IF YOUR BABY WAS INFECTED WITH GBS

Transcription

1 Grup B Strep Supprt IF YOUR BABY WAS INFECTED WITH GBS We are very srry yur baby has develped a serius infectin caused by grup B streptcccus (GBS). N wrds can make this easier fr yu r yur family. Yu prbably have lts f questins. We ll try t answer many f them and tell yu hw mst GBS infectin in newbrn babies can be stpped. Yu will need t talk t yur medical prfessinals abut yur wn circumstances. This leaflet means yu can benefit frm the knwledge and experience f ur medical experts and f ther families wh have had a baby infected with GBS. Hwever, this is nt a substitute fr discussins with yur dctrs. This leaflet gives infrmatin n: what the symptms f GBS infectins in babies are; backgrund infrmatin n what GBS is and what it des; and what is currently the mst effective methd f preventing GBS infectins in newbrn babies. Sadly, many busy health-care prfessinals are unaware just hw successful the preventative measures ur medical advisers recmmend can be s sme babies suffer frm preventable GBS infectins. Yu can help change this! Please get ur pster (call us fr cpies, r dwnlad them frm ur website) pinned t apprpriate ntice bards in hspitals, GP s surgeries, etc. And please d make cpies f ur leaflets and psters and give them t yur health prfessinals. Grup B Strep Supprt is a natinal charity ffering infrmatin and supprt t parents affected by GBS and t health care prfessinals. We raise awareness f hw mst GBS infectins in newbrn babies can be prevented and are generating funds fr cntinued research int GBS preventin. We rely n grants and dnatins frm parents and ther interested parties t fund ur activities. Please cntact us if yu wuld like: t make a dnatin; t jin GBSS, be kept up t date with develpments and receive ur 6-mnthly newsletter; r t receive mre infrmatin. Grup B Strep Supprt preventing GBS infectin in newbrn babies P O Bx 203, Haywards Heath RH16 1GF Tel/answerphne: (phnes manned weekdays 9.00 am t 3.00 pm) Fax: (calls charged at natinal rates) [email protected] Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 1

2 Grup B Strep Supprt Cntents WHAT IS GROUP B STREPTOCOCCUS?...3 GBS clnisatin...3 GBS infectin...3 Incidence f GBS infectin in babies in the UK...3 Hw des a baby get a GBS infectin?...4 Types f GBS infectin...4 Treatment f GBS infectin...6 Risk factrs fr GBS infectin in newbrn babies...6 Preventing mst GBS infectin in babies...7 Current UK Guidelines...10 UK Tests fr GBS carriage...11 Future preventin...12 GBSS VIEW...14 Infrmatin Prvisin:...14 Medical interventin:...14 YOUR BABY WHO HAD A GBS INFECTION...15 Talking t yur bstetrician/paediatrician...15 After effects f GBS infectin...16 Reinfectin in babies...16 Subsequent babies...16 USEFUL ORGANISATIONS...17 ANOTHER PREGNANCY...19 Yur baby has arrived - cngratulatins!...24 FREQUENTLY ASKED QUESTIONS...28 MEDICAL...36 LEAFLET ORDER FORM...37 MEMBERSHIP APPLICATION FORM...39 Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 2

3 Grup B Strep Supprt WHAT IS GROUP B STREPTOCOCCUS? GBS stands fr Grup B Streptcccus (Streptcccus agalactiae), which is a cmmn type f the Streptcccus bacterium. Up t a third f all men and wmen in the UK carry GBS in their intestines withut symptms. GBS is a nrmal bdy cmmensal (an rganism that lives n anther withut harming it) that, nce present, cannt be eradicated frm the bdy. Carrying GBS is perfectly natural and nrmal. GBS ften clnises the vagina, althugh carriage here may be intermittent. At any ne time, the vaginas f apprximately a quarter f all wmen f childbearing age are clnised with GBS. The mst cmmn surce f the bacteria causing GBS infectin in newbrn babies is the mther s vagina befre r, less frequently, during delivery. Thusands f newbrn babies are expsed t GBS withut ill effects - why sme babies are susceptible t the bacteria and develp infectin (typically septicaemia, pneumnia and/r meningitis) and thers dn t is nt fully understd. GBS COLONISATION GBS is a very cmmn naturally ccurring bacterium it lives in the intestines f abut a third f the ppulatin (men and wmen) and, nce present, cannt reliably be eradicated. GBS clnisatin is when the bacteria live in the bdy withut causing any harm r symptms. Clnisatin with GBS is nrmal and needs n treatment. Peple wh have the bacteria in their bdies in this way are described as being clnised r carriers. GBS clnises the vagina in up t 25% f wmen, again withut causing any symptms - it des nt cause increased vaginal discharge, sreness, painful intercurse, etc. Arund 5% f the time, GBS may clnise the back f the thrat. GBS clnisatin may be intermittent and the duratin f carriage is unpredictable. Outside f the intestines, GBS clnisatin may appear t be cleared by antibitics but these areas will usually becme reclnised, as antibitics d nt eradicate the GBS in the gut. GBS may be passed frm ne persn t anther thrugh hand cntact, kissing, clse physical cntact, etc. As GBS is ften fund in the vagina and rectum f clnised wmen, it is cmmnly passed thrugh sexual cntact. There are n knwn harmful effects f carriage itself and the GBS bacteria d nt cause genital symptms r discmfrt. GBS is nt a sexually transmitted disease, nr is GBS carriage a sign f ill health r pr hygiene. N-ne shuld ever feel guilty r dirty fr carrying GBS it s nrmal. GBS INFECTION GBS ccasinally causes infectin, mst cmmnly in newbrn babies arund the time f birth, in the elderly, peple with serius underlying medical cnditins that impair the immune system and wmen during pregnancy r after birth. Arund half f all GBS infectins ccur in babies aged less than ne mnth and nearly all f the remainder ccur in adults. GBS infectin is when the bacteria are actively causing disease directly by damage t cells r indirectly by the txins (pisnus substances) they release and is diagnsed when GBS is grwn. INCIDENCE OF GBS INFECTION IN BABIES IN THE UK GBS infectin in newbrn babies is relatively uncmmn althugh the actual incidence f GBS infectin in newbrn babies in the UK is unclear - it is unlikely nw that we will ever knw the true figure, given the difficulty bth f btaining full actual incidence data and f knwing hw much preventin is already ccurring which is reducing the actual incidence figures. Hwever, realistic estimates f the ttal incidence f GBS infectin in babies in the UK are needed s that realistic estimates f the risks f newbrn babies develping GBS infectin can be made. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 3

4 Grup B Strep Supprt The British Paediatric Surveillance Unit f the Ryal Cllege f Paediatricians and Child Health undertk a study (Heath PT, Balfur G, Weisner AM, Efstratiu A, Lamagni TL, Tighe H, O'Cnnell LAF, Cafferkey M, Verlander NQ, Nicll A & McCartney AC n behalf f the PHLS GBS Wrking Grup. Grup B streptcccal disease in UK and Irish Infants <90 days f age. Lancet 2004 Jan 24, Vl 363(9405):292.) t determine the number f babies brn in the UK and Republic f Ireland wh develp GBS infectin under age 90 days between 1 February 2000 and 28 February This fund 0.7 per 1,000 babies brn in the UK and Republic f Ireland develped culture-prven GBS infectin, althugh the researchers admitted their figures under-reprted the situatin by up t 40%, suggesting a true incidence f culture-prven cases f at least 0.9/1000 babies brn. Anther recent Lndn study (Luck S, Trny M, d'agapeyeff K, Pitt A, Heath P, Breathnach A & Bedfrd Russell A. Estimated early-nset grup B streptcccal nenatal disease. Lancet, 2003 Jun 07; 361(9373): ) estimated the incidence f culture-prven plus suspected cases f GBS infectin t be 3.6 per 1,000 babies brn, increasing the incidence f infectin figure significantly and bth f these studies were cnducted at a time when increasingly hspitals either had r were intrducing prtcls against GBS infectin in babies. GBSS medical advisry panel has lked at the available data fr the UK and cnsiders an incidence f GBS infectin in newbrn babies, where n preventative actin is taken, f ne in every 1,000 babies brn t be a cnservative estimate f the situatin in the UK. Assuming an annual birth rate f apprximately 700,000 babies fr the UK, we estimate that GBS causes infectin in at least 700 babies each year in the UK but mst f these infectins are preventable. Thusands f healthy babies are brn every year t wmen wh carry GBS, with n ill effects. Hwever, carrying GBS at delivery des increase the risk f the baby develping GBS infectin t arund ne in every 300 babies brn (where n preventative measures are taken): 299 times ut f 300, the mther s and baby s defence mechanisms successfully prevent infectin develping. The risk f the baby develping a GBS infectin really is quite small. HOW DOES A BABY GET A GBS INFECTION? A baby develps GBS infectin after it has been expsed t the bacterium. Where this expsure cmes frm may vary: if a baby has symptms within first six days f birth (early-nset GBS infectin), the GBS bacteria will mst prbably have been passed frm the mther t her baby befre r during delivery. Such transmissin ccurs if the mther is carrying GBS in her vagina at the time f delivery, and the bacteria either crssed the amnitic membranes r was passed t the baby during delivery. If a baby shws symptms f GBS infectin after age six days (late nset GBS infectin), the bacteria may have been passed t the baby frm the mther, but nt necessarily. Sme research shwed that ver 50% f cases f late-nset GBS infectin were the same strain f GBS as the mther was carrying. Where the rest came frm was unclear, but since GBS is passed frm ne persn t anther thrugh skin t skin cntact, smene wh tuched him/her will have expsed the baby t GBS. Being expsed t GBS is perfectly nrmal and mst babies expsed t GBS d nt develp infectin they successfully fight ff the bacteria. But there is n way f knwing which babies will be able t d this and which wn t. TYPES OF GBS INFECTION Early nset GBS infectin Rughly 80-90% f all GBS infectin in babies ccurs in the first six days f life and is usually apparent at birth. This early-nset GBS infectin is mst cmmn after bstetric cmplicatins, such as lw birth weight, prematurity, prlnged rupture f membranes and maternal fever. Early-nset GBS infectin mst cmmnly presents as septicaemia, fllwed by pneumnia and meningitis. At least 60% f early-nset GBS infectin is preventable using the risk-factr based preventin strategy recmmended by ur medical advisry panel, and significantly mre if intravenus antibitics in labur were ffered t all GBS carriers identified by universal reliable testing f wmen late in pregnancy. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 4

5 Grup B Strep Supprt TYPICAL SYMPTOMS OF EARLY ONSET GBS INFECTION IN BABIES INCLUDE: grunting pr feeding lethargy (being abnrmally drwsy) irritability abnrmal (high r lw) temperature, heart rates r breathing rates lw bld sugar and/r lw bld pressure Early-nset GBS infectin is characterised by the rapid develpment f respiratry distress (breathing prblems) and/r septicaemia (bld pisning). Early-nset GBS infectin has a higher mrtality rate than late-nset infectin - apprximately 15% f babies die. Typically at delivery r within a few hurs, an infected baby shws symptms f mild respiratry distress and needs additinal xygen; the baby s xygen requirements increase, the baby may stp breathing and need artificial ventilatin (a breathing machine). Early-nset GBS infectin may very clsely mimic the clinical presentatin and chest X-ray appearance f respiratry distress syndrme (RDS) and be cnfused with this cnditin. Late-nset GBS infectin Apprximately 10-20% f GBS infectin in babies ccurs after the baby is 2 days ld, mst cmmnly presenting as GBS meningitis, fllwed by septicaemia, fcal infectin and pneumnia. This late-nset GBS infectin nrmally develps by age ne mnth, but rarely up t age 3 mnths. Late-nset GBS infectin in newbrn babies is assciated with prematurity, prlnged rupture f membranes, multiple births and the mther carrying GBS. Arund 90% f cases f late-nset infectin include meningitis with septicaemia. Up t a half f the survivrs f GBS meningitis suffer lng-term mental r physical prblems and, in apprximately ne ut f every 8 survivrs f GBS meningitis, the prblem is severe. As yet, there are n knwn methds f preventing late-nset GBS infectin in babies. TYPICAL SYMPTOMS OF LATE ONSET GBS INFECTION Yur baby is at a little less risk f develping GBS infectin as each day passes, but yu may like t knw the usual symptms f late-nset infectin (develping after day 6). Typical symptms f late-nset GBS infectin are: fever; pr feeding &/r vmiting; impaired cnsciusness. TYPICAL SYMPTOMS OF MENINGITIS GBS can cause meningitis in babies. Typical symptms f meningitis, any f which culd develp and sme may nt be present at all, include: fever, which may include the hands and feet feeling cld, and/r diarrhea; refusing feeds r vmiting; shrill r maning cry r whimpering; flppy bdy; dislike f being handled, fretful; tense r bulging fntanelle (sft spt n the head); invluntary bdy stiffening r jerking mvements; pale and/r bltchy skin. blank, staring r trance-like expressin; abnrmally drwsy, difficult t wake r withdrawn; altered breathing patterns; & turns away frm bright lights. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 5

