GBS+ Now what?

[thebigfam]

So last weekend I spent a few hours in L&D.  I am 33 weeks they did a GBS test and well I am pos.  I need info!  Spam me!  I really don't want antibiotics and I was so early I am pushing for a re test.  I don't even really know what all this means.  I am just spent and want to sleep and cry!

Big Momma

[MegBoz]

I freaked out too.

Mothering has a great article - search on the home page.

The risk of side effects from ABTs is 10%!! Whereas the risk baby will get infected is something crazy like .5% - and the death rate for those who do get infected is low.

Check out babycentre.co.uk to see how it's managed in the UK. I'd only accept ABTs if I developed 2 or more risk factors (a + swab being only ONE risk factor), that's how they do it there.

Definitely NO AROM, and very, very minimal vaginal exams (ZERO if possible - they really aren't necessary.)

Also consider Hibiclens.

[nia82]

Hibiclens, garlic, retest. It is transient, you might test negative now. If you still test positive, you can do hibiclens, drink kefir, do the garlic thing, probiotics...

[Danielle283]

My daughter was infected with GBS even though I tested neg. We almost lost her and she spent 6 weeks in the NICU. With this next baby I'll be getting ABX no matter what.

[mylilmonkeys]

Ugh, GBS.  I've had an interesting history with this one the last couple pregnancies.  When I was 39 weeks with my last baby, I developed a uterine infection.  Since I was planning a homebirth, we had to be referred to an OB...long story short, everything turned out fine but I was GBS positive, though we can't be sure that is what caused the infection because that culture came back inconclusive gram-positive bacteria.  By the time I got the + swab, it was too late for a round of ABX before birth, and my labor is too short for an effective IV during labor, even though my midwife has that capability.  We monitored my dd's temps every couple hours for the first 24 or 48 hrs (can't remember exactly), and kept a close eye on her for any symptoms of infection.  

So, fast forward to the current pregnancy, and I have already gotten an GBS+ UTI.  I agreed to antibiotics, because this indicates a high rate of colonization and GBS can cause preterm labor.  The ABX have not totally rid me of the GBS, but the colonization is low enough to let it go for now.  Our current plan, since we are assuming I will not have time for an IV to be effective, is to do another course of oral ABX probably starting week 38, and do hibiclens washes during labor to minimize the chance of exposing the babies to it.  I am considering doing a garlic treatment, but orally due to it being in my urinary tract, too.  Garlic cured the last infection without the need for antibiotics.  I'm a little apprehensive at just letting this go for the next 12 weeks, knowing it can trigger preterm labor and just carrying twins is also a risk factor for PTL.

Now, years ago, my oldest dd caught some sort of bacterial infection when she was 6 weeks old.  She was so dehydrated when we brought her in to the ER they never were able to get a sufficient sample to culture her and just decided to put her on ABX.  It could have been late onset GBS, but I never had a swab done that pregnancy, so I don't know.  But having had the experience of a tiny baby in the hospital with an infection, I'd not like to repeat the experience.  

[swell_mel]

With my first dd I tested negative. She got late onset GBS at 6 weeks old. It was scary. She was very ill and ended up with a 10 day hospital stay. My obgyn at the time said the GBS tests have a 50/50 chance of being right. You could have it but not where they swab. He also said there was a slight chance she didn't get it from me but in all likelyhood it was me. In any case, with dd2 I was sufficently freaked out from dd1 getting so sick from it and me testing negative the first time that we decided to just treat me like I was GBS+ and gave me abx. DD2 was fine. With first hand experience on how sick GBS can make a newborn I think taking the abx way outweighs any risks. Good luck mama!

[MegBoz]

I made a short post (most uncharacteristic of me!) but this is an issue, like birth itself, you really have to do your homework on. I'm sure any mama would be just as devastated to have a baby sick with deadly ABT-resistant e.Coli as a result of getting ABTs in labor as she would be devastated at having the baby become infected with GBS as a result of NOT getting the ABTs. Birth is as safe as life gets, and there are just no guarantees.

