Friday, May 25, 2012

Group B Strep- What's Up with That?

Around 35 weeks of pregnancy, most women begin hearing the initials "GBS."  Standard protocol in the West is to have a pelvic exam that includes a swab which is tested for the presence of "Group B Strep," a bacteria that many of us carry around in our bodies in various concentrations at different times.  If a woman is "GBS+," meaning that she has Group B Strep bacteria colonizing her birth canal, she'll be told she will have to have IV antibiotics (usually one in the penicillin family, most often ampicillin) every four hours during labor and delivery, to keep her baby from getting a Group B Strep infection.  (Moms allergic to penicillins will likely receive vancomycin, cefazolin or clindamycin, depending on their care provider & situation.  These aren't as effective as penicillin & have their own risks.)  If a mom comes into the hospital too late or progresses too quickly to get the antibiotics, the babies are usually given antibiotics and have several blood samples drawn to ensure they aren't infected. Signs of early-onset Group B Strep infections in newborns include: fever or abnormally low body temperature, jaundice (yellowing of the skin and whites of the eyes), poor feeding, vomiting, seizures, difficulty in breathing, swelling of the abdomen, and bloody stools.

With Eowyn, I was tested and was GBS- (I didn't have any Group B Strep bacteria colonizing me at the time), so it wasn't an issue.  This time around, I had the option to not have a GBS test done, as well as having an interest as a doula in the issue.  So... I set off researching.  First off, I wanted to know the risks of having GBS and not being treated.  Second, I wanted to know the risks of standard practice (IV antibiotics to all GBS moms).  Thirdly, I wondered if there were more selective, less invasive means of treating GBS (if it needed to be treated), both before birth, and after birth.  Lastly, I wondered what steps could be taken to help babies and moms treated in the standard way.  Here's what I've found out!

First off, I wanted to know the risks of having GBS and not being treated.  
About 10-30% of all women have GBS colonizations (and generally have no symptoms). I'll use 25% as a steady figure:  1 in 4 moms are GBS+. According to CDC estimates, without treatment only 1-2% born to moms with GBS will become infected (2% of 25% is 0.5%, or 1 out of 200 babies), and of those, 6% will die.  So death is a risk of about 3 in 10,000 babies born to GBS+ moms with no treatment.  Infections in newborns are never good things-- GBS infections affect the brain, spinal cord, or lungs.  The risk of a baby getting a GBS infection goes up if the mom has a long labor (18+ hours with water broken), a fever above 100.4 in labor, or goes into labor before 37 weeks.  For perspective, about 1 in 150 of all delivering moms in the US will have some form of placental abruption, and 1 in 300 will have a prolapsed umbilical cord.

Second, I wanted to know the risks of standard practice (IV antibiotics to all GBS moms).
my belly at 35 weeks
IV antibiotics are a pretty big gun to pull out, as they kill bacteria that we need.  Not only are there thousands of beneficial bacteria in our bodies, they are all over our bodies!  They help us digest our food all along the digestive tract, they act as our immune system's main line of defense, they are our main source of Vitamin K, they keep harmful yeast and bacteria in check on our skin, in our guts, in our ears & sinuses, in our urinary tracts, and in the female reproductive tract.  Wiping them ALL out is pretty drastic-- we've heard a lot about the dangers of overusing antibiotics lately.  From yeast infections to weight gain to chronic gastrointestinal problems to super bugs, killing off all the little guys in our bodies opens us up to a whole new can of, umm... bacterial worms. :)  New babies especially need to receive a healthy dose of bacterial flora as they journey into the world, so that they are able to digest food properly and begin to form their own defense mechanisms against pathogens.  They get this through their eyes, nose, mouth, and skin as they are born, and later through breast milk. If they are born to a mom whose bacterial eco-system has just been severely thrown off-balance by antibiotics, they aren't going to be able to get that colonization, and it will take weeks for her breast-milk to return to normal --provided she doesn't get a yeast infection in the meantime.  What about the baby who is born during IV antibiotics who is also formula-fed?  Has anyone ever tried to nurse with thrush (a yeast infection)?  NOT FUN.  Obviously, the risk of dying from an infection is more severe than the risk of starting off life with bacterial imbalances, but if the risk of dying of infection is so low in the first place, yet a fourth of all moms and their babies are being put on IV antibiotics, it bears considering.