6 Grup B Strep Supprt Trust yur instincts it is yur baby! If yur baby shws signs cnsistent with GBS infectin r meningitis, call yur GP immediately. If yur GP isn t available, g straight t the nearest PAEDIATRIC Accident & Emergency Department. Early diagnsis and treatment are essential t cmbat late-nset GBS infectin delay can be fatal... Adult GBS infectin GBS is a rare cause f infectin in adults, mst ften affecting the elderly r thse with underlying medical prblems that impair the immune system. GBS infectin can develp in wmen during pregnancy r after birth, typically as urinary tract infectin, chriamninitis (chriamninitis is an infectin f the membranes and amnitic fluid), pst-delivery endmetritis (inflammatin f the lining f the uterus fllwing birth), septicaemia (bld pisning) after delivery and infectin after Caesarean sectins. These infectins usually respnd quickly t speedy antibitic therapy. TREATMENT OF GBS INFECTION GBS infectin needs t be treated prmptly and aggressively: high dses f intravenus (thrugh a vein) antibitics shuld be given as sn as pssible and antibitic therapy shuldn t be stpped prematurely (i.e. intravenus antibitic therapy shuld be cntinued fr at least 10 days r 14 days if meningitis is present). Given this, the majrity f babies with GBS infectin can be treated successfully with penicillin, althugh sme will require all the expertise f a nenatal intensive care unit (and sick babies may have t be transferred t a different hspital with specialised facilities). Sadly, even with full intensive care, between 1 and 2 ut f every 10 infected babies will die frm their GBS infectin (arund 15% f babies frm early-nset and arund 5% frm late-nset infectin). Befre discharge, a full wrk up shuld be dne fr a baby wh has recvered frm GBS infectin cmprising: BABY WORK UP Full examinatin by paediatrician Review f clinical parameters FBC (full bld cunt) and differential CRP (C reactive prtein) Twins, triplets r mre If a baby develps GBS infectin and is ne f a multiple birth, then the same antibitics shuld be given intravenusly t the ther baby/babies as a preventative measure, even if they appear well. Risk f reinfectin Reprts indicate a baby wh has recvered frm a GBS infectin is at lw but slightly increased risk f re-infectin (arund 1-3%). There is n established evidence t recmmend any specific treatments t prevent recurrent GBS. A few practitiners may prescribe a daily penicillin dse fr the baby fr the first 3 mnths f life, in the belief that it may prevent GBS infectin. There is n evidence t supprt this practice, althugh Penicillin given in this way has been shwn t reduce the risk f infectin with anther related bacterium, called pneumcccus, in individuals wh have lst their spleens. RISK FACTORS FOR GBS INFECTION IN NEWBORN BABIES There are five situatins where a baby is mre likely t be expsed t GBS and run the risk f pssible early-nset GBS infectin. Each f the risk factrs shwn belw increases the risk f GBS infectin in a newbrn baby. Mthers wh have previusly had a baby infected with GBS risk is increased10 fld Mthers wh have been shwn t carry GBS in this pregnancy r GBS has been fund in the urine at any time during this pregnancy risk is increased 4 fld Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 6

7 Grup B Strep Supprt Any f the fllwing clinical risk factrs risk f GBS infectin is increased 3 fld Labur starts r membranes rupture befre 37 weeks f pregnancy is cmpleted (i.e. preterm). Where rupture f the membranes is prlnged: mre than 18 hurs befre delivery. Where the mther has a raised temperature* during labur f 37.8 C r higher. *If a wman has an epidural, a slightly raised temperature may be f less significance than in a wman with n epidural. Mst cases f early-nset GBS infectin fllw deliveries with ne r mre f the abve risk factrs. Withut preventative medicine, the chance a newbrn baby will develp a GBS infectin in the UK is arund 1in every 1,000 babies. Fr a wman wh has had a baby wh develped a serius GBS infectin, the chance is multiplied by 10 t arund 1 in 100 if there are n additinal clinical risk factrs present. If, hwever, that same wman is given the intravenus antibitics in accrdance with ur medical advisry panel s recmmendatins, the risk can reduce dramatically t less than 1 in 2,000. PREVENTING MOST GBS INFECTION IN BABIES Preventing GBS infectin is better than treating it waiting t give antibitics t the baby until after delivery will sadly smetimes be t late. Clinical randmised trials have prven that mst GBS infectins in newbrn babies can be prevented by giving intravenus antibitics t wmen whse babies are at increased risk frm the nset f labur r waters breaking until delivery. The data n the time it takes fr the intravenus antibitics t be effective is limited. Research shws that antibitic penetratin f the amnitic fluid seems nly t reach a maximum at tw hurs and, preferring t be cnservative, GBSS therefre recmmends at least fur hurs f the intravenus antibitics befre delivery, where pssible and, ideally, the pregnant wman will have received tw r mre dses befre delivery. Hwever, lesser times have prved beneficial: smething is better than nthing. If nly tw hurs administratin is pssible, this may be sufficient and shuld give cnsiderable reassurance. T stp as many cases f GBS infectin in newbrn babies as pssible, pregnant wmen in all f the abve higherrisk situatins shuld be given intravenus antibitics in labur fr at least fur hurs befre delivery. Sme wmen will prefer nt t have the antibitics, especially if their baby s risk is nly slightly increased, as the intravenus antibitics wuld inevitably cmplicate an therwise natural birth, plus antibitics are assciated with rare but significant side-effects (see page 32). The risk f a GBS infectin in the baby must be balanced against the wishes and beliefs f the wman in labur and against the risk f her having an adverse reactin t the antibitics. As yet, there are n prven methds fr preventing late-nset GBS infectins, develping after age 6 days. Adpting the fllwing key recmmendatins fr preventing GBS infectin in newbrn babies even withut widespread reliable testing wmen fr GBS carriage late in pregnancy - culd stp at least 60% f GBS infectin in newbrn babies and 70% f resulting deaths: Key recmmendatins fr preventing GBS infectin in newbrn babies: Wmen at risk Wmen at high risk shuld be strngly advised t have intravenus antibitics immediately at nset f labur until delivery. At high risk means: Wmen with GBS and anther risk factr Wmen wh may/may nt have GBS, but have multiple risk factrs Wmen wh have had a previus baby infected with GBS Wmen with a fever during labur Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 7

8 Grup B Strep Supprt Wmen at increased risk shuld be ffered intravenus antibitics immediately at nset f labur thrugh t delivery. At increased risk means: Wmen wh are knwn t carry GBS and d nt have ther risk factrs Wmen wh d nt knw whether they carry GBS but have ne ther risk factr nt mentined abve Treatment appraches Intravenus antibitics against GBS infectin in the baby shuld be given t the mther fr at least 4 hurs befre delivery if pssible (if nly 2 hurs is pssible, this may be sufficient and shuld give cnsiderable reassurance) Intravenus antibitics recmmended fr wmen in labur are: Penicillin G: given as 3g (r 5MU) intravenusly at first and then 1.5g (r 2.5MU) at 4- hurly intervals until delivery Fr wmen allergic t penicillin: Clindamycin 900 mg intravenusly every 8 hurs until delivery Where infectin f the membranes is diagnsed r suspected r where there is preterm prlnged rupture f membranes, brad-spectrum intravenus antibitics shuld be given which include adequate GBS cver. IF YOU ARE ALLERGIC TO PENICILLIN OR ANY OTHER ANTIBIOTIC, YOU MUST TELL YOUR HEALTH PROFESSIONALS Care after birth Babies brn t mthers at increased/high risk wh HAVE received antibitics fr 4 hurs befre delivery shuld be: Carefully assessed by a paediatrician if cmpletely healthy n antibitics fr the baby are required. A perid f mnitring (12-24 hurs) may be apprpriate fr thse at highest risk f infectin. Babies brn t mthers at increased/high risk wh HAVE NOT received antibitics fr 4 hurs befre delivery shuld be: Examined thrughly and investigated by a paediatrician as apprpriate. Started n intravenus antibitics until it is knwn that the baby is nt infected, unless the baby is cmpletely well as determined fllwing a rbust baby examinatin carried ut by a trained individual. Implementing these recmmendatins culd reduce GBS infectin in newbrn babies by 60% and deaths frm GBS in babies by 70%. GBSS believes lw-risk pregnant wmen shuld be ffered sensitive testing fr GBS at weeks f pregnancy and, where GBS is detected, then intravenus antibitics shuld be ffered in labur t these wmen, plus t thse with ther recgnised risk factrs as abve. This apprach has been shwn t be bth mre effective at preventing GBS infectin in newbrn babies, as well as ptentially saving ver 37 millin a year, cmpared with current practice (Preventive strategies fr grup B streptcccal and ther bacterial infectins in early infancy: cst effectiveness and value f infrmatin analyses BMJ Sep 29;335(7621):655. Epub 2007 Sep 11. Clburn TE, Asseburg C, Bjke L, Philips Z, Weltn NJ, Claxtn K, Ades AE, Gilbert RE). Unfrtunately, sensitive testing is currently nly available frm a handful f NHS hspitals, althugh it is available privately (see Private Testing n page 12). Until sensitive testing is available rutinely, GBSS supprts the abve risk-based apprach t preventing GBS infectin in newbrn babies. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 8

9 Grup B Strep Supprt These recmmendatins will need peridic reappraisal t incrprate advances in technlgy, new research r ther refinements but are we believe the mst apprpriate fr Britain in the light f all data available at present. Pstnatal paediatric preventin With any plicy that invlves treating sme wmen with antibitics t prevent GBS infectin fllwing the start f labur, a strategy fr the subsequent management f the newbrn baby is required. The flwchart belw shws ur medical advisry panel s recmmended paediatric preventin strategy t stp GBS infectin develping in newbrn babies: 9 Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS

10 Grup B Strep Supprt CURRENT UK GUIDELINES Natinal Institute fr Clinical Excellence (NICE) NICE S Guidelines CG6 Antenatal Care Rutine care fr health pregnant wmen, Octber 2003 ( pint 10.9) recmmend that pregnant wmen shuld be ffered evidence based infrmatin and supprt t enable them t make infrmed decisins regarding their care addressing wmen s chices shuld be recgnised as being integral t the decisin making prcess. And yet infrmatin n GBS is nt rutinely given t pregnant wmen Mst wmen are nt infrmed abut GBS (a survey cnducted by Pregnancy & birth magazine fund nly 5% f the 1,000 pregnant wmen and new mthers surveyed had been infrmed abut GBS either at an 'antenatal class' r 'by their GP') as part f their rutine antenatal care, nr are mst invlved in deciding whether they shuld be tested fr GBS carriage they are simply nt tld it is pssible. The guidelines als recmmend antenatal appintments fr all pregnant wmen at 36 weeks gestatin ideal fr reliable testing fr GBS clnisatin. But NICE dn t recmmend such testing, saying evidence f its clinical effectiveness and cst effectiveness remains uncertain. Hwever, all the evidence clearly demnstrates the clinical effectiveness f testing pregnant wmen fr GBS and ffering intravenus antibitics in labur t higher-risk wmen such interventins dramatically reduce the incidence f GBS infectin in newbrn babies and cuntries which have intrduced such prgrammes have seen in their incidence f GBS infectin fall dramatically, including in the USA, Australia, New Zealand, Belgium, France, Spain and Italy. The cst effectiveness issue is less clear thugh a cst benefit study published in September 2007 indicated testing lw risk wmen, plus giving antibitics given t high-risk wmen and thse fund t carry GBS was a mre cst-effective ptin than current practice. Disappintingly, althugh a review f the guidelines was published in March 2008, n updates were made t the sectins relating t GBS, despite this being suggested by a variety f clinicians, health prfessinals rganisatins and by GBSS. This guideline is next due fr review in March Ryal Cllege f Obstetricians & Gynaeclgists (RCOG) RCOG issued their Green Tp Guideline N 36 "Preventin f early nset nenatal Grup B streptcccal disease" in Nvember 2003 ( This imprtant dcument is similar in many respects t the guidelines GBSS has been prmting since 1996, in that they qute likely incidences f GBS infectin based n the presence f recgnised risk factrs and recmmend intravenus antibitics in labur fr wmen in higher risk grups. Hwever, the guidelines use the minimum incidence figures quted in the Heath paper mentined n page 6 and, therefre, nt nly underestimate the true incidence f GBS infectin but, inevitably, als underestimate the risks t babies frm GBS infectin. GBSS was happy t endrse these guidelines which, when fully implemented in the UK, will prevent the majrity f lethal cases f GBS infectin in newbrn babies. GBSS views the guidelines as a key starting psitin as even mre GBS infectins culd be prevented thrugh adpting a culture-testing apprach t GBS preventin as described belw. The Ryal Cllege f Obstetricians & Gynaeclgists has recently (March 2008) started its review prcess f the Green Tp GBS Guideline issued in Nvember 2003 (due fr review Nvember 2006). The review shuld be cmpleted within apprximately tw years. In 2007, RCOG published the findings f an audit t evaluate practice in UK bstetric units against their recmmendatins (see The audit started ut by cmparing internatinal guidelines fr early-nset GBS disease; highlighting the fact that, in cntrast t the UK and New Zealand guidelines, mst f the ther cuntries surveyed recmmended identifying wmen fr intravenus antibitics in labur by ffering sensitive tests t all pregnant wmen. The audit reviewed hspitals prtcls against GBS infectin in newbrn babies f the 161 UK units which submitted their prtcl, 4 units didn t even have a prtcl fr GBS, f thse that did, 35% didn t mentin the 2003 RCOG guideline and even when sme f the recmmendatins were cnsistent with the RCOG guideline, nly a minrity f units had prtcls that were entirely cnsistent with the guideline. The audit reviewed hspitals practice as well - significant variatin in practice was identified between different hspitals, between the three prfessins (bstetrics, midwifery and nenatlgy) and even between clinicians in Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 10

