Thursday, 5 March 2009

Group B Strep

Today I am writing about a subject that I feel is really important and needs to be investigated and understood further, it’s one that seems to be worrying a great deal of parents to be - Group B Strep

Almost every week Mybirth.tv receives enquiries about Group B strep and the advice we give tends to run on the same principles. Having watched the video on the mybirth site we then tell the enquirer to contact the Group B Strep organization, which gives fantastic support and in depth information. They should also speak to their midwife or consultant obstetrician who will have up to date information. So, what is Group B strep?
It‘s a bacteria commonly found in a third of all male and female intestines. A quarter of women of childbearing age will carry the bacteria in their vagina at any given time. This bacterium is totally harmless in healthy individuals and is only of concern to a newborn infants and very young babies. As many as 700 babies per year are infected with this bug in the UK, and up to 75 die from further complications, the affects of this bacteria can run from septicaemia and pneumonia to meningitis. Keeping in mind that there are almost 700,000 babies born every year in this country, with approximately 175,000 pregnant carriers, the risks of infection are still very low, but to those infected by it the results are very real and can be disastrous. For in-depth information about Group B strep and the possible risks to babies visit http://www.gbss.org.uk/

Although this bacterium was identified as far back as the 1960’s it didn’t gain an awful lot of attention until much more recently, and I don’t recall when training as a midwife in the early 1980’s any mention of it either. Today, most hospitals in the UK will have a protocol for dealing with Group B strep infection; the recommendations may vary from hospital to hospital, but in general the offered course of treatment is intravenous antibiotics for women who are in labour and are known to be G B Strep positive. If there is no opportunity for IV antibiotics in labour the baby may be given them post birth. The whole point about antibiotics is to ensure that the baby is treated either prior to birth or immediately after, thus eliminating the risks of G B Strep infection. This scenario brings up many issues; many mothers would prefer that their babies were not subjected to antibiotics at such a tender age, other women do not want to have IV antibiotics in labour, and for many women if they want a homebirth most hospital trusts would rather they came into the maternity unit for the antibiotics, so the women’s choices are limited, there is also the question about the twenty five percent of pregnant women who are carriers, the majority of whom will not pass on the infection to their baby and will be unaware that there maybe an element of risk.

My third child was born almost 24 years ago at 31 weeks of pregnancy. She developed pneumonia almost immediately and for several days her life hung in the balance whilst the doctors fought to save her life. She was pumped full of drugs, antibiotics and intravenous infusions and blood transfusions and she finally pulled through,
There was mention of infection and I don’t remember its name but it could well have been Group B strep. As a mother I felt guilty that I had infected my child with this bacteria, and today I am glad that no one should be made to feel guilty with such a common infection, but from my perspective I think it would have been great if I had known about this bacteria and the risks it posed to my unborn baby. For women today the information is out there but is not discussed regularly in ante natal clinics for fear of alarming many mothers to be, but if you knew there was a potential risk you could then make the informed choice of whether to be tested or not.

Many mothers are asking why there isn’t a routine screening programme in the UK like there are elsewhere and the simple answer is that the government believes that a routine screening programme is not cost effective; some women maybe screened one day and be found to be positive for the bacteria and yet a few weeks later the same woman with no treatment in the interim will test negative. Therefore many women and their babies maybe subjected to antibiotics that they no longer need. Testing late in pregnancy could help to eliminate some of those who are no longer testing positive.

There is a petition being sent to the Prime Minister asking for routine screening in the UK which closes on the 11th March so if this is something you feel strongly about click on the link.


At the moment there are tests that women can obtain privately which screen for the bacteria; swabs are taken from the rectum and vagina (the mother can do this herself) and then sent off for analysis, details are on the gbss.org.uk site. My belief is that women should ensure that they are well informed about all aspects of their pregnancy, whether its making the choice to have a hospital or homebirth, screening for fetal abnormalities or the risk of passing on a very treatable bacteria.

If you have any comments or would like to contribute to the debate please do so, the more people who discuss the issues the better.

7 comments:

Lisa Barrett said...

As you say yourself if you look up the figures there is only a 0.1 or less chance of your baby becoming ill and dying from Step B. You have a 1 in 100 chance of a reaction to antibiotics 1 in 10 000 chance of anaphylaxis. The research says that your baby's gut and immune system can be highly compromised by antibiotics that aren't necessary. Simply saying my baby was ill is not a reason for the introduction of a test that creates panic and over use of a specialised drug that isn't necessary. Maybe you need to do a little more research before suggesting such a move. Facts and figures on this would be nice
http://www.homebirth.net.au/search/label/gbs

Group B Strep Support said...

As Lisa says, the risk of a baby developing GBS infection in the UK is around a 1 in 1000 chance or 0.1% for all women. For women who carry GBS late in pregnancy - and the only way to find that out is to test using tests not widely available in the NHS - that risk is approximately a 1 in 300 or 0.3% assuming no other risk factors are present. That 1/300 risk reduces to less than 1/6000 if the mum has the antibiotics in labour - a huge reduction.

