A 30 years old primigravida is admitted with PPROM at 28 weeks gestation. A HVS taken on day of admission is reported two days later showing profuse growth of group B- streptococci. The women and her fetus remain well. Justify your management.
Infant born through highly colonised vagina, approximately 1-2% develops early onset GBS disease (onset of infection <7days) due to intrapartum transmission and perinatal mortality is upto 18% in preterm neonate. Maternal risks are PTL and chorioamnionitis. Prolonged PPROM and maternal fever >38degree C (intrapartum) increases risk of transmission.
Decision to expedite delivery is undertaken through the safest possible route to prevent early onset disease, which is weighted against risk of prematurity.
Review of antenatal records to confirm gestational age. History of fever, uterine activity and tenderness should be taken. Examination includes pulse and temperature. Abdomen: uterine size, FHR, contraction, tenderness, fetal presentation and liquor volume. Vaginal speculum examination: leakage, colour of liquor and condition of cervix. Digital examination should be avoided to prevent introduction of infection.
CTG is performed. Fetal tachycardia is an early sign of chorioamnionitis. Blood samples collected for grouping, FBC and CRP.
USS is performed for fetal presentation (malpresentation is common at 28 week). If breech presentation; type of breech, placental position, any congenital anomaly, liquor volume and expected fetal weight. Footling breech and hyperextended head precludes vaginal delivery.
Antenatal treatment for GBS colonisation is ineffective to prevent early onset disease and antibiotic treatment may mask onset of infection and delay in delivery will lead to adverse fetal consequences.
If appropriate facilities for preterm baby resuscitation are lacking, transfer to a unit with SCBU is undertaken in the absence of PTL and signs of maternal infection (tachycardia, increased temperature or uterine tenderness).
Immediate delivery should be expedited in the presence of maternal infection or fetal distress.
Corticosteroid is administered to prevent RDS, cerebral haemorrhage and necrotizing enterocolitis in the preterm baby before delivery in absence of infection. Two doses of betamethasone 12mg each at 24hrs interval are preferred. No evidence that corticosteroid administration would increase risk of infection.
Tocolysis with nifedipine/autosiban may be considered if there is uterine contraction to complete the course of corticosteroids.
Maternal monitoring: 6hrly pulse, temperature and CRP. Fetal monitoring with CTG until the course of corticosteroids to be completed.
Counselling by the neonatal team regarding the prognosis and management of preterm neonate.
Patient should be counselled about the need of urgent delivery and also the mode of delivery taking consideration of the woman?s view. She should be enquired about penicillin allergy.
Whatever be the mode of delivery, a senior obstetricians presence is desirable during delivery. Neonatal team and SCBU should be informed before delivery for baby resuscitation.
Induction of labour is unlikely to be successful and prolonged labour increases risk of infection despite intrapartum antibiotic prophylaxis. However, in the presence of favourable cervix with active uterine contractions, vaginal delivery can be considered with intrapartum antibiotic prophylaxis (prevents upto 86% early onset GBS infection). I.V penicillin 3gm should be given soon after the onset of labour and then 1.5 gm 4 hrly until delivery. Clindamycim 900mg i.v 8 hrly when the woman is allergic to penicillin.
Elective C.S is recommended at 28 weeks in the presence of malpresentation or unfavourable cervix. Prophylactic antibiotics with penicillin 3 gm i.v should be given at least 4 hours before C.S to prevent infection effectively. Difficulties may be encountered during C.S due to poor formation of lower uterine segment with increased risk of haemorrhage.
If the woman is asymptomatic, no need to continue antibiotic after delivery.
Postpartum monitoring of the patient (pulse, temperature, uterus and lochia) is necessary to detect postpartum endometritis. Treatment is with broad-spectrum antibiotics if this develops.
Neonate should be closely monitored after delivery to detect early signs of infection.
Women should be informed about the possibility of recurrence of infection in future pregnancy.