11 Grup B Strep Supprt the same unit! Variatin was fund in all aspects f the care ffered t pregnant wmen, particularly with regard t which risk factrs were used t identify wh wuld be ffered a bacterilgical swab fr GBS,, the timing f swabs and the site(s) frm which it/they are taken, which risk factrs were used t identify wh shuld be ffered intravenus antibitics in labur, which antibitics and in what dses/timings are used and hw newbrn babies at risk f early-nset GBS disease are managed. Furthermre, mst staff did nt knw if the Enriched Culture Medium (ECM) methd f prcessing the swabs taken t detect GBS clnisatin which is recgnised as ptimal by bth the RCOG and the Health Prtectin Agency) was used in their labratries. At GBSS, we knw f nly a very few NHS hspitals that use the ECM methd. It is very disappinting that, in nearly 4 years since the RCOG Green Tp Guideline n preventing early-nset GBS infectin was published, mre hspitals haven t incrprated the recmmendatins int their wn prtcls. And, althugh the audit reprt made a series f recmmendatins t imprve the situatin, n detail was given as t hw these wuld be achieved. In March 2008, the Ryal Cllege f Obstetricians & Gynaeclgists started its review prcess f the Green Tp GBS Guideline issued in Nvember 2003 (due fr review in Nvember 2006). The review shuld be cmpleted by Natinal Screening Cmmittee The Natinal Screening Cmmittee s current plicy psitin n grup B Strep is that screening fr this cnditin shuld nt be ffered ( In May 2006, the UK Natinal Screening Cmmittee launched their GBS nline learning package. This learning package has been develped t raise awareness f GBS amngst health care prfessinals. Develped by the Wmen s Health Specialist Library (part f the Natinal Library fr Health), the learning package is based upn the current UK guidelines published by the Ryal Cllege f Obstetricians & Gynaeclgists. It is divided int three sectins - antenatal; delivery; and pstnatal. Within each sectin there is the ptin t access an intrductin t GBS, different clinical scenaris, a series f quiz questins t test knwledge and a FAQs sectin. Yu can access the GBS learning pack, which is primarily aimed at health care prfessinals, at UK TESTS FOR GBS CARRIAGE Clnisatin f the vagina with GBS prduces n symptms and can be intermittent. T predict with the best accuracy the chances f carrying GBS at delivery, the best time t test fr it is between weeks f pregnancy. Carrying GBS in the vagina des nt autmatically mean a baby will develp GBS infectin. Even mre GBS infectins in newbrn babies culd be prevented by ffering all pregnant wmen sensitive testing at weeks and als ffering intravenus antibitics t thse fund t carry GBS. There are three tests fr GBS carriage available t mthers ne is available n the NHS, usually called an HVS (High Vaginal Swab) r LVS (Lw Vaginal Swab) test. Anther the ECM (Enriched Culture Medium) test is available frm a handful f NHS hspitals and privately. The Plymerase Chain Reactin (PCR) test is available frm ne UK website. Currently, neither the HVS nr LVS test is rutinely used t detect GBS carriage in the NHS. Mrever, these tests nly detect carriage in up t 50% f wmen carrying the germ. The ECM test is cnsidered the "Gld Standard" and is the best GBS test available. It may miss a very small number f wmen wh carry GBS, althugh it will nt give a false psitive result. The PCR test has nt been validated fr use in the UK and therefre GBSS cannt recmmend its use. What are the tests fr GBS carriage? The HVS/LVS test invlves taking a swab frm the vagina. A psitive result with the HVS test is very reliable hwever it can give a falsely negative result fr up t 50% f wmen carrying GBS when the test is dne leaving them under the false impressin that they are nt carrying GBS and their baby is at n risk. An LVS is slightly mre likely t detect clnisatin than a HVS, but it is still gives many false negatives. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 11

12 Grup B Strep Supprt The ECM (r Enriched Culture Medium) test is much mre sensitive test at detecting GBS clnisatin and is available and frm a handful f NHS hspitals and privately (it currently csts arund 32 fr a pstal service). The test invlves taking a swab frm the vagina and rectum at weeks f pregnancy, and psting them back t the labratry. Earlier testing is nt gd at predicting GBS clnisatin at delivery, and later testing increases the chance that the baby will be brn befre the result is available. It is imprtant that yu discuss this test with yur health prfessinal, and ensure they receive a cpy f the test results. If dne within five weeks f delivery, this test is very sensitive: if yu have a psitive result fr GBS, there is an 87% chance that yu will carry GBS at delivery. Similarly, if yu have a negative result this is 96% predictive that yu will nt be carrying GBS at delivery. The Plymerase Chain Reactin r PCR test is being ffered in the UK thrugh ne website. Althugh this is believed t be a highly accurate and fast methd f detecting GBS clnisatin, it nt been validated in the UK and therefre GBSS is unable t recmmend its use. Why test? Testing is nt essential, but it is the nly way t knw which babies are mre likely t develp GBS infectin, s that it can be prevented effectively. Up t 40% f babies wh develp early-nset GBS infectin will be brn t wmen whse nly risk factr was unknwn carriage f GBS arund delivery as GBS carriage is asymptmatic, withut testing, these wmen whse babies are at higher risk can t be identified. Research has shwn that significantly mre early-nset GBS infectins can be prevented by using a bacterilgical testing strategy, rather than a risk-factr strategy alne. If a wman carries GBS during her current pregnancy, she can be ffered intravenus antibitics in labur t minimise the risk f GBS infectin in her newbrn baby. And, if she chses nt t have the intravenus antibitics, then knwledge f her GBS carriage status can still infrm the management f her labur and delivery, and the baby s first hurs f life. Private Testing If a wman wuld like t have a private ECM test fr GBS carriage, we knw f nly tw labratries in the UK frm which this is available. Mullhaven Medical Labratry Tel [email protected] The Dctrs Labratry Tel: [email protected] The pregnant wman cntacts either labratry by phne, fax r and asks fr a GBS Testing Pack. This is usually sent ut the same day by first-class pst. Once the test pack is received, then the swabs can be taken either by the pregnant wman herself, r by her health prfessinal. Either way, the pregnant wman s health prfessinal shuld authrise the test and it is imprtant t ensure that the health prfessinal is als sent a cpy f the results! The vaginal and rectal swabs shuld be taken (by the health prfessinal r the pregnant wman) at weeks f pregnancy they can be dne earlier but then they may nt be as reliable in predicting GBS carriage at delivery. They may be dne later, but then there s an increasing risk that the baby will be brn befre the test result is available! The swabs are then sent direct t the labratry (with payment) in the envelpe prvided as part f the GBS Testing Pack. The labratries undertake t have the results available within three wrking days f receipt f the swabs and t pst ut the results n that day t the health prfessinal, with if requested a cpy t the pregnant wman. FUTURE PREVENTION GBS have been a recgnised cause f serius infectin in babies since the 1960s in the USA and the 1970s in Eurpe. Research in the decades fllwing has shed cnsiderable light n hw GBS causes this particular type f infectin. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 12

13 Grup B Strep Supprt Testing Babies at greatest risk f develping GBS disease are thse brn t wmen wh carry GBS during labur. Testing wmen during pregnancy fr GBS is currently nt dne in the UK, largely because f the csts and lgistics invlved. Scientific evidence clearly shws testing lw-risk wmen fr GBS, using reliable culture methds (nt rutinely available n the NHS at present, thugh they are recgnised as ptimal bth by the Ryal Cllege f Obstetricians & Gynaeclgists and the Health Prtectin Agency) at weeks gestatin and then ffering intravenus antibitics frm the nset f labur r waters breaking t all wmen where GBS is detected during the current pregnancy, plus t thse wmen delivering prematurely, with prlnged rupture f membranes, with a fever in labur r with a histry f GBS, is a mre effective way f preventing nenatal GBS infectins than relying n risk factrs alne. One paper estimated that a risk-factr apprach wuld prevent 50-60% f GBS infectin in babies, whereas a culture testing apprach giving intravenus antibitics in labur t wmen where GBS had been detected during the current pregnancy, plus t thse with recgnised risk factrs, wuld prevent 80-90% f GBS infectin in babies. The charity s view is that reliable testing shuld be intrduced urgently. Until it is, the charity supprt the RCOG s risk factr apprach which if implemented, althugh nt as effective as a culture testing apprach, wuld still prevent the majrity f GBS infectins develping in newbrn babies. GBS Vaccine Mst GBS infectins in newbrn babies can be prevented and the fcus in this paper is n stpping the preventable infectins develping in higher-risk babies and their mthers. Hwever, GBS infectin als strikes babies wh appear nt t be at risk at birth apprximately 40% f all cases f nenatal GBS infectin ccur in babies where there are n apparent risk factrs, apart frm GBS clnisatin in the mther. Significant effrt arund the wrld is being put int the develpment f a vaccine which, ne day, will prevent almst all GBS infectins in babies - nt just thse in high-risk babies. Advances have been made in the vaccine field but a vaccine is still nt ready fr use: all the existing candidates still have significant technical prblems assciated with them. A recent paper by the Medical Screening Sciety s Wrking Grup n GBS disease demnstrates the strng case fr a vaccine against GBS, calling fr a trial t be undertaken with all urgency (Law MR, Palmaki G, Alfirevic Z, Gilbert G, Heath P, McCartney C, Reid T, Schrag S n behalf f the Medical Screening Sciety Wrking Grup n GBS disease. The preventin f nenatal grup B streptcccal disease. J Med Screen 2005;12:60-68). Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 13

14 Grup B Strep Supprt GBSS VIEW We want t see a tw-prnged apprach t preventing GBS infectin in newbrn babies: INFORMATION PROVISION: Fully infrm health prfessinals abut GBS Ensure the subject is cvered as part f the training in bstetrics, general practice, midwifery and health visiting, as well in nging training. Incentivise health prfessinals t update their knwledge abut GBS. Infrming health prfessinals is key - nly if health prfessinals are fully infrmed will they be able t prvide gd quality infrmatin n t the families in their care. Prvide relevant health prfessinals with infrmatin leaflets, setting ut the prs and cns f actin/inactin Fully infrm expectant parents abut GBS in a practive way at an antenatal appintment s they can make an infrmed decisin abut what s best fr them & baby MEDICAL INTERVENTION: Recmmend intravenus antibitics in labur t wmen whse babies are at higher risk f develping GBS infectin, namely thse wh have previusly had a baby with GBS infectin, where GBS has been fund in the urine during the pregnancy, r where a wman has multiple risk factrs Offer sensitive testing t wmen nt at higher risk and ensure health prfessinals and parents are aware it is available and give wmen the chice t have a sensitive test fr GBS late in pregnancy if they want t. Offer intravenus antibitics in labur t wmen whse babies are at raised risk, thse where GBS has been fund during the current pregnancy r where there is anther risk factr (risk factrs are where labur has started r membranes ruptured befre 37 cmpleted weeks f pregnancy, where the membranes have ruptured mre than 18 hurs befre delivery, r where the mther has a raised temperature during labur f 37.8 C r higher). In ur view, this is the best apprach fr preventing GBS infectin in newbrn babies. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 14

15 Grup B Strep Supprt YOUR BABY WHO HAD A GBS INFECTION If yu baby is ne f the very small minrity wh has suffered lng-term prblems as a result f GBS infectin, r has even died frm it, please try t take heart frm the infrmatin in this leaflet. Sme f it may be difficult fr yu t read, but it is ur hpe and intentin t help yu understand what happened t yur baby. And, shuld yu decide t have anther baby, this dcument will prvide yu with infrmatin yu need fr that pregnancy. Yu may need answers t specific questins relating t yur baby and his/her GBS infectin. Yu may keep thinking if nly... and g ver what happened again and again. What happened befre, during and after yur baby s birth can nly really be clarified by yur bstetrician and yur baby s paediatrician - dctrs rarely mind being asked questins and it s better t ask than spend yur time wrrying. Once yu have read this dcument, please cntact us with any general queries abut GBS, r t be put in tuch with anther family whse baby was infected with GBS. TALKING TO YOUR OBSTETRICIAN/PAEDIATRICIAN If yu have specific questins, then make appintments t see the bstetrician and/r yur baby s paediatrician (as apprpriate) t discuss what happened. Expect t wait abut 6 weeks r s frm the day yu make the appintment, lnger if yur dctrs are away fr any reasn. This gives yu time t prepare yur questins fr the meeting. Write t cnfirm the dates and times f meetings. Sme dctrs ffices make appintments in the name f the cnsultant in charge and, n the day, allcate cases amngst several dctrs in that cnsultant s area. If this is nt acceptable t yu, clearly state in writing the name f the persn yu wish t see and that yu d nt wish t see a clleague. Explain in the letter the purpse f the meeting and what yu want t discuss (e.g. yur recent pregnancy, the baby s medical histry, anther pregnancy, GBS and hw it affected yu and yur baby, etc.). Give yur health prfessinals a cpy f this leaflet (r ur GBS & Pregnancy leaflet) Mst medical prfessinals dn t have as much knwledge r experience f GBS as thse wh cntributed t this leaflet. S it might be helpful fr yu t send them a cpy f this leaflet r ur little GBS & Pregnancy leaflet in advance. Take a list f all yur questins with yu t the meeting(s). The questins will prbably fall bradly int tw categries: firstly, what has happened t yu and yur baby (e.g. clarify whether any risk factrs fr GBS infectin were present during yur labur and, if s, hw they were acted upn; ask abut the curse f yur and yur baby s treatment, why were varius decisins made, whether yur baby is likely t suffer lng-term effects and, if s what, etc.) and, secndly, what the implicatins are fr a future pregnancy (e.g. what wuld be dne differently and why). At the meeting(s), ask all yur questins, asking fr further explanatins if necessary. Make sure yu fully understand the answers. Medical prfessinals respect the pinins f parents and will be cncerned that yur questins are answered. It might be useful t make brief ntes f the answers, particularly if yu have a lt f questins. Yu may find the meetings with the bstetrician and yur baby s paediatrician stressful and may want smene with yu (e.g. yur partner, a clse friend r family member). It can be useful t have smene there t make sure all yur questins are asked, answered and understd and, afterwards, t g ver what was said. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 15