Although often quoted, the figures Lisa quoted of allergic reactions to antibiotics are generally accepted as significantly over-estimating the risk; a paper written by leading experts in the field of GBS research and published in 2005 reported “in a review of 1225 hospital admissions in Britain related to adverse drug reactions, in a population of 630,000 over six months, none were due to penicillin, again indicating that severe reactions are rare.” The same paper concluded, “that the risk of death is negligible.” (The prevention of neonatal group B streptococcal disease. MR Law, G Palomaki, Z Alfirevic, R Gilbert, P Heath, C McCartney, T Reid, S Schrag on behalf of the Medical Screening Society Working Group on GBS Disease. J Med Screen 2005;12:60-68.) In the USA since GBS policies were implemented in 1996, it's estimated that over 12 million women have been given intravenous antibiotics in labour - so far, there have been no reported deaths as a result and, searching the literature, finds only 7 cases of non-fatal anaphylaxis in the mother that resulted in 5 babies not developing normally after birth. Clearly this is a real issue, but the risk is tiny in comparison with the number of babies whose GBS infections – which cause much more death and disability – have been averted by the intravenous antibiotics in labour.

I'd like to see the references for the statement that 'The research says that your baby's gut and immune system can be highly compromised by antibiotics that aren't necessary'. When antibiotics are given around birth and in the early weeks of life, there is the chance they may increase the likelihood of the baby developing allergies. Although a lot of press space is given to this, unfortunately data are lacking on whether it’s the antibiotics that cause the allergies, or whether there are other reasons (for example, genetics, environment, disease, etc.). Indeed, the same paper quoted above says, “Increased risk to the infant of allergic reactions in later life has been inferred based on evidence summarized by Murch that ‘specific input from the faecal flora to the innate immune system is essential for the establishment and maintenance of mucosal immune tolerance’, and assuming that penicillin during labour would disrupt this. This is speculative. Penicillin is not a broad-spectrum antibiotic and, in any event, the faecal flora only become established a few days after birth. There are no data to support infant sensitization.” Clearly, this is an area where more research is needed.

Introducing a testing for GBS late in pregnancy would not create panic. It would give pregnant women the opportunity to find out whether they carry GBS and, therefore, whether their baby is at higher risk of GBS infection. A negative result would mean it's very unlikely the baby would develop GBS infection. A positive result would mean the baby’s at higher (not high, higher) risk of developing GBS infection but that higher risk can be minimised by offering intravenous antibiotics to the mother in labour. It’s up to her then to decide whether she wants them routinely or only if other risk factors are present. Of course she can decline them and, if she does, the knowledge of her GBS carriage status can inform the management of her labour and the baby's first hours of life.

What creates panic is information which is hugely biased one way or the other. Health professionals who have been fully informed about the subject (including the pros and cons of action/inaction) plus accurate information will empower expectant parents to make educated choices about what is best for them and for their baby, based on their personal circumstances. And surely that can only be good!

You can download more information about group B Strep from the charity's website at www.gbss.org.uk .

phytolipide said...

What concerns me is that the penicillin given can be persistent for 4 weeks and readily passes into the breast milk. I am not excited at the prospect of contaminated breast milk. The other part not highlighted is that the mother passes antibodies to Strep B to the fetus and there are also antibodies in the cord blood (which the child would receive if cord clamping was delayed), plus antibodies in the breast milk. So, when I read the studies I wonder, are the babies who are infected breast fed? Did they receive cord blood? I also think that as you stated the mother's strep B status can be very dynamic. I'm in my last week or so of pregnancy - tested positive once - went for another swab yesterday (I'm in Canada) and worried about whether to choose to take the antibiotics the midwives are pushing or not.

JaneEliz said...
This comment has been removed by the author.
Group B Strep Support said...

We totally agree that it's important to know the facts about group B Strep infection and about the methods of minimising the risk of these infections occurring in babies. Once in possession of these facts, then women can make an informed decision about what is best for her and her baby. And one of those facts it's important to know is whether you're carrying GBS - in Canada you're fortunate to be able to have the sensitive testing for GBS carriage in pregnancy. Unfortunately, apart from at a handful of hospitals and a couple of private laboratories, they are simply not available here in the UK.

Breast milk will contain antibodies and other anti-infection agents, but this is not known to prevent early-onset infection in the way that this can prevent late-onset infection. The start of early-onset GBS infection is usually too early for that protective effect, bearing in mind that very little breast milk is produced initially. And, although a very tiny amount of penicillin will be excreted in breast milk, we know of no research showing the penicillin persists for 4 weeks - indeed, the reason that it should be offered at 4 hourly intervals in labour is because it's cleared relatively rapidly from the body.

There is a risk of invasive GBS infection developing in the baby when the mother is known to be colonised with GBS. Statistically she is more likely to have a baby who is not infected, but if she would like to minimise this risk, then intravenous antibiotics in labour is the best way to reduce that risk. There are theoretical risks in having intravenous antibiotics in labour for both the mother and her baby so the mother, in conjunction with her health professionals should make the decision about what is best for her and her baby based on the balance of risks. The consequence of declining intravenous antibiotics in labour is an increased (albeit relatively small) risk of her baby having invasive GBS infection - however, the choice should absolutely be hers. Some mothers may be happier with a low threshold for antibiotics being given to her or her baby, depending on what happens around the time of her delivery (for example, if another risk factor develops) and what condition her baby is in at birth. If she declines intravenous antibiotics in labour, our medical panel would strongly advise a minimum of 12 hours temp/ pulse/resps monitoring (and preferably for 24 hours).

I would reiterate that the charity's position is that this is a question of balancing risks and the decision about antibiotics is ultimately up to her. Unfortunately, the specific questions she asks are not answerable - we have seen no studies of early onset GBS infection looking at early versus late cord clamping, or breast feeding. While both of these behaviours are laudable in themselves, we no of no research which indicates they could be the answer to early onset GBS infection.

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