Granted, the risk of ABT-resistant infections isn't very high, but then again the risk of baby getting GBS, even if you're GBS+ is also not very high. It really is honestly like so many other choices we face in birth - there is some degree of risk on either side (induce or wait it out at 41, 42 weeks? comes to mind.)

With a 10% side-effect rate from ABTs, combined with the fact that this recommendation results in over one-third of all birthing women getting IV ABTs in labor, I just had to pause on this one. Over 30% of women needing IV ABTs in labor... I don't think the bodies of American women are that "broken" that such a huge percentage of us really and truly have 'toxic vaginas' and need such a significant intervention. It seems contradictory to my entire view of birth, so I investigated further.& even one of my MWs (hospital-based CNMs) made a comment to me that she thinks the CDC will end up changing the recommendation in the future.

My husband had the absolutely brilliant idea to see what protocols are in other countries since maternity care is vastly superior outside the US. I couldn't figure out what the standard was in The Netherlands. Japan is inconsistent & varies by hospital, and as I mentioned previously, in the UK they give IV ABTs only when 2 or more risk factors are present & don't even routinely test for GBS!

My doula got the ABTs & had a nasty, itchy rash that lasted THREE MONTHS that she attributes to ABTs. Thrush is another common side-effect and can potentially kill a BFing relationship. :(

All this aside, hibicleans vaginal washes are very effective with much, much less risk! I joke that IV ABTs are like taking a sledge hammer to kill an ant. You are indeed going to kill the bug you are trying to kill, but you're also going to have a lot of collateral damage, and there's a smarter way to kill it - with less collateral damage. (Hibicleans washes of course affect only the vagina, rather than going through the entire vascular system.)

Also remember it's not like say being HIV positive or not - it's not that you either have it or you don't, there are DEGREES of colonization. As others have noted, a UTI with GBS connotes a high degree of colonization & is a case where I too would chose the ABTs. Find out if you can get a colony count to know HOW colonized you are - that's a good piece of info for making a decision.

Bearing that in mind, you can also eat fermented foods (such as kefir) which are known to help reduce it - heck, even if you test positive again, taking steps like that should reduce your colony count and thus reduce risk.

My MW now, a HB MW - CPM - says that since she's started encouraging fermented foods, only about 10% of her clients test positive - whereas it's over 30% nationally. & for the ones who DO test positive, following up with other protocols such as garlic, she's been able to get them ALL to retest negative with the exception of maybe 1 or 2 in the past 10 years!

But you can also take other steps to reduce risk of transmission in the case of being positive - as I noted - no AROM, no vaginal exams. Eat lots of protein to keep the amniotic sac strong & hopefully delay breaking of waters as long as possible (my bag broke, spontaneously, only when I started actively pushing, and it's certainly possible for the bag to NEVER break! with baby being born "in the caul.")

[vulnerable]

Originally Posted by Danielle283 

My daughter was infected with GBS even though I tested neg. We almost lost her and she spent 6 weeks in the NICU. With this next baby I'll be getting ABX no matter what.

This.  My daughter was born via c-section and ended up with GBS because my water had broken almost 40 hours prior to her delivery.  I am getting ABX no matter what to prevent myself from infection and the baby as well.

[Magali]

Vulnerable, I see that your water was broken for 40 hours, and I have a question for the other moms who's little ones suffered from GBS.  Did you have any risk factors like water broken for a long time, maternal fever or premature labor? 

[swell_mel]

Originally Posted by Magali 

Vulnerable, I see that your water was broken for 40 hours, and I have a question for the other moms who's little ones suffered from GBS.  Did you have any risk factors like water broken for a long time, maternal fever or premature labor? 

 My water broke first which started labor for me. From the time my water broke until dd1 was born was 7.5 hours. I tested negative and had no complications or anything... no fever, dd was born at 40 weeks. As I said earlier dd1 had late onset GBS.