16 Grup B Strep Supprt AFTER EFFECTS OF GBS INFECTION Mst babies make a full recvery frm their GBS infectin, althugh sadly up t 75 babies each year will die as a result f their GBS infectin. Unfrtunately, a small number f babies wh recver frm GBS infectin, and up t a half f the survivrs f GBS meningitis, will be left with lng-term mental r physical prblems and in ne ut f every 8 f these babies, the prblem is severe. Brain damage can ccur fr tw reasns. One is meningitis, and the ther is in respnse t a number f stimuli including lack f xygen and infectin. This is much mre cmmn in preterm than full-term babies and can ccur indirectly as a result f any infectin, including GBS. There is n evidence that GBS infectin leaves a legacy f extra vulnerability t ther illnesses, such as cughs, clds, allergies, clic, etc but there is nt a lt f infrmatin available n this. If yu have any cncerns r questins abut yur baby s medical care r expected lng-term utcme, please ask the dctrs r nurses caring fr yur baby. Hwever, general infrmatin abut meningitis and its after effects and n prematurity and its after effects is available frm the charities listed n page 16, as are charities which prvide supprt t bereaved parents and siblings REINFECTION IN BABIES Reprts indicate a baby wh has recvered frm a GBS infectin is at lw but slightly increased risk f re-infectin (arund 1-3%). There is n established evidence t recmmend any specific treatments t prevent recurrent GBS. A few practitiners may prescribe a daily penicillin dse fr the baby fr the first 3 mnths f life, in the belief that it may prevent GBS infectin. There is n evidence t supprt this practice, althugh Penicillin given in this way has been shwn t reduce the risk f infectin with anther related bacteria, called pneumcccus, in individuals wh have lst their spleens. SUBSEQUENT BABIES Babies brn after an lder sibling develped GBS infectin are at raised risk f develping GBS infectin themselves it is estimated the risk increases perhaps ten-fld r mre. In this circumstance, intravenus antibitics are strngly recmmended t be given t the mther any subsequent labur as being highly effective preventative medicine against early-nset GBS infectin in the baby. There is n evidence that cntinuing t give penicillin t a well baby after delivery is effective at preventing GBS infectin after birth. Hwever, where a family has suffered the trauma f a baby being seriusly ill with GBS infectin, a few practitiners may cnsider prescribing a daily penicillin dse fr the baby, fr the first 3 mnths f life in the belief that it may prevent GBS infectin and s reduce understandable anxiety. There is n evidence t supprt this practice, althugh Penicillin given in this way has been shwn t reduce the risk f infectin with anther related bacteria, called pneumcccus, in individuals wh have lst their spleens. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 16

17 Grup B Strep Supprt USEFUL ORGANISATIONS Pregnancy, childbirth & general BLISS, 2nd Flr, Camelfrd Huse, 89 Albert Embankment, LONDON SE1 7TP ( Fr parents f babies in intensive & special care. La Leche League, BM3424, Lndn WC1N 3XX ( ). Lcal supprt grups. Maternity Alliance, 45 Beech Street, LONDON EC2P 2LX ( ) Infrmatin n maternity care & rights. Natinal Childbirth Trust, Alexandra Huse, Oldham Terrace, Actn, Lndn W3 6NH ( ). Infrmatin n pregnancy and childbirth. Lcal supprt grups and classes. Tmmy's Campaign, 1 Kenningtn Rad, LONDON SE1 7RR ( ) Supprt and research int prblem pregnancies. Organisatins linked t specific medical cnditins Cerebral Palsy Helpline, P.O. Bx 833, Miltn Keynes, MK12 5NY (Helpline: Supprt fr peple affected by cerebral palsy. Cntact-A-Family, City Rad, LONDON EC1V 1JN. ( ) Fr parents f children brn with disabilities and rare and/r handicapping cnditins. Links with lcal and natinal grups. In-Tuch Trust, 10 Nrman Rad, SALE, Cheshire M33 3DF ( ). Prvides individual links, cntact and infrmatin fr parents f children with all special needs and rare medical cnditins. Meningitis Research Fundatin, Midland Way, Thrnbury, Bristl BS12 2BS (24-hur helpline: ). Meningitis Trust, Fern Huse, Bath Rd, Strud, Gls. GL5 3TJ ( ; Helpline: Cunselling, advice & supprt AVMA (Actin fr Victims f Medical Accidents), 44 High Street, CROYDON, Surrey, CR0 1YB ( ) Legal advice abut medical treatment. AIMS (Assciatin fr Imprvements in the Maternity Service), 21 Iver Lane, IVER, Bucks SL0 9LH ( ) Advice n rights, cmplaints prcedures and chices in maternity care. British Assciatin fr Cunselling, 1 Regent Place, RUGBY, Warwickshire CV21 2PJ ( /9. ). Infrmatin n where t get cunselling lcally. Patients Assciatin, 8 Guildfrd Street, Lndn WC1N 1DT ( ). Natinal pressure grup. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 17

18 Grup B Strep Supprt Fr parents whse baby has died Baby MPS, FREEPOST 29 LON20771, Lndn W1E 9ZT ( ) Baby MPS is a free service which allws yu t register nt t receive baby related mailings. Child Bereavement Trust, Astn Huse, High Street, West Wycmbe, High Wycmbe, Bucks HP14 3AG ( ) Resurces fr bereaved families and prfessinals. Child Death Helpline ( ) Fr anyne affected by the death f a child. Based at Great Ormnd Street Hspital, staffed by bereaved parents (Mnday, Wednesday, Friday, 10 am t 1 pm. Every weekday evening 7pm-10pm). FSID (Fundatin fr the Study f Infant Deaths), Artillery Huse, Artillery Rw, LONDON, SW1P 1RT ( ) Fr families affected by sudden infant death. Miscarriage Assciatin, c/ Claytn Hspital, Nrthgate, Wakefield, West Yrks. WF1 3JS ( , answer phne ut f hurs. ). Supprt and infrmatin n miscarriage. Multiple Birth Fundatin, Queen Charltte s & Chelsea Hspital, Gldhawk Rad, Lndn W6 0XG ( / ). Supprt fr parents wh have lst ne r mre f their babies frm a multiple pregnancy r at birth. Natinal Assciatin f Bereavement Services, 20 Nrtn Flgate, Bishpsgate, Lndn E1 6DB ( ; referrals: ). Cunselling, supprt and referral lcally fr anyne bereaved. Natinal Assciatin fr Maternal and Child Welfare, Osnaburgh Street, Lndn NW1 3ND ( /4117/4541). Cunselling and supprt. Sciety f Cmpassinate Friends, 53 Nrth Street, Bristl BS3 1EN (Helpline: ; admin: ). Supprt fr parents f children wh have died. Stillbirth & Nenatal Death Sciety (SANDS), 28 Prtland Place, Lndn W1N 4DE (Helpline: ). Fr parents whse babies die at r arund the time f birth. Organisatins f faith Asian Family Cunselling Service, 76 Church Rad, Hanwell, Lndn W7 1LB ( r [email protected] ) Offers caring, persnal and cnfidential cunselling (thugh nt bereavement cunselling) in the client s language with an awareness f their cultural and ethnic backgrunds. Bereaved Parents Netwrk, Care fr the Family, P O Bx 488, Cardiff CF15 7YY ( ) Supprts families and friends f a child wh has died. Staffed by bereaved parents wh, althugh cmmitted Christians, prvide supprt t peple f all faiths and n faith. Jewish Bereavement Cunselling Services, P O Bx 6748, Lndn N3 3BX ( ) Cunselling and supprt fr members f the Jewish cmmunity. Visits available in the Lndn area and referrals t supprt utside Lndn if needed. Muslim Wmen s Helpline, ( / ) A telephne cunselling service prviding supprt fr Muslim wmen. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 18

19 Grup B Strep Supprt ANOTHER PREGNANCY It may seem insensitive t raise the issue f a future pregnancy but it is vital yu knw that a future baby may be at risk frm GBS infectin and that effective preventin strategies exist. We want t give yu the infrmatin yu need abut GBS, and cnfidence fr the future. This sectin has been put tgether s yu can benefit frm the knwledge and experience f ur medical experts and the experiences f ther parents. Carrying GBS is nrmal and very cmmn, and GBS infectin in babies is, thankfully, relatively uncmmn. Thusands and thusands f healthy babies are brn every year t wmen wh carry GBS. The fact that yur baby develped GBS infectin des nt mean a future baby will t, althugh it des mean that any babies yu have in the future have an increased risk f develping GBS infectin. The risk f a future baby als develping GBS infectin is apprximately a 1 in 100 (a 1%) chance if n preventative actin is taken. Our medical advisry panel therefre strngly recmmends mthers wh have previusly had a baby wh had serius GBS infectin shuld be given intravenus antibitics frm the nset f labur r waters breaking until delivery fr any subsequent children. Given what happened t yur baby, yu re bund t want t knw hw t prevent GBS affecting a future baby. Hwever, there really is nthing that can be dne during pregnancy that has been prven t prevent GBS infectin in babies until labur starts r membranes rupture. Once this happens, having intravenus antibitics at 4 hurly intervals thrughut labur until yur baby is brn (and ideally fr at least 4 hurs befre birth) will stp mst GBS infectin develping in newbrn babies. If given antibitics in accrdance with ur medical advisry panel s recmmendatins, we estimate that the risk fr a baby brn t a wman wh has previusly had a baby infected with GBS (and wh has n ther clinical risk factrs) reduces frm arund a 1 in every 100 chance f develping GBS infectin t less than 1 in 2,000. That s less than the risk fr a wman nt knwn t carry GBS! Wmen at increased risk f premature labur and birth Alng with many ther bacteria fund in the vagina, GBS can cause infectin f the baby in the wmb, which can result in preterm birth, stillbirth and late miscarriage. Hwever, these are usually caused by a variety f factrs ther than GBS: genetic defects, gynaeclgical prblems, ther infectins, etc. If a wman has had any f these prblems in the past, she shuld ensure these pssibilities are investigated fully by a cnsultant bstetrician at bking (r befre) regardless f whether r nt she has a histry f GBS. GBS is a rare cause f these cmplicatins. We are smetimes asked if there s anything that can be dne during a subsequent pregnancy fr wmen wh have had a preterm delivery, which may have been caused by GBS. Unfrtunately, n antibitics tested s far can prevent a mther ging int premature labur fr any reasn, including because f GBS. Current pinin is that a substantial prprtin f premature laburs may be assciated with infectin, including perhaps as many as 50% f spntaneus laburs (i.e. when the baby is nt being delivered prematurely fr medical reasns). Hwever, it appears that almst any rganism that nrmally lives in the vagina (and there are many that d) can cause this prblem. There is n way f sterilising the vagina, r knwing in advance which rganism will cause truble, which prbably explains why antibitic treatment has nt been shwn t be effective (we dn t knw which antibitic t give in any specific case, befre the infectin has actually ccurred). Techniques t imprve the ability f the cervix t keep infectin ut (such as special stitching techniques) may prve t be mre effective in future. Mst bstetricians wuld agree that a wman wh has had a premature labur which may have been caused by infectin (with symptms such as silent dilatin r spntaneus premature rupture f membranes) and nt caused by ther unrelated cmplicatins (e.g. severe hypertensin, placental abruptin, etc.) is at raised risk f having anther premature delivery in a future pregnancy. On a theretical basis, a curse f antibitics during pregnancy when the baby is at its mst vulnerable may be beneficial. The idea that antibitics may reduce vaginal clnisatin with GBS and s reduce the risk f GBS causing preterm labur seems lgical, since studies suggest a relatinship between heavy vaginal clnisatin and premature labur. Hwever, there is actually n data t supprt this. Indeed, a large UK study, the ORACLE trial 1, prduced n evidence that ral antibitics prevent preterm labur. [The exceptin t this is erythrmycin Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 19

20 Grup B Strep Supprt given t wmen whse waters ruptured prematurely: in this circumstance, the erythrmycin bth delayed delivery and reduced adverse utcmes in the babies.] Research suggests that ral antibitics given fr perids f lnger than a week may be harmful t the mther and baby, increasing antibitic resistance and clnisatin by resistant bacteria. Hwever, there is n evidence that ral antibitics given fr up t a week are harmful. If n theretical grunds yu want t try t reduce vaginal clnisatin with GBS during the perid when the baby may be at greatest risk then, in agreement with yur dctr, a ne-week curse f ral antibitics may be cnsidered. Apprpriate drugs include erythrmycin (250 mg 4 times a day fr a maximum f 7 days r, amxycillin 1 (500 mg 3 times a day fr a maximum f 7 days). There is n evidence this will be effective, but neither is there any evidence that this will be harmful t yu r the baby. 1 The ORACLE trial was a randmised, multicentre trial t establish whether ral antibitics fr wmen in spntaneus preterm labur r with preterm prelabur rupture f membranes wuld have health benefits fr the babies. The ORACLE trial fund amxiclav increased the risk f necrtising enterclitis, a serius bwel disease, in babies and this antibitic is therefre nt recmmended during pregnancy. Amxiclav is a cmbinatin f amxycillin and clavulanic acid. It is the cmbinatin that appears t cause prblems, there is n evidence at present t suggest that amxycillin n its wn is harmful in this way. Kenyn SL, Taylr DJ, Tarnw-Mrdi W; ORACLE Cllabrative Grup. Brad-spectrum antibitics fr spntaneus preterm labur: the ORACLE II randmised trial. Lancet 2001 Mar 31; 357(9261): Kenyn SL, Taylr DJ, Tarnw-Mrdi W; ORACLE Cllabrative Grup. Brad-spectrum antibitics fr preterm, prelabur rupture f fetal membranes: the ORACLE I randmised trial. Lancet 2001 Mar 31; 357(9261): Is there anything else I culd d? One small study 1 shwed that giving intramuscular penicillin eradicated GBS clnisatin fr a perid f 6 weeks r mre in 75% f wmen knwn t carry GBS. Hwever, this is nly ne small study (nly 50 f 78 wmen received intramuscular antibitics), which s far has nt been repeated. S it is difficult t reach cnclusins based upn this data. It may be that fr wmen wh have previusly had a baby wh develped GBS infectin, an injectin f intramuscular Penicillin G at arund 35 weeks f pregnancy may be useful in an effrt t eradicate GBS clnisatin until after delivery. (They may als be wrth cnsidering earlier in the pregnancy fr wmen with a histry f preterm labur where GBS may have been a factr, and fr wmen wh carry GBS and have a histry f fast laburs where it is unlikely intravenus antibitics can be given fr at least 4 hurs befre delivery.) There are dwnsides f the intramuscular penicillin, nt least that the injectin is painful and there is a small risk assciated with taking antibitics, including f a sudden allergic reactin, antibitic resistance develping, etc. These risks are repeated with the intravenus antibitics recmmended during labur and delivery. Regardless f whether yu receive intramuscular antibitics in an effrt t eradicate GBS clnisatin, ur medical advisers recmmend yu shuld be ffered intravenus antibitics frm the nset f labur r waters breaking and at 4 hurly intervals until delivery. There are n knwn alternatives t the intramuscular penicillin fr wmen knwn t be allergic t penicillin. 1(Bland ML, Vermillin ST, Sper DE. Late third-trimester treatment f rectvaginal grup B streptccci with benzathine penicillin G. Am J Obstet Gynecl 2000 Aug;183(2):372-6) Caesarean sectins Caesarean sectins d nt eliminate the risk f GBS t a baby f develping GBS infectin since the bacteria can crss intact amnitic membranes t set up an infectin in the baby, althugh they d reduce the risk. Hwever, Caesareans are nt recmmended as a methd f preventing GBS infectin in babies: there are significant risks assciated with a Caesarean sectin; and the recmmended intravenus antibitics during labur are bth lw risk and highly effective. Our medical panel s recmmended curse f actin with regard t GBS and Caesarean sectins is as fllws: Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 20

