Choosing to Use Botanical Therapies for Reducing group B Streptococcus Infection during Pregnancy
Despite the 2002 revised protocol, many pregnant women prefer to avoid routine antibiotic prophylaxis for a variety of reasons including:
• philosophic reasons (i.e., they prefer to minimize medical intervention or want a “natural” approach),
• due to concern about sequelae (i.e., development of resistant infections, increased likelihood of neonatal Candida infection (thrush))
• or choice of birth setting (i.e., home birth, making it difficult if not impossible to access antibiotic prophylaxis in labor)
For women choosing to birth naturally at home, the use of prophylactic intravenous antibiotics in labor is sometimes not a realistic option — most home birth midwives do not administer intravenous medications. Home birth midwifery protocol therefore continues to follow the risk-assessment model, transporting to the hospital for intravenous antibiotic prophylaxis should indications arise, including rupture of membranes longer than 18 to 24 hours (length of time varies with the protocol of different medical and midwifery communities) or any signs of infection. Group B Streptococcus-positive women planning home births commonly seek herbal options prenatally for reducing their micro-bial load, hoping to avoid PROM, thus prolonging the length of time before the need to transport to the hospital during delivery.
Herbal treatment has been demonstrated to be effective in reducing group B Streptococcus colonization if it is started 2 to 3 weeks before the onset of labor. Note that herbal prophylaxis is done during pregnancy and not as a substitute for intranatal antibiotic prophylaxis. It is common for women in this situation to also use herbs to augment labor in the event of PROM, to encourage birth to occur within the allotted 18- to 24-hour window. PROM is discussed elsewhere in this book.
Should women choose to follow an herbal protocol for reducing group B Streptococcus colonization, it is imperative that the protocol be accompanied by retesting as close to the expected due date as possible but with enough time to receive results prior to labor. Group B Streptococcus-positive pregnant women should be made fully aware of the risks of group B Streptococcus before laboring without antibiotic prophylaxis. Women should also be informed that, in cases in which antibiotics are declined intranatally for the mother, they might then be routinely administered to the baby if she transports to the hospital and if at any time during the pregnancy she had a positive group B Streptococcus test. Faced with these choices, a woman may prefer to receive antibiotic prophylaxis herself rather than have it directly administered to the baby. Yet other facilities and practitioners will allow antibiotics to be deferred unless there is ROM for more than 24 hours, allowing a period of observation of the baby for signs of infection rather than routinely administering antibiotics intranatally or postnatally. Women who test group B Streptococcus positive during pregnancy should discuss their concerns and options with their obstetric and pediatric care providers prenatally. There is no substitute for antibiotics in women with signs of infection and prolonged rupture of membranes (>24 hours rupture), and all newborns exhibiting signs of group B Streptococcus infection must receive immediate and aggressive antibiotic therapy.
Given the potential narrow time frame between a positive group B Streptococcus test at 35 to 37 weeks and the time of birth, especially considering the possible need for antibiotic follow-up and the increased risk of premature rupture of membranes and premature labor associated with group B Streptococcus, midwives may consider an initial culture during pregnancy earlier than the recommended 35 to 37 weeks gestation, particularly in women with a history of chronic UTI or vaginal yeast infection. Although a positive result earlier in pregnancy is not predictive of risk of neonatal infection, earlier testing allows time to address the potential problem using botanical strategies, with a reculture during the predictive period. This approach is consistent with the preventative philosophies of both herbal medicine and midwifery care, and also allows adequate time for more aggressive medical intervention with antibiotics should this be optimal.
Botanical Protocol for Group B Streptococcus
Botanical treatment for group B Streptococcus infection relies on the vaginal application of antimicrobial herbs, and the internal (oral) use of probiotics to normalize intestinal flora and reduce S. agalactiae colonization. When women have had a protracted history of group B Streptococcus infection, with repeated uro-genital infections or other signs of decreased immune response, for example, frequent colds, sore throats, and so forth., an internal herbal protocol to enhance immunity is sometimes recommended; however, options during pregnancy are somewhat limited.
Group B Streptococcus
There is absolutely no substitute for antibiotics in women with a history of a positive group B Streptococcus test and prolonged rupture of membranes (>24 hours rupture). All newborns exhibiting signs of group B Streptococcus infection must receive immediate and aggressive antibiotic therapy.
Many herbs are known in Western herbalism for their antibacterial actions. These include garlic, oregano, myrrh, thyme, and tea tree oil, to name a few. After an exhaustive search of a number of key medical and chemical databases; however, no clinical trials looking at the clinical treatment or prevention of group B Streptococcus infection with herbal medicine are available in the world literature. In vitro tests show S. agalactiae to be inhibited by a number of herbs, however, many of these are not safe for use during pregnancy.
Given the paucity of research available directly on this topic, and the long history of clinical efficacy of many botanicals in reducing a variety of infections, including vaginal infections, contemporary herbal practitioners tend to rely on traditional indications of herbs enhanced by contemporary understanding of disease pathology and herbal pharmacology for developing modern clinical applications. Those herbs most commonly used by herbalists, midwives, and naturopathic physicians for the treatment of group B Streptococcus are listed in Table Summary of Botanical Treatment Strategies for group B Streptococcus. Information on specific categories of herbal actions and exemplary herbs follows.