[Bexo]

MegBoz, where are you getting your info? While it is true that the % of babies who will actually become infected with GBS to an untreated mother is relatively low, babies who DO get infected have a very high fatality rate...for someone who claims to have done so much research, I'd like to see where you're getting your info...

That being said, abx DO carry side effects, and some of those side effects can be quite serious - especially gut flora issues. Abx are not the only efficient protocol for treating GBS. I'd encourage anyone who is interested to Google "Hibiclens Douche" or "Chlorhexidine Douche" (same thing) as an alternative treatment. 

GBS is tricky, because as another poster mentioned, the tests for determining whether or not a mom has GBS aren't really very accurate...it can depend where you swab, etc. Some docs are even testing the concentration of urine if a mom tests positive for GBS...supposedly the risk of a baby becoming infected is greater when the concentration of GBS in the urine is greater...I haven't looked into this, but I suppose it makes sense.

It's true that some countries don't test for GBS at all. It's also true that the % of babies who become infected born to untreated mothers is relatively low. But it's also true that GBS IS very serious...just ask anyone who has had an infected baby or anyone who works in L&D (such as myself) who has seen perfectly healthy babies become infected. It's tragic, and in many cases preventable. That being said, antibiotics are not one's only treatment option...there are alternatives.

[Beverly]

I tested GBS+ a few weeks ago and have since done a great deal of research on the subject.  Everything I've read agrees with MegBoz assertion that very few babies who become infected die as a result (the number I've seen consistently is 2-5%, and that's 2-5% of the .5-1% who are infected, which is already a very small number).  Furthermore, research as consistently shown that treatment with antibiotics, while perhaps slightly reducing the numbers of infected babies, does not reduce the fatality numbers of all.  Here's just one of the many links I've found: http://www.preciouspassage.com/treating_group_b_strep.htm

As for me, I've started taking a probiotic supplement, vitamin C, and garlic capsules.  I've also stocked up on Chlorhexidine and plan to wash with that when I'm in labor.  Absent any other risk factors, there is no way that ABX are the right choice for me and my baby.

[MegBoz]

Originally Posted by Bexo 

MegBoz, where are you getting your info? While it is true that the % of babies who will actually become infected with GBS to an untreated mother is relatively low, babies who DO get infected have a very high fatality rate...for someone who claims to have done so much research, I'd like to see where you're getting your info...

I'd have to dig up all the research I originally did 3 years ago, but here are some results from some Googling:

http://mothering.com/pregnancy-birth/treating-group-b-strep

"Some studies have shown a decrease in GBS infection in newborns whose mothers accepted IV antibiotics during labor, but no decrease in the incidence of death.^{8, 9} Still other research has found that preventive use of antibiotics is not always effective.¹⁰ In fact, one study found no decrease in GBS infection or deaths among newborns whose mothers were given IV antibiotics during labor.^11"

The article sites is sources, so you can refer directly to the studies.

"6 percent of those who develop a GBS infection will die"

http://www.aafp.org/afp/2006/0901/p875.html

(They are getting the below from this CDC report:)

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5447a2.htm

"Of term infants, 4 percent with early-onset infections died, whereas no infants with late-onset infection died."

(again, that is of those who DID get infected & we've already agreed taht the % of babies who will actually become infected with GBS to an untreated mother is relatively low.)

http://www.merckmanuals.com/professional/sec19/ch279/ch279m.html

"The overall mortality rate of early-onset sepsis is 3 to 40% (that of early-onset GBS infection is 2 to 30%) and of late-onset sepsis is 2 to 20% (that of late-onset GBS is about 2%). More recent studies have shown lower mortality rates."

--------I was briefly browsing, but I don't think they're separating out premies vs. term neonates here, which would explain the huge range. Prematurity is a secondary risk factor in addition to a positive swab and, as I've said, I personally would take ABTs if I had 2 risk factors (the way it's managed in the UK.)