21 Grup B Strep Supprt ELECTIVE CAESAREANS There is n evidence t shw intravenus antibitics are indicated against GBS when given t a wman knwn t carry GBS r wh previusly had has a baby infected with GBS befre an elective Caesarean unless she is in labur r her membranes have ruptured. If a baby is at higher risk f develping GBS infectin and the mther is having an elective Caesarean AND is in labur r her waters have brken, she shuld be ffered the recmmended intravenus antibitics as sn as pssible after labur has started, ideally fr at least 4 hurs befre delivery. The baby wuld nly need intravenus antibitics against GBS infectin if brn prematurely r if there are signs f pssible infectin in either the mther r the baby. EMERGENCY CAESAREANS If a wman has a histry f GBS and needs an emergency Caesarean, she shuld be treated as fr an elective Caesarean n intravenus antibitics are indicated against GBS unless she is in labur. If she is in labur, she shuld be treated as fr a nrmal labur up until the time when an emergency Caesarean sectin becmes necessary, when she shuld be delivered immediately. The treatment f the baby fr GBS wuld fllw the charity s nrmal paediatric recmmendatins. Prelabur & preterm rupture f membranes Prelabur and preterm rupture f membranes (PPROM) are nt usually related t GBS but, as PPROM is a risk factr fr GBS infectin, the GBS risk must be addressed. Management f PPROM may be cmplex and requires the input and judgement f the bstetric team. It may r may nt include the administratin f antibitics fr reasns ther than the preventin f GBS infectins. PPROM is a signal that the chance f the baby cntracting GBS infectin is increased. It is therefre recmmended that the mther receive intravenus antibitics at the nset f labur, which is the nly time that research has demnstrated such an interventin is effective. This may be in additin t ther ral antibitics given fr ther reasns. This situatin is a cmplex ne medically where a number f different appraches can be taken. Our experts suggest the fllwing as a typical apprach against GBS infectins develping in newbrn babies fr wmen whse membranes rupture withut ther signs f labur, based n their experience and available research, but please remember ther interventins may be mre apprpriate based n the individual case: WHERE THE PREGNANT WOMEN IS AT LESS THAN 36 COMPLETED WEEKS OF PREGNANCY: Give the pregnant wmen intravenus penicillin as sn as a diagnsis f labur is made, cntinuing them fr the next 48 hurs, regardless f ther ral antibitics that may be administered; Discntinue the intravenus penicillin after 48 hurs if labur has stpped r the diagnsis turns ut nt t have been crrect; and Resume intravenus penicillin if any sign f infectin appears r the wman is nce again diagnsed t be in labur. WHERE THE PREGNANT WOMAN IS AT 36 OR MORE COMPLETED WEEKS OF PREGNANCY AND IS KNOWN TO CARRY GBS OR ONE OR MORE CLINICAL RISK FACTORS ARE PRESENT: Administer intravenus penicillin t the pregnant wman immediately, cntinuing them until the baby is brn; and Induce labur. WHERE THE PREGNANT WOMAN IS AT 36 OR MORE COMPLETED WEEKS OF PREGNANCY, IS NOT KNOWN TO CARRY GBS AND NO OTHER CLINICAL RISK FACTORS ARE PRESENT: As sn as it s apparent that the membranes will have been ruptured fr mre than hurs befre delivery: Recmmend the inductin f labur; and Offer intravenus antibitics t the pregnant wman. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 21

22 Grup B Strep Supprt If the wman is allergic t penicillin, then alternatives shuld be given as stated in the preventin strategy (see page Errr! Bkmark nt defined. at the recmmended dses. What yu can d during pregnancy AGREE YOUR CARE REGARDING GBS When yu knw yu are pregnant, ensure the bstetrician in charge f yur pregnancy is aware f yur full medical histry (especially relating t GBS). If yu want intravenus antibitics in labur (whether nly in certain circumstances r regardless f ther risk factrs), establish that yu can have them. And remember t tell yur health prfessinals if yu have ever had an allergic reactin t penicillin r any ther antibitic. Make sure yur hspital ntes clearly detail the circumstances in which yu are t receive the intravenus antibitics and ask yur bstetrician t add this t yur ntes (he/she may nt be available when yu actually need the antibitics!) and include the details in yur birth plan. Yur bstetrician may be willing t cmplete the necessary hspital frm authrising the intravenus antibitics immediately n yur arrival at hspital in labur t keep in yur ntes. This will help ensure yu receive the antibitics as sn as pssible, rather than waiting fr a dctr t authrise the drugs after yu arrive. If yu re nt satisfied with yur bstetrician s respnse, yu may wish t seek a secnd pinin r even change yur bstetrician: yur GP can advise yu n this. Seeking a secnd pinin is an accepted practice within the medicine. Find ut the name(s) f the paediatrician(s) wh will lk after yur baby after birth and give him/her a cpy f this leaflet r ur little GBS & Pregnancy leaflet. Yu might want t ask whether they will use ur paediatric preventin strategy fr treating yur baby. INFORM YOUR HEALTH PROFESSIONALS ABOUT GBS Give all f yur health prfessinals a cpy f this leaflet r ur little GBS & Pregnancy leaflet, and make sure they knw yu carry GBS. (Keep several with yur birth plan, s they re handy t give ut.) Yu ll be helping yurself and yu may be helping thers t! Place ne f ur GBS Alert stickers n the frnt f yur hand-held ntes t alert any health prfessinals seeing them t the fact yu carry GBS, and that yu shuld be ffered intravenus antibitics as sn as pssible nce yur labur has started. If yu haven t gt ne f ur stickers, cntact us and we ll send ne t yu. Or ask yur midwife r bstetrician they may have sme. SWABS FOR GBS Rutine swabbing fr GBS during yur pregnancy using the cnventinal tests is nt helpful. Firstly, because yu have had a baby wh develped serius GBS infectin, a swab result wn t change the recmmendatin fr intravenus antibitics during labur/after waters break. Secndly, the cnventinal tests used in the UK aren t very reliable (giving a falsely negative result 40% t 50% f the time when it shuld be psitive fr infrmatin abut highly reliable tests, see page 13. Remember that, as a higher-risk mther, it is recmmended that yu be ffered the intravenus antibitics in labur irrespective f any test result). Thirdly, GBS clnisatin can cme and g s the situatin ne time culd be different the next (thugh research has shwn that, if using ptimal tests, the results are highly predictive f clnisatin status fr a perid f five weeks). And finally, there s n treatment required if yur vagina is clnised with GBS, s why bther? URINE TESTS FOR GBS As yu have had a baby wh develped serius GBS infectin, ur medical advisers suggest yu have mnthly urine cultures (nt just the dip-stick test) during anther pregnancy, starting at arund 18 weeks f pregnancy. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 22

23 Grup B Strep Supprt Urine is suppsed t be sterile and, if GBS is fund in yur urine, it shuld be treated with ral antibitics and yur urine retested 7-10 days after treatment. If the urine is nt clear f GBS, the treatment shuld be repeated until it is. Treatment fr a GBS psitive urine sample, whether yu have symptms f a urine infectin r nt, is essential during pregnancy since, if left untreated, such infectins can cause kidney damage and have been linked t preterm labur. MEMBRANE SWEEPS Using a glved finger passed thrugh the cervix (neck f the wmb) t separate the baby s membranes frm the lwer part f the uterus is knwn as a membrane sweep. In wmen wh are at r beynd the due date, it encurages spntaneus labur and can enable abut 10% f wmen t avid an artificial inductin f labur. There is currently n gd evidence that membrane sweeps are harmful in wmen knwn t carry GBS. Indeed the results f trials f membrane sweeps dn t shw any increase in prblems caused by GBS in wmen having sweeps, and it is highly likely these trials wuld have included many wmen carrying GBS at the time. Hwever, there remains a theretical risk that a membrane sweep might ccasinally intrduce GBS int the uterus, and s ur medical advisry panel advises cautin in using a membrane sweep fr wmen knwn t carry GBS when there are ther acceptable alternatives (fr example, inductin f labur with prstaglandin gel intrduced int the vagina). VAGINAL EXAMINATIONS Research has shwn that digital (by hand) vaginal examinatins shuld be kept t a minimum where a baby is at raised risk f GBS infectin. Clearly, if they have t be dne, they have t be dne althugh perineal vaginal ultrasunds can be alternatives at mst hspitals. INDUCTION If yu need t be induced, ur medical advisers recmmend that the intravenus antibitics shuld be given as sn as pssible nce labur has started r waters have brken (and that s whether the waters break naturally r are artificially brken) and that they are repeated at 4 hurly intervals (r 8 hurly fr clindamycin) until the baby is brn. IF IN DOUBT, CHECK IT OUT! Yur midwife, bstetrician and GP will understand if yu are mre nervus than ther pregnant wmen. S, if there is anything yu are unsure f during yur pregnancy, check it ut with them. Once labur starts r yur waters break (r leak) WHEN TO GO TO HOSPITAL If the circumstances arise in which yu want intravenus antibitics, fr best prtectin, yu shuld receive them fr at least 4 hurs befre delivery. Hwever, the earlier the antibitics are given the better nce labur starts r membranes rupture. G t hspital as sn as yu suspect yur waters have brken (r are leaking) r yu re in labur - it wuld be reasnable t get t the hspital within an hur f this happening, althugh quicker if yu can. Give yur ntes and a cpy f yur birth plan t the midwife n arrival. If pssible, phne the Labur Ward t let them knw yu re n yur way and that yu ll need intravenus antibitics as preventative medicine against GBS when yu get there. PRETERM LABOUR Althugh ther causes are mre cmmn, GBS can be a rare cause f preterm labur (labur befre 37 weeks gestatin). The symptms f preterm labur are generally subtler than thse f full-term labur. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 23

24 Grup B Strep Supprt In the unlikely event that yu need this infrmatin, the fllwing are the mst cmmn signs f preterm labur: tightenings (can feel like the baby mving) vaginal sptting lwer back pain change r increase in vaginal discharge lss f mucus plug pelvic pressure lse stls menstrual-like cramps the mst cmmn symptm, in additin t the abve, is that the pregnant wman simply feels smething is nt quite right. We suggest yu have a lw let s check this ut threshld with regard t any f these symptms: if in dubt, cntact yur midwife r labur ward and explain yur cncerns. If yu are in premature labur, the hspital may be able t give yu drugs that may halt yur labur but yu need t have the intravenus antibitics fr yur baby as sn as pssible. S get t the hspital as quickly as yu can, taking yur ntes with yu. If yur labur is very premature (befre abut 34 weeks gestatin), yur lcal hspital may need t send yu t anther hspital that has better facilities fr dealing with babies brn very early. ONCE YOU GET TO HOSPITAL If yu want them, the recmmended intravenus antibitics shuld be given t yu immediately upn yur arrival at hspital. Tell everyne wh lks after yu in hspital (r get yur partner t) that yu carry GBS and (if yu d) that yu want intravenus antibitics immediately t prtect yur unbrn baby - and keep telling them until yu get them. But d remember t tell yur health prfessinals if yu have ever had an allergic reactin t any antibitic, including penicillin. Nthing is ttally withut risk but, even if it were a false alarm, it wuld be reasnable fr yu t have them... and then again when it s fr real! If it s nt a false alarm, precius time is being wasted which culd be used t prtect yur baby. Once yu ve had 2 dses f intravenus antibitics at 4-hurly intervals befre yur baby s birth, s/he has had the best prtectin available frm GBS infectin. Remind yur medical staff yu need the antibitics every 4 hurs until yur baby arrives. It s unlikely yu ll need t be a nuisance but if necessary d: it s yur baby yu re prtecting. THE BIRTH YOU D PLANNED Having intravenus antibitics shuldn t prevent yu frm having the birth yu d riginally planned. What nrmally happens is that a cannula (a thin tube) is inserted int a vein, usually in the back f yur hand, and remains there until after the baby is brn. The antibitics can then be given t yu thrugh this cannula at the required intervals, either by slw injectin (ver several minutes) r by drip (ver half an hur r s). Yu dn t have t be attached t a drip the whle time when the antibitics have gne thrugh, the cannula can be detached frm the drip and yu re then free t mve arund as yu wish and t have (almst) the birth yu d planned. YOUR BABY HAS ARRIVED - CONGRATULATIONS! The chance f yur baby develping a GBS infectin is very small. Hwever, remind the medical staff abut yur GBS histry (especially the paediatrician(s) lking after yur baby and the midwife lking after yu) as yur new Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 24