Another, more dramatic risk of the antibiotics, is the risk of anaphylactic (allergic) reaction-- this can happen even if a mom's never reacted to a drug allergically before, at about a 1 in 10,000 rate.  These cases put both mom and baby at a very real risk of dying.  I'll quote again from an overview of the topic in Mothering magazine:
"We can compare this to CDC estimates that 0.5 percent of babies born to GBS-positive mothers with no treatment will develop a GBS infection, and that 6 percent of those who develop a GBS infection will die. Six percent of 0.5 percent means that three out of every 10,000 babies born to GBS-positive mothers given no antibiotics during labor will die from GBS infection. If the mother develops anaphylaxis during labor (one in 10,000 will), and it is untreated, it is likely that the infant, too, will die. So, by CDC estimates, we save the lives of two in 10,000 babies-0.02 percent-by administering antibiotics during labor to one third of all laboring women. We should also keep in mind that this figure does not take into account the infants that will die as a result of bacteria made antibiotic-resistant by the use of antibiotics during labor-infants who would not otherwise have become ill. When you take that into account, there may not be any lives saved by using antibiotics during labor."  (emphasis mine)
** The linked-to article is very helpful, and is a GREAT starting point to thinking through this issue!  Every GBS+ mom should read it and use it as a jumping-off point-- there are plenty of citations to journal articles and scientific studies that bear reading!**

A final risk of the routine IV treatment is non-GBS infections (often anti-biotic resistant), especially E. coli infections.  
A study published in 1998 on the effects of the use of ampicillin before delivery concluded that:
"The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non–group B streptococcal organisms that are resistant to ampicillin. At this time penicillin G, rather than ampicillin, is therefore recommended for prophylaxis against group B streptococci. In addition, future studies are needed to determine whether alternate approaches, such as immunotherapy or vaginal washing, could be of benefit. "
E seems unimpressed with the idea of IV antibiotics for GBS
In English (:D), they found that there is an increase in infections from bacteria besides Group B strep (especially E. coli) which don't respond to normal antibiotic treatment.  Especially scary is that this risk is even more pronounced in preemies, and labor before 37 weeks is one of the #1 signs of GBS infection, and therefore moms of preemies are the women most likely to get IV antibiotics.  The researchers recommended the use of penicillin G instead, and research into another approach, such as localized use of antibiotics.  (Mind, this was 14 years ago... WHY are IV drugs STILL the treatment of choice for GBS??) Two more quotes from Mothering magazine highlight the risk of antibiotic-resistant infections:
"We should not take lightly the use of antibiotics for 200 women and their babies to prevent only a single blood infection-however serious that infection might be-especially in this age of increasing resistance to antibiotics. [Edit:  remember the figure that 1 out of 200 babies get a GBS infection if their moms are untreated.] Concerns have arisen in several areas regarding the use of antibiotics for so many laboring women. One dilemma is that colonization of the vaginal area by GBS is, at best, a poor method of predicting whether a newborn will develop a GBS infection. As mentioned, even without any intervention during labor, fewer than 1 percent of infants born to carriers of GBS develop infections."
"A study of 43 newborns with blood infections caused by GBS and other bacteria found that, when the mothers of the ill newborns had been given antibiotics during labor, 88 to 91 percent of the infants' infections were resistant to antibiotics. It is unlikely to be a coincidence that the drugs to which the bacteria showed resistance were the same antibiotics that had been administered during labor. For the newborns who had developed blood infections without exposure to antibiotics during labor and delivery, only 18 to 20 percent of their infections were resistant to antibiotics."

So, are there more selective, less invasive means of treating GBS (if it needed to be treated), either before birth, during labor and after birth?
YES!!  The more I've read about IV-antibiotics, the more they seem like using an AK-47 to shoot a fly:  waayyyyy overkill.

First line of defense:  help the body regulate its own bacteria before birth.  If a mom is re-tested before she goes into labor and is GBS-, this whole issue is removed from the table.  This occurs without any intervention in some moms, and it can be helped along by non-invasive natural means, the biggest of which are:  probiotics (in capsules and in fermented foods like saurkraut and yogurt), garlic, and echinacea.  My own midwife puts any GBS+ moms on doses of garlic & echinacea, and retests in 3 weeks.  Read here about using garlic & goldenseal.  A fuller listing of suggestions is here.  As far as probiotics go, L. rhamnosus GR-1 and L. reuteri RC-14 are really helpful in regulating vaginal flora, and S. cerevisiae boulardii, Lactobacillus rhamnosus GG, and Bacillus coagulans GBI-30 are good for regulating digestive flora, so probiotics containing those strains would probably be most helpful.  (See a great article on using probiotics to fight various ailments here.)

Second line of defense, during labor: avoid cervical exams (and stripping of membranes), dilute the bacteria by giving birth in the water, or use a chlorhexadine vaginal wash (once every 6 hours) during labor once water has broken.  Not only are these methods less invasive, they target the only area where the GBS is located, as opposed to flooding the entire body.  To use the wash, a mom is handed a periwash squirt bottle and irrigates herself... no needles, no invasion of privacy, it's simple and done.  This has the added benefit of reducing other, non GBS infections, such as E. coli, as well-- remember, IV antibiotics INCREASED the risk of those!
"In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine." (from “Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.” J Matern Fetal Med 2002 Feb;11(2):84-8.-- Read its abstract and other related articles here.)
Third line of defense, after birth: as has been stated before, if a mom goes into labor without knowing her GBS status, or as an untreated GBS carrier, her baby can be tested for GBS infection and treated immediately if infected.