Interesting, maybe I'm over-analyzing, but this sounds to me like they are saying, 'Um, we're not entirely sure this guideline is the right thing to be 'doing.'

"Continued examination is needed to evaluate the effects of the 2002 guideline revision on early-onset infections and to determine the long-term effects of intrapartum use of antimicrobial agents on neonatal GBS infection."

Came across this in the Mothering article which I find interesting & relevant to this thread:

"Late-onset GBS infection is more complex and has not been convincingly tied to the GBS status of the mother. Late-onset GBS infection in infants occurs between seven days and three months of age."

From that AAFP article linked above:

"The CDC found that the incidence of early-onset GBS infection in 2004 decreased 31 percent from 2000 and 2001, the period just before the universal screening was implemented. The incidence of late-onset GBS infection remained the same from 1996 to 2004."

Interesting. That, to me, might seem to confirm the above statement that late-onset GBS is really unrelated to status of mother and/or intrapartum ABT treatment.

(Incidentally, early-onset GBS dropping only 31% is, IMO, a rather negligible improvement for a treatment with such substantial risks.)

[thebigfam]

Well I had my doctors appointment today.  I was all ready to fight for a retest closer to my due date but she didn't even fight me.  So... I will be doing hibiclense before my next test and during labor just to be safe.  I was all prepared to fight her about accepting that test but I am relieved I didn't have to!  This makes me like my family doctor even more!

Big Momma

[mylilmonkeys]

Originally Posted by Magali 

Vulnerable, I see that your water was broken for 40 hours, and I have a question for the other moms who's little ones suffered from GBS.  Did you have any risk factors like water broken for a long time, maternal fever or premature labor? 

Nope.  My only labor where my water broke ahead of labor, ctx began around an hour later and babe arrived 4 hours after that.  All my babies have been post-40 weeks gest. and no fever.  But, IV abx are inappropriate for me, because they are said to be effective only if given at least 4 hours before birth, and my last 3 labors have been 3-4 hours.  No way would I get an IV soon enough.  I think the research on hibicleans looks very good, and is a great option.

[MegBoz]

Originally Posted by mylilmonkeys 
  But, IV abx are inappropriate for me, because they are said to be effective only if given at least 4 hours before birth, and my last 3 labors have been 3-4 hours.  No way would I get an IV soon enough.

Actually, not true. The colony count is found to go down even just one hour after the first IV ABT dose.

Although it is true that giving the ABTs about 4 hours before birth is the ideal (I think 2 doses total are given in 4 hours before birth as the ideal.) But still, even one dose given 1 hour before birth still has some positive impact.

But yeah, I still think hibiclens is a better option if you don't have 2 or more risk factors.

[mylilmonkeys]

Originally Posted by MegBoz 

Originally Posted by mylilmonkeys 
  But, IV abx are inappropriate for me, because they are said to be effective only if given at least 4 hours before birth, and my last 3 labors have been 3-4 hours.  No way would I get an IV soon enough.

Actually, not true. The colony count is found to go down even just one hour after the first IV ABT dose.

Although it is true that giving the ABTs about 4 hours before birth is the ideal (I think 2 doses total are given in 4 hours before birth as the ideal.) But still, even one dose given 1 hour before birth still has some positive impact.

But yeah, I still think hibiclens is a better option if you don't have 2 or more risk factors.

Good to know.  My midwife arrived about 20 min before baby last birth though.  Even though I may be in labor "long enough", it takes an hour to be sure labor is established, another hour for my birth team to arrive (or me to get to them)...I'd probably birth before the IV was set up. LOL
 

[~Adorkable~]

Three questions about all this:

Best time in pregnancy to test
When do folks think is the best timeframe to get an accurate test and give yourself time to deal with the results. I may have to adjust my timeframe since I have twins but less assume for the sake of the question I am still calling 40w my expected birth time.