25 Grup B Strep Supprt baby has a higher risk f develping GBS infectin than ther babies. Yur baby needs t be mnitred especially carefully by a paediatrician and needs a lw threshld fr being given intravenus antibitics. In Hspital IF YOU VE RECEIVED AT LEAST FOUR HOURS OF INTRAVENOUS ANTIBIOTICS BEFORE YOUR BABY S BIRTH. The risk f yur baby develping a GBS infectin is still small, but remind the medical staff, especially the paediatrician lking after yur baby and the midwife lking after yu, that yu have previusly had a baby wh develped GBS infectin and s yur baby has a higher risk f develping GBS infectin. Babies brn t mthers at increased/high risk wh HAVE received antibitics fr 4 hurs befre delivery shuld be carefully assessed by a paediatrician if cmpletely healthy, n antibitics fr the baby are required. A perid f mnitring (12-24 hurs) may be apprpriate fr thse at highest risk f infectin. And remind them f this when there is a change f staff. IF YOU DIDN T RECEIVE AT LEAST FOUR HOURS OF INTRAVENOUS ANTIBIOTICS BEFORE DELIVERY. The risk f yur baby develping a GBS infectin is still small, but remind the medical staff, especially the paediatrician lking after yur baby and the midwife lking after yu, that yu have previusly had a baby wh develped GBS infectin and s yur baby has a higher risk f develping GBS infectin. Babies brn t mthers at increased/high risk wh HAVE NOT received antibitics fr 4 hurs befre delivery shuld be: Examined thrughly and investigated by a paediatrician as apprpriate. Started n intravenus antibitics until it is knwn that the baby is nt infected, unless the baby is cmpletely well as determined fllwing a rbust baby examinatin carried ut by a trained individual. And remind them f this when there is a change f staff. ANTIBIOTICS FOR YOU Yu dn t need antibitics after the birth fr GBS clnisatin prvided yu are well. The intravenus antibitics during labur and delivery are fr yur baby, nt yu GBS clnisatin des nt need t be treated. It s nrmal! Breastfeeding Our medical advisry panel strngly recmmends that yu shuld be encuraged t breastfeed yur baby. Althugh there have been islated cases describing GBS infectin pssibly related t breast milk cntaminatin, the advantages f breast feeding will, in ur medical advisry panel's pinin, greatly utweigh the remte risk f transmitting GBS thrugh breast feeding. High hygiene standards need t be maintained fr all breastfeeding mthers, with the hands and nipple areas being kept clean. The intravenus antibitics recmmended during labur are safe fr breast-feeding mthers; althugh yu shuld make sure yur medical prfessinals knw yu intend t breast-feed yur baby anyway! If yu develp mastitis r a breast abscess, yu shuld seek medical advice regarding breast-feeding. If GBS is grwn frm a surface swab taken frm yur baby If GBS is grwn frm a surface swab (e.g. ear, nse and/r tummy buttn) taken frm yur baby AND he/she shws n sign f infectin, this indicates the baby is clnised with GBS, nt infected. (GBS infectin wuld be identified frm the bacteria grwn frm a bld, spinal fluid r urine culture). Yu and yur baby s health prfessinals (GP, midwife and health visitr) shuld all be infrmed f this. In the unlikely event that yur baby shws any symptm f late-nset GBS infectin during the next 3 mnths (see page 5), yu shuld cntact yur Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 25

26 Grup B Strep Supprt GP urgently. If he/she is unavailable, yu shuld take yur baby t Casualty fr an urgent medical review, explaining why yu are particularly cncerned abut GBS. Ging hme If yu have had at least 4 hurs f intravenus antibitics befre delivery and the baby is full-term and healthy, then there is n reasn why yu culd nt have an early discharge if yu want ne, althugh it s a gd idea t remind yurself f the signs and symptms f GBS infectin in babies s yu knw what t lk ut fr! Antibitics fr yur baby at hme Babies brn after an lder sibling develped GBS infectin are at raised risk f develping GBS infectin themselves it is estimated the risk increases perhaps ten-fld r mre. In this circumstance, intravenus antibitics are strngly recmmended in any subsequent labur as being highly effective preventative medicine against early-nset GBS infectin in the baby. There is n evidence that cntinuing t give penicillin t a well baby after delivery is effective at preventing GBS infectin after birth. Hwever, where a family has suffered the trauma f a baby being seriusly ill with GBS infectin, a few practitiners may cnsider prescribing a daily penicillin dse fr the baby, fr the first 3 mnths f life in the belief that it may prevent GBS infectin and s reduce understandable anxiety. There is n evidence t supprt this practice, althugh Penicillin given in this way has been shwn t reduce the risk f infectin with anther related bacterium, called pneumcccus, in individuals wh have lst their spleens. If yur baby needs medical treatment If yu need t cntact a dctr abut yur baby during the first 3 mnths, make sure the dctr is aware f yur histry f GBS. And in the unlikely event that yur baby has had a GBS infectin, make sure the dctr knws that t since a baby wh has had a GBS infectin is at slightly increased risk f reinfectin. General pints fr the baby s first 3 mnths: The fllwing suggestins apply t all newbrn babies, nt nly thse where there is a histry f GBS: HANDLING YOUR (OR ANYONE ELSE S) NEWBORN BABY GBS can be fund n the hands and in the respiratry tract f a clnised persn and may be passed t the baby frm repeated expsure after birth (e.g. frm family members, ther parents, hspital staff, etc.). Everyne, (including the parents), whether they knw they re clnised with GBS r nt, shuld wash their hands and carefully dry them fr the first 3 mnths f a baby s life (sap and water are perfectly adequate), and it is very imprtant t dry the hands as well as wash them thrughly. These are nrmal gd hygiene measures fr a yung baby, irrespective f GBS. VISITORS As lng as visitrs are well and withut upper respiratry infectins, cughs, clds, etc., there is n need t limit visitrs r their handling f the baby (althugh, again, it s a gd idea fr peple t wash and dry their hands thrughly befre ding s in the early days this is gd paediatric hygiene, irrespective f the issue f GBS). GOING OUT The baby may be taken ut, althugh ideally prbably nt fr the first 2-3 weeks, especially if the weather is bad. If pssible, the baby shuldn t be taken t very crwded areas where there might be clse cntact with respiratry viruses and ther illnesses, fr example, t shpping centres, supermarkets, etc. Rare pst-birth GBS infectins Over half f all GBS infectins in babies are apparent at birth, with up t 90% develping in the baby s first 2 days f life s they shuld be detected and treated in hspital. Study yur baby carefully yurself fr any sign that he r Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 26

27 Grup B Strep Supprt she is nt well. Unfrtunately, in the mst severe cases, infectin can take hld very quickly s draw the health prfessinals attentin t anything that cncerns yu. SYMPTOMS OF EARLY ONSET GBS INFECTION IN BABIES Just in case yu need this infrmatin, remind yurself f the typical symptms (see page 4). Yu may pt t stay in hspital fr a cuple f days, after which time GBS infectin in babies becmes increasingly uncmmn up t 9 ut f 10 GBS infectins in babies develp in the first 2 days f life. GBS infectin in babies is rare after age 1 mnth, and after age 3 mnths is virtually unknwn. SYMPTOMS OF LATE ONSET GBS INFECTION IN BABIES Yur baby is at a little less risk f develping GBS infectin as each day passes, but yu might like t remind yurself f the symptms f late-nset GBS infectin (develping after day 2) and f meningitis (see page 5). Trust yur instincts it is yur baby! If yur baby shws signs cnsistent with GBS infectin r meningitis, call yur GP immediately. If yur GP isn t available, g straight t the nearest PAEDIATRIC Accident & Emergency Department. Early diagnsis and treatment are essential t cmbat late-nset GBS infectin delay can be fatal... TREATMENT OF GBS INFECTION IN BABIES In the unlikely event yur baby develps a GBS infectin; he r she shuld be given intravenus antibitics as sn as pssible and fr at least 10 days (r 14 days if meningitis is present). Fr mre infrmatin abut treatment, see page 6. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 27

28 Grup B Strep Supprt FREQUENTLY ASKED QUESTIONS Hw can peple becme carriers f GBS? GBS may be passed frm ne persn t anther thrugh hand cntact, kissing, clse physical cntact, etc. As GBS is ften fund in the vagina and rectum f clnised wmen, it is cmmnly passed thrugh sexual cntact. There are n knwn harmful effects f carriage itself and, since the GBS bacteria d nt cause genital symptms r discmfrt, GBS is nt a sexually transmitted disease, nr is GBS carriage a sign f ill health r pr hygiene. N-ne shuld ever feel guilty r dirty fr carrying GBS it s nrmal. What are the chances f my baby develping a GBS infectin? The fllwing are estimates f the chances a baby in Britain will becme infected with GBS if n preventative measures are taken and n ther clinical risk factrs are present: 1 in 1,000* where the wman is nt knwn t be a carrier f GBS; 1 in 400 where the wman is carrying GBS during the pregnancy; 1 in 300 where the wman is carrying GBS at delivery; and 1 in 100 where the wman has had a previus baby infected with GBS. *This is a bradly accepted estimate f the number f GBS infectins in newbrn babies that wuld ccur if n preventative intravenus antibitics in labur were given. Sme recent UK research has suggested this may be a serius underestimate f the incidence f GBS infectin in newbrns, which culd be as high as 3.6 per 1,000. If a wman wh has previusly had a baby with GBS infectin is given antibitics during labur thrugh delivery in accrdance with ur medical advisry panel s recmmendatins (see Errr! Bkmark nt defined.), the baby s risk is reduced significantly t less than that f a wman nt knwn t carry GBS wh is nt given antibitics in labur: 1 in 8,000 where the mther carries GBS during pregnancy; 1 in 6,000 where the mther carries GBS at delivery; and 1 in 2,200 where the mther has previusly had a baby infected with GBS. The vast majrity f pregnancies can be managed s that babies are prtected and brn free f GBS infectin. I carry GBS in my vagina. D I need antibitics t get rid f it? N. Antibitics fr GBS carriage are nt required. GBS grwn frm a vaginal swab shws clnisatin with GBS, nt that yu have a GBS infectin. Clnisatin is nrmal and des nt need treatment. Oral antibitics are nt recmmended fr wmen fr GBS carriage during pregnancy r labur there s simply, n evidence that they prevent GBS infectins in babies. And, s far, n antibitics have been shwn t eradicate GBS reliably frm the intestines s, even if antibitics clear the GBS clnisatin f the vagina (and they may nt), reclnisatin frm the intestines will ccur. Studies have shwn n substantial difference in GBS carriage at delivery between wmen treated with antibitics during pregnancy, and thse nt treated. (In ne study, nearly 70% f clnised wmen given antibitics fr 12 t 14 days during the last 12 weeks f pregnancy were clnised 3 weeks later and again at delivery.) The time when antibitics have been shwn t be highly effective at stpping GBS infectins in newbrn babies is when they are given intravenusly t the pregnant wman nce her membranes have ruptured r labur has started. Shuld I take antibitics befre I get pregnant t get rid f the GBS? N antibitics tested s far seem able t d this reliably. Antibitics may temprarily eradicate vaginal clnisatin with GBS, but clnisatin in the intestines will remain and reclnisatin f the vagina will ccur. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 28

29 Grup B Strep Supprt I carry GBS in my vagina. Des my partner need t be tested? N. Clnisatin with GBS is nrmal and des nt need treatment. A third f the adult ppulatin carries GBS, withut symptms yu dn t need t be tested fr it, nr d yu (r he) need antibitics fr it. GBS is nt a sexually transmitted disease. Will antibitics get rid f GBS clnisatin frm my vagina during pregnancy? Antibitics wn t necessarily get rid f clnisatin in the vagina and, even when they d, they will d s nly temprarily - reclnisatin will ccur. Evidence shws taking antibitics befre labur des nt reliably eradicate GBS carriage - and there s n evidence that it reduces the incidence f GBS infectin in newbrn babies either. Studies have shwn n substantial difference in GBS carriage at delivery between wmen treated with antibitics during pregnancy and thse nt treated. In ne study, nearly 70% f clnised wmen treated with antibitics fr 12 t 14 days during the third trimester (28 t 40 weeks f pregnancy) were clnised three weeks later and again at delivery. Antibitics during pregnancy fr GBS carriage are nt indicated. GBS cultured frm a vaginal swab shw the vagina is clnised with GBS, nt infected. N antibitics tested s far have been shwn t eradicate GBS reliably frm the bdy s, even if antibitics clear the GBS clnisatin f the vagina (and they may nt), reclnisatin frm the intestines will ccur. Evidence shws taking antibitics neither gets rid f GBS carriage nr reduces the incidence f GBS infectin in newbrn babies. Antibitics have been prven t be highly effective at stpping GBS infectins in newbrn babies when given intravenusly t the pregnant wman as sn as her membranes have ruptured r labur has started. Des having the IV antibitics during labur mean that the GBS will be eradicated? GBS is a very cmmn naturally ccurring bacterium, which lives in the intestines f abut a third f the ppulatin (men and wmen) and, nce present, cannt reliably be eradicated. Once labur starts, intravenus (thrugh a vein) antibitics given t the mther until her baby is brn are the best knwn way t prevent mst GBS infectins in newbrn babies. They wrk in tw ways. Firstly, the antibitics start t crss t the baby within minutes f their being given t the mther this means that, ideally, the baby will be brn with fighting dses f antibitics in his r her system which will help t stp any infectin frm starting. Secndly, they may temprarily reduce the level f GBS carriage in the mther s vagina, which may mean the baby is expsed t fewer GBS bacteria during delivery. Hwever, antibitics wn t eradicate the mther s GBS carriage; althugh they may suppress it fr this crucial perid. D I need antibitics if GBS is fund in my urine? Yes, thugh remember t tell yur health prfessinals if yu have ever had an allergic reactin t penicillin r any ther antibitic. Urine is suppsed t be sterile s, if GBS is fund in yur urine, yu shuld be treated with ral antibitics when diagnsed and this treatment repeated until urine tests cme back clear. A 5-day curse wuld be apprpriate and it s imprtant the urine is retested 7-10 days after finishing the antibitics. Treatment fr a GBS psitive urine sample, whether yu have symptms f a urine infectin r nt, is essential during pregnancy since, if left untreated, such infectins can cause kidney damage and have been linked t preterm labur. Shuld I be tested regularly fr GBS? N. If yu have previusly had a baby infected with GBS r if yu have had a psitive test result fr GBS at any time during yur pregnancy, yu shuld be ffered intravenus antibitics frm the start f yur labur, until delivery. The cnventinal test available n the NHS is unreliable it misses up t 50% f GBS carriers. There is a reliable test but this is nly available privately (see the next questin). Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 29