Summary of Botanical Treatment Strategies for group B Streptococcus
|Therapeutic Goal||Therapeutic Activity||Botanical Name||Common Name|
|Reduce microbial infection||Antibacterial||Allium sativum||Garlic|
|Baptisia tinctoria||Wild indigo|
|Commiphora mol mol||Myrrh|
|Mahonia aquifolium*||Oregon grape root|
|Melaleuca alternifolia||Tea tree|
|Althea officinalis||Marsh mallow|
|Reduce local inflammation, support tissue integrity||Anti-inflammatory||Calendula officinalis||Calendula|
|Hypericum perforatum||St. John’s wort|
|Symphytum officinale||Comfrey root|
|Astringent||Hamamelis virginiana||Witch hazel|
|Quercus spp.||Oak bark|
*Coptis, goldenseal, barberry, and Oregon grape root all contain berberine, which may theoretically increase the risk of neonatal jaundice; thus, they are contraindicated for oral use during pregnancy. These herbs may be used safely in vaginal preparations in the last 4 weeks of pregnancy.
The basic approach for treating group B Streptococcus is the nightly insertion of either vaginal suppositories or capsules of antimicrobial, anti-inflammatory, and vulnerary herbs for a minimum of 3 weeks prior to the onset of labor. The suppositories, which are the most effective delivery model, are typically inserted in the evening, prior to bed, the woman instructed to wear a panty liner to prevent damage to bedding and underclothes from leakage as the suppository melts in the vaginal canal. This melting allows the vaginal and cervical tissue to be slowly bathed in the herbs and emollient. This is repeated nightly for 14 days, a 2-day break allowed, and reculturing done. Some practitioners choose to alternate nightly between the use of a suppository and an inserted capsule or garlic clove. A single “00” capsule can be filled with goldenseal powder and the woman instructed to insert these into the vaginal fornix every other night for the same duration as the suppository protocol. Again, a panty liner is worn. Perianal rinses are also sometimes used if there is heavy colonization or history of repeated urogenital infection. Astringent herbs may be included in topical preparations if there is a great deal of tissue irritation, as they also help to improve tissue integrity and make the tissue less permeable to infection. Douching should be avoided, because it is not an optimally safe practice during pregnancy and may also drive microorganisms upward toward the uterus. The combination of actions of herbs reduces microbial load while reinforcing the integrity of the vaginal tissue, reducing the ability of organisms to colonize in fissures and irritated areas. Probiotics are used concurrently on a daily basis to maximize the body’s ability to produce flora that prevents overgrowth of group B Streptococcus and enhances the presence of normal vaginal flora. Satisfactorily low levels of the organism should be achieved at least 1 to 2 weeks before the onset of labor. Should group B Streptococcus bacteriuria persist later than this, an antibiotic protocol can be offered, according to CDC guidelines.
Discussion of Botanical Protocol for Group B Streptococcus
This is an important therapeutic category for women with a history of repeated or intractable vaginal or urinary tract infections. These herbs are taken as decoctions or tinctures with the goal of strengthening the immune response. Herbs with low toxicity that can be given in therapeutic doses include medicinal mushrooms such as Lentinus edodes (shiitake), Trametes versicolor (turkey tails), and Ganoderma lucidum (reishi). They can be safely employed for extended use throughout the pregnancy and are taken at a dose of 6 to 12 g for decoction, 1 to 4 g of a 5:1 powdered extract as an instant tea or in caps, 1 to 4 bid. Echinacea is the only antimicrobial, immune-enhancing botanical to have a study specifically validating its safe use during pregnancy, and is the herb most confidently relied upon by most midwives for this purpose. Inefficacy of echinacea products in treating infections is most likely owing to poor-quality product or inadequate dosing. Liquid extracts of fresh echinacea, rather than dried, powdered, or encapsulated products should be used; strong infusions can also be made from high-quality dried plant material. The dose should approximate 5 mL daily for general prophylactic use and up to two to three times that quantity for aggressive reduction of group B Streptococcus colonies. Garlic can also be used during pregnancy safely. Although it may be more of a theoretical than an actual concern, because of concerns of increased bleeding with high levels of garlic consumption, the practitioner may wish to discontinue its oral administration 2 weeks prior to the due date.
Topical Antimicrobial Treatment
Antimicrobial herbs most commonly included in suppositories for group B Streptococcus treatment include goldenseal, thyme, ore-gano, calendula, tea tree, and usnea. They are used in combination in forms most appropriate to each herb, for example, powder, tincture, or essential oil. Discussion of these herbs is found in their individual plant profiles (see Plant Profiles). An example of a suppository recipe, designating proper forms, can be found in the case history for group B Streptococcus at the end of this chapter, and a discussion of suppository preparation can be found in site. Garlic cloves have a long history of use as suppositories for the treatment of vaginal infections. A single garlic clove (not a full bulb!) is carefully peeled to avoid nicking of the garlic flesh, dipped in a small amount of olive oil and inserted into the vaginal fornix and left overnight. Whereas the suppositories and capsule will melt and do not require removal, the clove may fall out on its own when the woman urinates in the morning, or it may need to be manually removed by the woman if it does not spontaneously drop out. The woman can be instructed to remove the clove with a clean finger; some patients may find this offensive, and can be directed to the previous strategies. Capsules are usually filled with only one or two herbs, usually stronger antimicrobials, in powder form. Perhaps most commonly applied is goldenseal root powder, which is inserted on alternate nights to the suppository, as described in the preceding.