Where to test, vaginal/ rectum/ urine or what combo?
I had one midwife say she tested only in the vaginal area and not rectum because she thought nearly everyone tested pos in rectuml tests and that it didn't relate to anything. What do you gals think about this? I think my OB where I will be tested to bring the results back to my current midwife does a test in both areas.

Hibiclense and broken sack?
Secondly for those that do the hibiclense wash, are you doing this douche at all after your water has broke? I ask this because this is a drug I would not want coming in contact with my babies head in any way what so ever and I still can't find the info on how far into labor folks do it till. My current midwife likes to do it and does not have abs capability, so I'm just wanting to learn more now so if it comes up I'm not scrambling at the last minute.

[MegBoz]

Originally Posted by ~Adorkable~ 

Best time in pregnancy to test
When do folks think is the best timeframe to get an accurate test and give yourself time to deal with the results.

Tough one. I think the standard is 36W, I honestly can't recall. Obviously since prematurity is a secondary risk factor, it would be good to know your GBS status if you went into labor at 35W. OTOH, since it's transient, data from a 35W test isn't as useful or accurate at a 41W birth. Hm... I'm torn. I guess if you're paranoid about it, you could always test at 35W (well, for a singleton that is, adjusting accordingly as needed for multiples) & retest at 39 maybe. You'd probably have to pay out of pocket (I did for my retest), but again if you're really concerned, it might be worth it.

Where to test, vaginal/ rectum/ urine or what combo?
I had one midwife say she tested only in the vaginal area and not rectum because she thought nearly everyone tested pos in rectuml tests and that it didn't relate to anything. What do you gals think about this? I think my OB where I will be tested to bring the results back to my current midwife does a test in both areas.

I actually don't know about nearly everyone being pos in rectum. I would doubt that though because I think swabbing anus (not necessarily inserting the swab into the rectum, but at least the outside of the anus) is standard CDC recommendation - so if that's true, the nationwide pos rate would be a lot higher than the approx 30% it is now.

I'm pretty sure if you are pos in urine, that means you're HIGHLY colonized, so I don't know that I'd recommend testing urine ONLY. Also, I believe GBS in urine is a sign of a UTI - & I know that UTI with GBS is another risk factor. If you have a UTI - you know it! So if you do NOT have a UTI, is it possible to have GBS in your urine without an infection? I don't know.

Hibiclense and broken sack?
Secondly for those that do the hibiclense wash, are you doing this douche at all after your water has broke? I ask this because this is a drug I would not want coming in contact with my babies head in any way what so ever and I still can't find the info on how far into labor folks do it till. My current midwife likes to do it and does not have abs capability, so I'm just wanting to learn more now so if it comes up I'm not scrambling at the last minute.

 

Hm, I'd have to read up more on this too. Actually the wash is only supposed to rinse the outer area of the vaginal opening, so when you're still in 1st stage (not yet 10 cm) the hibiclens really shouldn't come into contact with baby's head anyway. Sure, if there's a residue of it, baby's head could come into contact with it while he's on the way out. Once I was 10 cm & pushing, I think I'd stop doing the wash.

Personally, 2nd stage for me with DS, my first, was only 45 min, so I'm expecting 2nd stage to be even shorter the 2nd time around. If I did do hibiclens, I'd stop bothering to do it once I felt I was in/nearing transition (based on my feelings of course, not a VE!)

[mylilmonkeys]

I can answer with experience on the GBS UTI question.  I tested positive for nitrites on the urine dip about 24 hours before I started experiencing UTI symptoms.  My midwife recommended we do a urine culture, which came up + for GBS, hence abx treatment.  The treatment took care of the UTI, but a follow up urine culture still had low levels of GBS.  The urine dip had come up clean.  The consulting OB recommended not treating for the levels of GBS colonization that came up with the follow up at this time.  So it is possible to have GBS in the urine without a symptomatic UTI.