30 Grup B Strep Supprt If yu get a psitive result frm the cnventinal test, all it tells yu is that yu are carrying GBS. If yu get a negative result, all it tells yu is that yu may nt be still carrying GBS (but the negative test results aren t very reliable). Neither f these results shuld make any difference t yur being ffered intravenus antibitics in labur. Are the tests fr GBS clnisatin reliable? The cnventinal tests available are nt very reliable when they give a negative result they give a falsely negative result up t 50% f the time when they shuld be psitive! On the ther hand, if yu get a psitive cnventinal test result, that is very reliable. There is mre infrmatin abut the different tests available in the UK n page 15. Any psitive result (cnventinal, ECM r PCR) means yu shuld be ffered intravenus antibitics as sn as pssible after the start f yur labur r membrane rupture t prtect yur baby frm GBS infectin. [GBSS fully endrses the availability f reliable antenatal GBS testing but has n links t nr receives any mney frm any particular labratry. Indeed we hpe many ther labratries will fllw The Dctrs Labratry s example in ffering this test and, as they d, we'll prvide details f their service t.] I am n a curse f antibitics fr a chest infectin. Will that affect the results fr the GBS test? The antibitics may make it mre difficult t grw the GBS s, in an ideal wrld, yu shuld nt take the swabs fr the GBS test until at least seven days after yu ve finished the curse f antibitics; the lnger the delay, the mre reliable the result. It shuld be remembered that even a negative result frm a swab test dne at weeks f pregnancy can t be 100% predictive that yu wn t be carrying GBS at delivery (althugh it is highly likely yu wn t), since a very small prprtin f wmen will acquire carriage in the intervening weeks. A psitive result hwever des mean that yu shuld be ffered the recmmended intravenus antibitics in labur. I carried GBS in my last pregnancy - my baby was fine. D I need IV antibitics this time? GBS can quite naturally cme and g frm the vagina s the bacteria can be there ne mnth and nt the next... and back again at sme ther time (thugh research has shwn that, using sensitive tests, the results are highly predictive f clnisatin status fr arund five weeks). There is currently n gd data that can predict carriage f GBS ver perids f a year r mre. Hwever, since there may be sme increased chance f a wman carrying GBS in a pregnancy if GBS has been islated previusly, it is the view f ur medical panel that, if pssible the pregnant wman shuld be ffered a reliable (ECM) test at weeks f pregnancy t establish whether she is still carrying GBS. If the test is psitive, then she shuld be ffered intravenus antibitics as sn as pssible nce labur has started. If a reliable ECM test result is nt available and labur starts after 37 weeks f pregnancy, then the view f ur medical panel is that previus carriage status shuld be treated as an additinal risk factr (increasing the risk f a baby develping GBS infectin where preventative antibitics in labur are nt given frm an estimated ne in 1,000 in the general ppulatin, t apprximately ne in 500 fr a wman whse current GBS status is unknwn, but where GBS was islated befre the current pregnancy). Our medical panel's view is that the 'previus carrier' risk factr alne is insufficient t recmmend ffering intravenus antibitics in labur against GBS infectin in the baby, unless anther clinical risk factr was als present. I had a GBS infectin after the birth f my last baby. Will any babies I have in the future be mre at risk f GBS infectin? There s n research n which t answer this. Our medical panel s view is that a pstnatal GBS infectin is unlikely t increase the risk f any future babies develping GBS infectin abve that f simply being a carrier. In this Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 30

31 Grup B Strep Supprt situatin they wuld recmmend yu have a sensitive test fr GBS carriage late in yur next pregnancy t find ut yur status at that time. What happens if I get a Negative Enriched Culture Methd (ECM) test result? A wman wh has a negative ECM (enriched culture medium) test result at 35 plus weeks f pregnancy des NOT need t be ffered intravenus antibitics in labur t prevent GBS infectin in her baby (but antibitics may be indicated fr ther reasns). Research shws that, if perfrmed within five weeks f delivery, an ECM test giving a negative result is 96% predictive f GBS nt being carried at delivery (4% f wmen acquired carriage between testing and delivery) s the risk f acquiring carriage between ding the test and giving birth is very small. If a wman has nt had an ECM test result OR the less reliable cnventinal test has been negative during the pregnancy, she shuld be ffered intravenus antibitics frm the nset f labur if ne r mre risk factrs listed abve (see page 6) is present. A wman wh has previusly had a baby wh develped GBS infectin shuld ALWAYS be ffered intravenus antibitics in subsequent pregnancies, frm the nset f labur r membrane rupture until delivery, regardless f any test results. And a wman wh has had any psitive test result (frm the urine, vagina r rectum) during the current pregnancy shuld als be ffered intravenus antibitics frm the nset f her labur r membrane rupture until delivery. I had a psitive result early in my pregnancy. Shuld I be tested again? If yu have had a psitive GBS test result (frm the vagina r rectum) during the current pregnancy, and n further tests, yu shuld be ffered intravenus antibitics frm the nset f labur r membrane rupture until delivery (antibitics are recmmended if the psitive result was frm the urine). Hwever, if the psitive result was early in yur pregnancy, yu may have lst carriage by the time yur baby is brn. If yu want t find ut whether yu are still carrying GBS, yu can have a sensitive test at weeks. If the sensitive test result is negative, then intravenus antibitics are prbably nt indicated, since research shws that a sensitive test giving a negative result within 5 weeks f delivery is highly predictive f the mum nt carrying GBS at delivery. The risk f acquiring carriage between ding the test and giving birth is very small. Must I have intravenus antibitics if I ve had a psitive result during this pregnancy? If yu have had any psitive GBS test result frm the vagina r rectum during the current pregnancy, yu shuld be ffered intravenus antibitics frm the nset f labur r membrane rupture until delivery. Hwever, yu may chse nt t have them if there are n additinal risk factrs - nly a small percentage f babies brn t clnised mthers will develp GBS infectin. Hwever, if yu decide against antibitics, it wuld be prudent fr the baby t be bserved by trained staff fr at least 24 hurs (and ideally fr 48 hurs). If the psitive test was frm the urine, this means that the GBS was mre invasive, and s antibitics will be recmmended even if a vaginal swab is subsequently negative. I m at risk f premature labur, shuld I take lng-term antibitics? Alng with many ther bacteria fund in the vagina, GBS can cause infectin f the baby in the wmb, which can result in preterm birth, stillbirth and late miscarriage. Hwever, these are usually caused by a variety f factrs ther than GBS: genetic defects, gynaeclgical prblems, ther infectins, etc. If a wman has had any f these prblems in the past, she shuld make sure these pssibilities are investigated fully by a cnsultant bstetrician at bking (r befre) regardless f whether r nt she is clnised with GBS. Such cmplicatins are uncmmn and GBS is a rare cause f them. And this paper tells yu what yu can d t make sure yur baby is best prtected frm GBS. Fr the antibitics tested s far, their use thrughut pregnancy des nt prevent preterm delivery due t any cause, including GBS. Als, the effects f lng-term antibitics n the baby during pregnancy have nt been Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 31

32 Grup B Strep Supprt assessed, althugh we knw that shrt curses f, fr example, amxycillin, seem t be exceptinally safe (see ur medical advisry panel s view n pages 19 and 20)). I m wrried I wn t get 4+ hurs f IV antibitics befre my baby is brn. A very small study 1 shwed giving intramuscular penicillin eradicated GBS clnisatin fr at least six weeks in 75% f wmen knwn t carry GBS. S far, this very small study (50 f 78 wmen received intramuscular antibitics) has nt been repeated, s it is difficult t give advice based upn this data. Fr wmen knwn t carry GBS where it is nt expected that the intravenus antibitics can be given fr at least fur hurs befre delivery, an intramuscular injectin f 4.8 MU (2.9 g) f Penicillin G at abut 35 weeks f pregnancy may be useful in additin t intravenus antibitics given frm the nset f labur r membranes rupturing until delivery t try t eradicate GBS clnisatin until after delivery. Regardless f whether yu have intramuscular antibitics t try t eradicate GBS clnisatin, it is recmmended that all wmen in higher risk categries be ffered intravenus antibitics frm the nset f labur r waters breaking, plus at fur hurly intervals until delivery. There are dwnsides f intramuscular penicillin - the injectin is painful, there is a small risk f an allergic reactin and f antibitic resistance develping (see belw). These risks are repeated with the intravenus antibitics given in labur. Fr intramuscular antibitics, there are n knwn alternatives t penicillin fr penicillin-allergic wmen. 1 (Bland ML, Vermillin ST, Sper DE. Late third-trimester treatment f rectvaginal grup B streptccci with benzathine penicillin G. Am J Obstet Gynecl 2000 Aug;183(2):372-6) Shuld I be induced, with the intravenus antibitics starting as I m induced? Carrying, r being at risk f, GBS is nt a reasn t be induced and ur medical advisers dn t recmmend inductin fr anyne as a way f cmbating GBS infectin in babies. If yu live a lng way frm the hspital r have a histry f very fast laburs, then an inductin is ne way t try and ensure yu get sufficient intravenus antibitics in labur. Hwever, inductin is nt withut risk itself, especially befre the due date. Yu shuld discuss the ptential risks and benefits f an inductin with yur bstetrician, because they will vary dependent upn yur persnal circumstances. If yu need t be induced fr an bstetric r medical reasn, the recmmended intravenus antibitics shuld be started as sn as pssible nce labur has started r waters have brken, whichever happens first (and that s whether the waters break naturally r are artificially brken) and shuld be repeated 4-hurly until delivery, and ideally fr at least 4 hurs befre delivery. What are the ptential risks f taking antibitics? Taking antibitics shuld nt be dne lightly they can have side effects that need t be cnsidered in relatin t the ptential benefits and it is imprtant that yu tell yur health prfessinals if yu have ever had an allergic reactin t penicillin r any ther antibitic. Althugh gd data is hard t find n this subject, the generally quted estimated risks fr penicillin are: 1 in 10 f the mther develping a mild allergic reactin, such as a rash; 1 in 10,000 f the mther develping a severe allergic reactin (anaphylaxis); and 1 in 100,000* f the mther develping fatal anaphylaxis, resulting in her death. And severe cmplicatins can ccur in the unbrn baby even when the anaphylaxis develped by the mther is nt life threatening, althugh this risk is prbably verstated. Althugh ften quted, these figures are generally accepted as being a significant ver-estimate f the risk - a recent paper stated that, in the US between 1997 (the year after the CDC recmmended intravenus antibitics in labur fr wmen whse babies were at higher risk f develping GBS infectin) and 2001, an estimated 1.8 millin wmen were given penicillin in labur and n deaths ccurred, s an estimate f a 1 in 100,000 risk f Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 32

33 Grup B Strep Supprt death frm penicillin anaphylaxis is likely t be an ver-estimate. The preventin f nenatal grup B streptcccal disease. MR Law, G Palmaki, Z Alfirevic, R Gilbert, P Heath, C McCartney, T Reid, S Schrag n behalf f the Medical Screening Sciety Wrking Grup n GBS Disease. J Med Screen 2005;12: Whenever antibitics are taken, there are always risks f antibitic resistance develping. When antibitics are given t pregnant wmen, this culd affect the mther and her baby. When antibitics are given arund birth and in the early weeks f life, there is the chance they may increase the likelihd f the baby develping allergies. Althugh a lt f press space is given t this, unfrtunately data are lacking n whether it s the giving f antibitics that causes the allergies, r whether there are ther reasns (fr example, genetics, envirnment, disease, etc.). This is yet anther area where mre research is needed! Bearing all this in mind, yu need t weigh up whether yu cnsider the risks are acceptable in cmparisn with the ptential benefits and, if s, in what circumstances yu wuld want t be ffered antibitics. What are the signs that GBS is affecting my unbrn baby? If yur pregnancy is prgressing nrmally, then there is n reasn t suspect GBS is infecting yur baby. If a GBS infectin is present, yu ll usually g int labur r yur membranes will rupture. And that s the time t get t hspital as quickly as yu can t receive the intravenus antibitics t give yur baby the best prtectin pssible. Will a Caesarean prevent GBS infecting my baby? Caesarean sectins d nt eliminate the risk f GBS t a baby f develping GBS infectin since the bacteria can crss intact amnitic membranes t set up an infectin in the baby, althugh they d reduce the risk. Hwever, Caesareans are nt recmmended as a methd f preventing GBS infectin in babies: there are significant risks assciated with a Caesarean sectin; and the recmmended intravenus antibitics during labur are bth lw risk and highly effective. See page 21 fr ur medical panel s recmmendatins regarding Caesareans. Are membrane sweeps safe fr wmen wh carry GBS? Using a glved finger passed thrugh the cervix (neck f the wmb) t separate the baby s membranes frm the lwer part f the uterus is knwn as a membrane sweep. In wmen wh are at r beynd the due date, it encurages spntaneus labur and can enable abut 10% f wmen t avid an artificial inductin f labur. There is currently n gd evidence that membrane sweeps are harmful in wmen knwn t carry GBS. Indeed the results f trials f membrane sweeps dn t shw any increase in prblems caused by GBS in wmen having sweeps, and it is highly likely these trials wuld have included many wmen carrying GBS at the time. Hwever, there remains a theretical risk that a membrane sweep might ccasinally intrduce GBS int the uterus, and s ur medical advisry panel advises cautin in using a membrane sweep fr wmen knwn t carry GBS when there are ther acceptable alternatives (fr example, inductin f labur with prstaglandin gel intrduced int the vagina). I want a water birth There are n knwn cntra-indicatins fr a wman knwn t carry GBS having a water birth. As fr all wmen carrying GBS during the current pregnancy, ur medical advisry panel recmmends they shuld be ffered intravenus antibitics frm the nset f labur until delivery. It is nt a gd idea t get the cannula (which delivers the intravenus antibitics t the mther) wet, but this can be managed - specially designed waterprf dressings are available which keep the site sterile and dry whilst still enabling the health prfessinal t mnitr the site visually. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 33

