Group B Strep Infection In Pregnancy

In the 1970s, Group B Streptococcus (GBS), infection with Streptococcus agalactiae, emerged as a leading cause of pneumonia, sepsis, and meningitis in newborns. Group B Streptococcus is a normal inhabitant of the intestinal tract and colonizes the vaginal tracts of many women; it can be demonstrated by culture of combined rectal and vaginal swabs in 15% to 40% of pregnant women on random sampling. Most bacterial transmission to the neonate occurs during birth via passage of the baby through the birth canal, or via ascendant bacteria during labor with ruptured membranes. Premature babies and babies of mothers with premature or prolonged rupture of membranes (PROM) are at higher risk of infection. Group B Streptococcus can also cross the membranes, so cesarean section is not protective and carries additional surgical risks to the mother. Infection is categorized as either early or late onset. Early-onset disease symptoms manifest within a few hours, and up to a week after birth. Antibiotic prophylaxis administered to the mother during labor, as is discussed in the following, is used to prevent early-onset infection in the neonate. Late-onset disease develops through contact with hospital nursery personnel and usually manifests in the first 3 months after birth. Up to 45% of health care workers carry the bacteria on their skin, and may transmit the infection to newborns. Meticulous hand-washing practices in the hospital are essential for reduction of nosoco-mial disease transmission.

Although group B Streptococcus transmission rates are high, the rate of neonatal sepsis is surprisingly low. Unfortunately, the mortality rate associated with early-onset disease can be as high as 50% in premature infants and approaches 25% even in otherwise healthy term infants. Over 1600 cases of early-onset infections occur in newborns annually, with as many as 80 deaths per year. Long-term sequelae of meningitis in survivors include mental retardation, and hearing or vision loss. The bacterium can also cause maternal bladder and uterine infections; increases the risk of premature labor and premature rupture of membranes (PROM) and stillbirth in pregnant women; and can lead to blood infections, skin or soft tissue infections, and pneumonia in the general population.

Diagnosis

The gold standard test used in screening is a bacterial culture of a sample collection from a simultaneous vaginal and rectal swab. The best time to test for the presence of the organism is between the 35th and 37th weeks of pregnancy. Testing at this time is as much as 50% more effective at predicting and preventing perinatal disease than screening earlier in pregnancy, although the numbers of organisms in any individual might fluctuate, making detectable levels variable. CDC guidelines published in 2002 recommend universal screening for pregnant mothers between 35 and 37 weeks gestation. The FDA has recently approved a new “quick” test that can diagnose group B Streptococcus in pregnant women in about an hour. Some studies have shown the test to be up to 94% sensitive, whereas other studies show less consistent results. Because group B Streptococcus resistance to specific antibiotics has developed, especially to those used for penicillin-allergic women, culture and sensitivity testing is recommended.

Conventional Treatment Approaches

Botanical Treatment of Group B Streptococcus

Nutritional Considerations

Probiotics

A high-quality probiotic blend should be taken, two capsules in the morning with the meal, and one or two in the evening with the meal. The active dose is from 9 to 12 billion organisms per day. It is recommended that probiotic products not be taken while using antibiotics or strong doses of antibiotic or bacteriostatic herbs. Start the probiotic product as soon as the antibacterial medications or herbs are discontinued.

Additional Therapies

Improper toilet hygiene (i.e., wiping back-to-front after a bowel movement) and anovaginal sexual contact, both of which can increase transmission of group B Streptococcus to the vaginal canal, should be avoided.

Case History

Lisa, a 22-year-old woman, 36 weeks pregnant, tested positive for vaginal group B streptococcal (GBS) infection with routine screening. She was asymptomatic with no accompanying history of vaginal infection or UTI.

She was planning a home birth and did not have ready access to intranatal antibiotics because of the political climate of home birth midwifery in her community. Home birth midwifery protocol with group B Streptococcus is quite strict, and thus her midwife would require her to transport to the hospital for intravenous antibiotics within 18 hours of ROM, regardless of her stage of labor. Her midwife supported her choice to reduce group B Streptococcus infection prenatally in the hopes of achieving a negative culture and keeping her birth options open. The following treatment protocol was maintained for 2 weeks, and then Lisa was recultured for group B Streptococcus.

CBS Treatment Protocol

Nightly insertion of the following vaginal suppository blend for at least 5 nights per week, for 3 weeks:

• To ¼ cup each of melted coconut oil and cocoa butter add:

1 tbs calendula oil

½ tsp each of rosemary, lavender, and rosemary essential oils

2 tsp tincture of Usnea barbara

2 tsp tincture of Thymus vulgaris

2 tbs Hydrastis Canadensis powder

1 tbs Ulmus rubra powder

1 tbs Commiphora mol mol powder

Instructions: Begin at 36 weeks. Wear a light menstrual pad each night to protect underwear and bedding, as the oil and goldenseal powders can stain as the suppository melts.

Lisa continued protocol for two weeks at which time a vaginal culture for group B Streptococcus was performed. Culture came back negative 3 days later. She continued the protocol for an additional week (3 weeks total). A final culture several days before she went into labor also yielded a negative group B Streptococcus finding. She continued the protocol until 40 weeks, at which time she gave birth to a healthy 7 lb 7 oz boy, at home, after 18 hours of labor with no PROM. The baby was closely observed in the neonatal period, and showed no signs of infection.

Treatment Summary for Group B Streptococcus Prior to Labor Onset

• If group B Streptococcus is detected prior to 36 weeks and woman has history of group B Streptococcus, chronic vaginal candidiasis, or recurrent UTI, begin treatment with nutritional and botanical strategies to improve immunity:

Zinc, vitamin A, folate, and vitamin C to adequate pregnancy amounts

• Assess hemoglobin and hematocrit to determine whether anemia is present and supplement iron if needed.

• Use Echinacea or other immunity-enhancing herbs daily, 2 to 5 mL tid for up to 6 weeks.

• Reduce stress through stress reduction exercises, modifying stressful situations, and use of nervines and adaptogens, as needed.

• Treat accompanying conditions such as UTI or vaginal infection.

• If greater than 36 weeks, use oral and topical antimicrobial agents to reduce colonization, heal vaginal tissue, and improve resistance to infection. Orally, consider echinacea, garlic extracts, and medicinal mushrooms as immunomodulators.

• Apply suppositories nightly for 2 weeks consecutively, and reculture. Specific herbs to consider for suppositories are presented in Table Summary of Botanical Treatment Strategies for group B Streptococcus and discussed in this section.

• In all cases include a high-dose active probiotic daily.