness.
• Diagnosis - positive urine culture

• Empiric treatment - intravenous hydration and intravenous antibiotics

• Should receive intrapartum chemoprophylaxis at the time of delivery

Chorioamnionitis
• Infection of the amniotic fluid, membranes, placenta, and/or umbilical
cord .

• Fever, uterine tenderness, maternal and fetal tachycardia, foul

smelling amniotic fluid, maternal leukocytosis and raised CRP.

• Microbiologic and pathologic criteria - isolation of GBS

Endometritis
• Post partum period

• 2 - 14 % of cases

• More commonly a component of polymicrobial infections

• Treated with broad spectrum antibiotics including anaerobic

coverage.
Other
• Maternal meningitis (both antepartum and postpartum)

• Endocarditis

• Abdominal abscess

• Necrotizing fasciitis
Fetal risks
• Premature rupture of membrane

• Preterm birth

• Still birth
NEONATAL RISKS
Neonatal GBS infection
• 0.5 per 1000 live births

• Colonization with a high inoculum (>10⁵ colony-forming units/mL)--

increases the risk of vertical transmission and early-onset disease in
neonates.
Mother to Infant Transmission of GBS

GBS colonized mother

50% 50%
Non-colonized Colonized
newborn newborn

1-2 %
98%
Asymptomatic Early-onset sepsis, pneumonia,
meningitis
Epidemiology
• Early-onset disease – declined from 1.8 cases per 1000 live births in
1990 to 0.24 cases per 1000 live births in 2016
- Ethnic disparity

• Late onset - 0.3 to 0.4 per 1000 live birth

Risk factors

• Major risk factors :

- Low birth weight (<2500 g)

- Premature delivery(<37 week of gestation)
- Prolonged duration of rupture of membranes (>18 hour)
- Intrapartum fever (≥38.0 degree C)
Risk factors
• Additional risk factors :

- Previous neonate with invasive GBS disease

- GBS bacteriuria during the current pregnancy

74% of neonates with early-onset infection and 94% of those infections

with a fatal outcome occur among those neonates with one or more of
these risk factors.
• Bacterial and immunologic risk factors :

- GBS strain with enhanced virulence

- Heavy maternal colonization (vaginal inoculum >10*5 cfu/mL)

- Deficient maternal GBS capsular type-specific immunoglobulin G at

term delivery
Neonatal infection
• Early-onset – Within 7 days of life
Bacteremia (80%)
Pneumonia (7%)
Meningitis (6%)

• Late-onset - after the first week of life until 3 months of age with a
range of 3 to 4 weeks.
Early onset
Sepsis
• 80 - 85%

• Irritability, lethargy, respiratory symptoms (eg, tachypnea, grunting,

hypoxia), temperature instability, poor perfusion, and hypotension

• Many infants presenting at <24 hours after birth do not have fever

• Fever can occur in the 2nd or 3rd day after birth.

• Pneumonia :10%
- tachypnea, grunting, hypoxia, and increased work of
breathing.
Chest X ray - diffuse alveolar pattern - difficult to distinguish from
hyaline membrane disease or transient tachypnea of the newborn

• Meningitis : 7 % , uncommon
presents with signs of -
central nervous system inflammation
respiratory abnormalities (eg, tachypnea, grunting, apnea)
Late onset
• Often presents as bacteremia without a focus (approximately 65 % of
cases)
• However, meningitis (25 - 30 %) and focal infections also occur
• Bacteremia — Infants with late-onset infection commonly present
with fever ≥38°C.
May have a history of a preceding or intercurrent upper respiratory
infection.
Other - irritability, lethargy, poor feeding, tachypnea, grunting, and
occasionally apnea.
Late onset
• Meningitis : 25 to 30 % of cases of late-onset
- Indistinguishable from that of neonatal sepsis without meningitis.

- Temperature instability, irritability or lethargy, and poor feeding or

vomiting.
- 50 % of survivors – neurological sequelae
Late onset
Other focal infection —

• Septic arthritis, osteomyelitis, cellulitis, and adenitis

• Rare - endocarditis, myocarditis, pericarditis, pyelonephritis,

endophthalmitis and brain abscess.
 Evaluation
• Complete blood count (CBC)

• Blood culture

• Chest radiograph (if respiratory signs present)

• Lumbar puncture for cerebrospinal fluid (CSF)

• Urine culture

• The lumbar puncture should be performed before the institution of antibiotic

therapy
Diagnosis
• Isolation of GBS

• GBS antigen may be detected in CSF

• However, antigen testing of other body fluids is not recommended

because of poor specificity.
 Management
• Antimicrobial therapy and supportive care combined with drainage of
purulent collections if present

• Empiric therapy — broad spectrum antibiotics to cover for early- and late-
onset disease in neonates and infants younger than three months of age