34 Grup B Strep Supprt I was GBS psitive and had a water birth at hme; can smene else catch GBS frm the pl? N. Research suggests that standard hygiene measures need t be taken in the cleaning f the pl befre r after use by GBS carriers (and anyne else!). S please d pass the pl nt yur friend but as yu wuld anyway please clean it prperly befre yu d. I want a hme birth Our medical advisry panel's recmmendatins fr stpping GBS infectins in newbrn babies are the same fr hme births as fr hspital births - wmen whse babies are at higher risk f develping GBS infectin shuld be ffered intravenus antibitics frm the start f labur until delivery. Hme births are becming increasingly ppular and, if yu want a hme birth with intravenus antibitics during labur until delivery, it may be pssible fr yur midwife t give yu intravenus antibitics prescribed fr yu by yur GP. This is nt widely available. Sme areas wn't permit intravenus antibitics t be given at hme - there is a small risk that yu wuld get a severe allergic reactin t the antibitics (see What are the ptential risks f taking antibitics? n page 32) and, bviusly, there is n intensive care unit nearby. The risk is small but yur health prfessinals may be anxius. Of curse, arund 25% f wmen having hme births prbably carry GBS in their vagina at delivery withut knwing it. This issue needs t be discussed with yur medical team. Oral antibitics are nt recmmended fr wmen fr GBS carriage during pregnancy r labur quite simply, there s n evidence that they prevent GBS infectins in babies. If yu have set yur heart n a hme birth, yu may wish t cnsider having intramuscular antibitics as utlined in I m wrried I wn t get 4+ hurs f IV antibitics befre my baby is brn. n page 32, thugh ur medical advisry panel d nt recmmend them in lieu f intravenus antibitics during labur, but they may be better than nthing if that really is the nly alternative. I want t breastfeed my baby Our medical advisry panel strngly recmmends yu shuld be encuraged t breastfeed yur baby. Althugh there have been islated cases describing GBS infectin pssibly related t breast milk cntaminatin, the advantages f breast feeding will, in ur medical advisry panel's pinin, greatly utweigh the remte risk f transmitting GBS via breast feeding. High hygiene standards need t be maintained fr all breastfeeding mthers, with the hands and nipple areas being kept clean. The intravenus antibitics recmmended abve (see page 7) fr pregnant wmen during labur thrugh t delivery t prtect her unbrn baby frm GBS infectin are safe fr breastfeeding mthers, althugh yu shuld make sure yur medical prfessinals knw yu intend t breastfeed yur baby. If yu develp mastitis r a breast abscess, yu shuld seek medical advice regarding breast-feeding. Is it safe t breastfeed my baby just after birth as my milk will cntain antibitics? Any antibitics that are safe t give t mthers during pregnancy are als safe in themselves in relatin t breastfeeding. The intravenus antibitics recmmended abve fr pregnant wmen during labur thrugh t delivery t prtect their unbrn babies frm GBS infectin will already have passed in significant amunts t the baby while it was in the wmb, and they prvide imprtant prtectin fr the baby during labur and in the first few hurs after birth. In cmparisn, the amunts passed in breast milk are small. Hwever, the cntinuing expsure t antibitics in the milk can change the way the baby acquires its gut flra (the bugs the baby gets frm its mther that help t digest fd) and this can affect the way that the baby s p changes in the first days f life. S yu shuld make sure yur medical prfessinals knw yu intend t breastfeed yur baby. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 34

35 Grup B Strep Supprt Can my baby have the nrmal immunisatins? If a baby has recvered frm a GBS infectin, then the GBS infectin is nt a factr in the decisin t immunise the child. This is als true fr subsequent children. Is strep thrat caused by the same bug as GBS? N. Strep thrat is caused by grup A Streptcccus (GAS r Streptcccus pygenes) which, althugh it has a similar name and is frm the same family f bacteria, is a bug with very different characteristics. Grup A Strep is carried by many perfectly healthy peple and mst cmmnly causes mild sre thrats r skin infectins (impetig), althugh fr every thusand such mild infectins there are ne r tw that are mre serius and can affect pregnant r recently delivered wmen fr example, txic shck syndrme r necrtising fasciitis. Frtunately, these severe cnditins are very rare. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 35

36 Grup B Strep Supprt MEDICAL Key medical references PHLS Cmmunicable Disease Surveillance Unit. Incidence f grup B streptcccal disease in infants aged less than 90 days. CDR weekly Vl. 12(N 16):3. 18 April Heath PT, Balfur G, Weisner AM, Efstratiu A, Lamagni TL, Tighe H, O'Cnnell LAF, Cafferkey M, Verlander NQ, Nicll A & McCartney AC n behalf f the PHLS GBS Wrking Grup. Grup B streptcccal disease in UK and Irish Infants <90 days f age. Lancet 2004 Jan 24, Vl 363(9405):292. Law MR, Palmaki G, Alfirevic Z, Gilbert G, Heath P, McCartney C, Reid T, Schrag S n behalf f the Medical Screening Sciety Wrking Grup n GBS disease. The preventin f nenatal grup B streptcccal disease. J Med Screen 2005;12: RCOG Clinical Green Tp Guideline. Preventin f Early Onset Nenatal Grup B Streptcccal Disease (36) Nv 2003 Centers fr Disease Cntrl & Preventin. Preventin f Perinatal Grup B Streptcccal Disease: Revised Guidelines frm CDC. MMWR Reprts & Recmmendatins Vl. 51(N. RR 11) 16 August Yancey MK, Schuchat A, Brwn LK, Ventura VL, Markensn GR. The accuracy f late antenatal screening cultures in predicting genital GBS clnizatin at delivery. Obstet Gynecl Nv 1996; 88(5): Clburn T E. Assesburg C, Bijke L, Philipa Z, Weltn N J, Claxtn K, Ades A E, Gilbert R E. Preventive strategies fr grup B streptcccal and ther bacterial infectins in early infancy: cst effectiveness and value f infrmatin analyses. BMJ 2007;335;655 riginally published nline 11 Sep GBSS medical advisry panel The infrmatin in this leaflet is based upn ur medical advisry panel s knwledge and n recent research (published and unpublished). Yur medical prfessinals may nt have as cmprehensive knwledge r experience in this specialised area, s please make sure they have (and read) this leaflet r ur little GBS & Pregnancy leaflet. Sharing ur infrmatin with peple wh can make a difference in preventing GBS infectin is vital. This leaflet has been checked fr medical accuracy by ur medical advisry panel, cmprising: Prf Philip Steer (Chairman), Emeritus prfessr at Imperial Cllege and cnsultant bstetrician at the Chelsea and Westminster Hspital in Lndn Dr Christine McCartney OBE, FRCPath, Directr f the Health Prtectin Agency s Reginal Micrbilgy Netwrk Dr Alisn Bedfrd-Russell MRCP, Cnsultant Nenatlgist at Birmingham Heartlands Hspital Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 36

37 Grup B Strep Supprt LEAFLET ORDER FORM T rder leaflets, please cmplete this frm and send it t GBSS, PO Bx 203, Haywards Heath, West Sussex RH16 1GF, r it t [email protected] r rder n All f ur current leaflets can be dwnladed free f charge frm ur website at Yu are welcme t phtcpy ur leaflets, but please phtcpy them in their entirety. We dn t charge fr ur leaflets, but GBSS is a small charity with limited funds and relies n dnatins t help defray csts. The cst f printing each leaflet excluding pstage & packing (including p&p in brackets) is shwn belw fr ne f each item: N Req. LEAFLETS: Print Cst (Inc p&p). GBS & pregnancy (intrductin t GBS fr pregnant wmen) 0.08 ( 0.50) Bulk rder f 50 leaflets Bulk rder f 100 leaflets ( 6.50) ( 11.00).. Cngratulatins n the safe arrival f yur baby 0.25 ( 0.80) (intr fr parents where Mum r baby is clnised with GBS and the baby is well). Understanding yur baby s GBS infectin (intr fr parents f a GBS baby) 0.25 ( 0. 80). GBS: The Facts (a detailed dcument, including medical reference list) 1.25 ( 2.25). If yur baby was infected by GBS detailed leaflet fr parents f GBS babies) 1.25 ( 2.25). Fr wmen wh carry GBS 1.00 ( 1.70) (detailed leaflet fr wmen fund t carry GBS during their current pregnancy) POSTERS:. Pster Pregnant? Find ut abut GBS and reduce the risk t yur baby 0.15 ( 1.30). Pster Labur & Delivery Preventin Guidelines fr Nenatal Early Onset GBS Disease 0.15 ( 1.30). Pster Understanding yur baby s GBS infectin. Fr Special Care Baby Units 0.15 ( 1.30). Pster Grup B Strep Supprt helping t save babies lives A2 general pster 0.25 ( 2.60) OTHER MATERIALS:. Medical infrmatin pack (Flder cntaining small supply f intrductry leaflets, 7.50 ( 10.00) plus GBS The Facts, ne f each pster, a sheet f stickers & back issue f GBSS newsletter). GBS Alert Stickers 35 clur stickers fr pregnant wmen s ntes 0.35 ( 0.90). GBS Aware Stickers 35 clur stickers fr pregnant wmen s ntes 0.35 ( 0. 90). PwerPint presentatin fr PC n CD fr health prfessinals 5.00 ( 7.40). GBSS Ballns Please prvide yur details verleaf. Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 37

38 Grup B Strep Supprt Please tick all that apply: I enclse a dnatin f... fr these leaflets Please send me a receipt I am a UK taxpayer. Please recver tax n my dnatin thrugh Gift Aid. Please invice me fr these leaflets (including P&P csts) Please send me infrmatin abut jining GBSS I am unable t cntribute twards the cst f the leaflets Please add me t yur mailing list Name: Jb Title: Hspital/Clinic/Medical Centre: Address: Pst Cde: Tel N: Date: address: Please share ur infrmatin with thers interested in GBS. If yu wuld like t prvide us with any further infrmatin, r wuld like t make any cmments, please d s here: Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 38

39 Grup B Strep Supprt MEMBERSHIP APPLICATION FORM Please cmplete and return t Grup B Strep Supprt, P O Bx 203, HAYWARDS HEATH, West Sussex RH16 1GF. If yu have any queries, phne us n , r us at [email protected]. Name(s) Parent / Grandparent / Obstetrician / Paediatrician / Midwife / GP / Health Visitr / Other (please state) Address (including pstcde please) Tel/Fax n: address: Please tick as apprpriate: I/We enclse ur cheque fr my/ur first year s membership f the charity (see belw) I/We wuld like t dnate by Banker s Order (please cmplete frm n the reverse & return it t GBSS) I/We are the parents f a GBS baby Baby s name Baby s date f birth / / My baby develped GBS infectin Yes/N I/We wuld like t speak t ther parents abut GBS Please send me/us vlunteer guidelines n fund-raising raising awareness becming a cntact persn I/We wuld like t help Grup B Strep Supprt by: We charge a minimum annual membership fee. Fr this, yu receive ur 6-mnthly newsletter and any updates. If yu can affrd a larger dnatin t help us achieve ur aims f infrming and supprting mre families; raising awareness and imprving practice within the medical prfessin; and funding medical research, that wuld be greatly appreciated and it wuld be put t gd use! I/We enclse a cheque r pstal rder payable t Grup B Strep Supprt fr a year s membership: 9.00 student/unwaged (evidence may be required) If yu are a UK taxpayer, charities can claim back 28% f tax n dnatins made since April 2000, increasing ur funds at the gvernment s expense! If yu can help in this way, please tick the bx and we will claim back sme f yur tax individual/family verseas.... vluntary dnatin Signature Date Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 39

40 Grup B Strep Supprt GBSS - STANDING ORDER MANDATE T: Yur Bank Name: The Manager Yur Bank s Address: Pst cde: Please pay: Cafcash Ltd CAF Gld Srt cde: Fr the credit f: Accunt N: The sum f (in wrds and numbers please): Cmmencing (date): Grup B Strep Supprt Every (frequency): Year / Mnth Until (final payment date): further ntice/.. (delete as applicable) Name f accunt t be debited: (full name f yur accunt) Name and Address f Accunt Hlder: (yur full name and address) Accunt N: (Yur Bank Accunt N)... Bank Srt Cde: (Yur Bank s Srt Cde) Signature Date Please cmplete and return this frm t Grup B Strep Supprt at P O Bx 203, Haywards Heath, RH16 1GF r by t us at [email protected] Registered Charity N Cmpany Registratin N _06_If_yur_baby_was_infected_with_GBS 40