Lastly, I wondered what steps could be taken to help babies and moms treated in the standard way.
Probiotics!!  Both mom & baby will desperately need to rebuild their bacterial ecology.  One study found huge reduction in "colic" in infants who received the probiotic L. reuteri.  It would make sense to proactively give antibiotic-exposed infants such probiotics (the specific brand in the study was BioGaia, and it's readily available online at Amazon or at drugstores such as Walgreens), and to have moms taking therapeutic doses of the above mentioned probiotics.

One final note I'll make is that there is no real need for an expectant mom to have to have a full pelvic exam to be tested for GBS.  Many midwives simply hand their patients a swab and send them to the restroom to privately culture themselves.  I must say I greatly prefer this method. :)  As a dear friend put it yesterday, "they're called PRIVATE parts for a reason-- I'd like to keep it that way!"

[Personally, I feel the proactive measures of taking probiotics-- both in fermented foods and capsules (I'm taking first Renew Life Ultimate Flora Extra Care Probiotic- containing 10 probiotic strains including L. rhamnosus, L. acidophilus and several Bifidobacteria strains, then Nature's Way Primadophilus Reuteri, which contains L. reuteri, L. acidophilus & L. rhamnosus)-- as well as planning a water birth are the way to go.  If I'd had the option, I would have cultured myself and been tested that way... next time!  If I were GBS+ I'd first try the preventative measures of probiotics & garlic, etc, and if those weren't enough, I'd do the chlorhexadine wash.  :)]


brismith said...

You really have to decide for yourself. But my cousin, after 10 years of trying to get pregnant had an uneventful pregnancy and not until the last hour of labor did they realize something was dreadfully wrong. She delivered a perfectly formed 8lb baby that wasn't breathing and they could not resuscitate...she had the strep virus. that was 22 years ago....The Lord did bless them 3 years later with another daughter..i know it is all in God's hands...but this was preventable.

Eowyn's Heir said...

You are so right-- it's totally preventable, and there are WAY less risky ways of preventing it than using IV antibiotics! (there is also the very rare possibility of getting GBS infections prior to birth, which seems like what may have happened in this case, in which case measures like probiotics and immune-boosters like garlic could have been helpful).

Anonymous said...

IV abx in labor has proven to be highly effective and safe at preventing GBS infection in newborn babies. Probiotics and immune boosters may yet prove beneficial, but there's no good evidence for yet.

In the meantime, I'd rather go for something that has been proven to prevent these devastating infections rather than something that sounds like it could help but hasn't been proven yet.

Having said that,I'd also defend the right of any pregnant woman to make their own informed decision.

Eowyn's Heir said...

hmmm... I guess I'd have different definitions of effective safe and evidence, as well as devastating... GBS can be devastating in rare cases, yes. But so can routine abx treatment (anaphalaxis and abx-resistant infections). IV abx save MAYBE 1 in 10.000 lives while risking the woman and baby's health (throwing off their entire bacterial ecology) as well as putting future moms at a higher risk for abx-resistant infections.

On the other hand, the probiotics & natural immune boosters you discount have no side effects, boost overall health, and if they remove the GBS threat in the first place, make any "treatment" a moot point. Many midwives testify to their effectiveness.

Likewise, the vaginal washes have been shown to be as effective as the IV abx in preventing GBS infections, with the added benefits of NOT throwing off bacterial ecology, NOT contributing to antibiotic-resistant bugs, and preventing non-GBS infections (while abx make those more likely, especially in preemies, for whom they are most deadly).

IV abx are, in my opinion an overreaction, and every overreaction has unforeseen repercussions. However, using something more targeted and/or preventative is a reaction in keeping with the risk, and therefore has far less of a ripple effect.

Let's keep IV abx in reserve for the infections that actually call for them (for ex. an infection from a retained placental piece) so that they will work when we need them to!

Anonymous said...

Good thoughts! Just to clarify - if a mom is allergic to penicillin, she would not be given ampicillin, since it's in the same class as penicillin, a mom would react similarly to ampicillin as to penicillin. Instead, she'd likely be given Clindamycin every 8 hrs, Cefazolin every 8 hrs, or Vancomycin every 12 hrs, depending on her physician/midwife. Those bring with them other side effects, and some aren't as effective as penicillin, but it's still protocol to give a mom antibiotics for GBS, fever, or prolonged labors where the water has been broken more than 18 hrs. Definitely lots to think through when giving birth in a hospital! :)

Eowyn's Heir said...

Thanks Megan!