• Definitive treatment – injection penicillin G

• Duration —10 days for bacteremia without a focus

14 to 21 days for meningitis , septic arthritis
21 to 28 days for osteomyelitis.
Management of newborn after maternal IAP
Prevention
• Screening pregnant women for GBS colonization and intrapartum
antibiotic prophylaxis (IAP) during labor for those colonized

• Treatment of all women during labor who have specific risk factors for
early onset GBS infection

• Vaccination of all women when GBS vaccines

 1996 Consensus Guidelines for GBS
Prevention
• Screening-based approach:

- Vaginal-rectal culture at 35-37 weeks

- IAP for GBS carriers

- IAP for preterm delivery (unless negative

culture result available)
1996 Consensus Guidelines for GBS Prevention

• Risk-based approach : • Both strategies - IAP to women

with:
- No vaginal-rectal culture - GBS bacteriuria during
pregnancy
- Preterm deliveries, - Previous infant with GBS
disease
- Prelabour rupture of
membrane >18 hours,

- Intrapartum fever (>38˚C /

100.4 F )
• Infants whose mothers are screened for GBS are less than
half as likely to develop early-onset GBS disease as
mothers who are not screened

• Screening identifies colonized women without obstetric

risk factors (18% of all deliveries in 1990s)

Schrag et al, NEJM 2002, 347:233-9

 2002 GBS Guidelines: Key Changes

• Single strategy for identifying candidates for

IAP: universal screening by culture at 35-37
weeks
• IAP agents for penicillin-allergic
• Cefazolin, except for women at high risk
of anaphylaxis
• No routine IAP for planned cesarean
deliveries
Key Prevention Strategies Remain Unchanged
in 2010
• Universal screening of pregnant women for GBS at 35-37
weeks gestational age

• 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
Key Prevention Strategies Remain Unchanged in 2010

• Intrapartum antibiotic prophylaxis for:

- 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
ACOG 2019
• Recommends screening cultures over risk-based screening for GBS

• Culture-based approach — All pregnant women at 36+0 to 37+6

weeks of gestation with the following two exceptions
- Women with GBS bacteriuria during the current pregnancy
- Women who previously gave birth to an infant with invasive GBS
disease
Pre- pregnancy
• Treatment of GBS carriers before pregnancy has no benefit.

• Immunization strategies are being evaluated currently.

Intrapartum prophylaxis indicated:

• Previous infant with invasive GBS disease

• GBS bacteriuria current pregnancy

• Positive GBS screening culture during current pregnancy (unless a planned

cesarean delivery, in the absence of labor or amniotic membrane rupture, is
performed)
Intrapartum prophylaxis indicated:

• Unknown GBS status (culture not done, incomplete or results

unknown) and any of the following:
- Delivery at <37 weeks’ gestation
- Amniotic membrane rupture >18 hours
- Intrapartum temperature 100.4degree F (38.0 degree C)
Intrapartum prophylaxis not indicated:
• Previous pregnancy with a positive GBS screening culture (unless a
culture was also positive during the current pregnancy)

• Planned cesarean delivery performed in the absence of labor or

membrane rupture (regardless of maternal GBS culture status)

• Negative vaginal and rectal GBS screening culture in late gestation

during the current pregnancy regardless of intrapartum risk factors
For threatened preterm
Suggested management of threatened
preterm delivery:

• No culture done: obtain cultures and

initiate IAP for 48 hour until results
obtained or delivery occurs.

• Culture positive prior to or during labor:

IAP for 48 hr or until delivery occurs.
• Culture negative prior to labor (or after
48 hr): no IAP (or stop IAP).
Recommended prophylaxis regimens:

• Penicillin G 5 million U IV followed by 2.5 mU IV q4h until delivery

(ampicillin 2 g IV initially followed by 1 g IV q4h until delivery is
acceptable but less preferred owing to broader-spectrum activity).

• For penicillin allergic (low anaphylaxis risk): cefazolin 2 g IV initial

dose followed by 1 g IV q8h until delivery.
Recommended prophylaxis regimens:

• For penicillin allergic (high anaphylaxis risk, documented susceptibility

of GBS) : clindamycin 900 mg IV q8h.

• For penicillin allergic (high anaphylaxis risk and resistance to

clindamycin or susceptibility unknown) : Vancomycin 1 g IV q12h.
Postnatal
• Antibiotic prophylaxis need not be continued after delivery.

• Diagnosis of postpartum endometritis in a GBS-positive woman

should be treated with broad-spectrum antibiotics.
Reference
William’s obstetrics 25th edition
High risk pregnancy- D. K . JAMES , 8th edition
High risk pregnancy – ARIA’S
Recent advances on obstetrics – 23
Uptodate 2020