Case Presentation Mdm. JT is a 30 year old primigravida at 40+9 weeks of gestation who presented to us with Leaking liquor for ~6 hours prior to arrival Irregular tightening for ~2 hours, with no other symptoms of labour, with good fetal movement Not clinically suggestive of chorioamnionitis TCM 2:10 ~30 sec Speculum was demonstrable of liquor, with an open os at 2 cm
At 12 weeks of gestation, she was diagnosed to have Group B Streptococcus infection via a “routine” vaginal swab in Singapore, where she has been regularly followed up antenatally. A course of antibiotics was prescribed and completed.
Who should we screen? previous baby affected by GBS GBS bacteriuria detected during the current pregnancy preterm labour prolonged rupture of the membranes (more than 18 hours) fever in labour
How do we isolate this miscroorganism (namely Streptococcus agalactiae)?
How do we isolate this miscroorganism (namely Streptococcus agalactiae)? Normal commensal in vagina and rectum Detection via low vaginal swab and rectal swab cultures in women at 35 to 37 weeks of gestation
Who should we treat? Intrapartum prophylaxis is justified if 2 or more of: previous baby affected by GBS (NOT previous GBS with unaffected baby) GBS bacteriuria detected during the current pregnancy preterm labour prolonged rupture of the membranes (more than 18 hours) fever in labour
What is the recommended treatment? IV penicillin G 3g should be administered as soon as possible after the onset of labour and at least 2 hours before delivery followed by 1.5g every 4 hours during labour. IV Clindamycin 900mg 8–hourly for women allergic to Penicillin
In the ward, she was started on IV Penicillin 3 g then 1.5 g 4 hourly. She delivered via emergency LSCS for secondary arrest of labour (~44 hours after PROM)
Her 3.425 kg baby boy was admitted to the Nursery for presumed sepsis due to maternal GBS status.
What happens to the baby? Strongly associated with five-minute Apgar scores below 6, neonatal seizures and unexplained spastic cerebral palsy in infants of normal birth weight, sepsis and pneumonia Neonates with maternal GBS require at least 12 hours of observation, or blood cultures taken and treatment with penicillin commenced until results available.
Definition, Incidence and NaturalHistory of PPROM Rupture of membranes before 37 completed weeks of gestation and before onset of labour Occurs in 2% of pregnancies but associated with 40% of preterm deliveries
Some practical points The diagnosis is best made by history, speculum examination and, for a few patients: Observation over time Tests for AF e.g. pH strips/sticks or Amnisure (expensive) There is no role for ultrasound If, at the end of the day, you can’t decide if the forewaters are ruptured they probably haven’t
Detection of chorioamnionitis Requires a high index of suspicion and concern about Any low grade fever Fetal (or maternal) tachycardia Discolouration of the liquor Uterine tenderness Decreased fetal movements
PPROM - The Dilemma Is the use of antibiotics justified?
Results of the Oracle -1 and -2studies The data of the ORACLE study (Great Britain), published in the Lancet in 2001,shows that in PPROM and also in imminent preterm birth, the prognosis of the newborn is improved by the use of erythromycin. Ever since, the use of antibiotics in pregnant women has increased. These results have been questioned in follow-up studies
ORACLE children study Follow-up children of women randomized to ORACLE at 7 years of age to determine whether antibiotics have effects on their development, educational attainment, and the risk of conditions such as cerebral palsy and respiratory illness.
ORACLE children study UK follow-up began in 2002 The original ORACLE trial participants were asked to fill in questionnaire about their child’s health and how they were doing at school at age 7. 4148 born to mothers with PPROM were eligible, 3171 (75%) returned a questionnaire 4221 children born to mothers without PPROM, 3196 (71%) returned a questionaire
ORACLE children studyResults for women without PPROM • In the group who received erythromycin (either with or without co-amoxiclav), there were slightly more children with a functioning problem compared to those who did not receive erythromycin
ORACLE children studyResults for women without PPROM There is also an unexpected increase in number children with cerebral palsy in those who were given either antibiotic
ORACLE children studyResults for women without PPROM •The risk was clearest for mothers given both antibiotics : 35 (4.4%) of children had cerebral palsy compared with 12 (1.6%) for mothers receiving double placebo.
ORACLE children studyResults for women without PPROM Neither erythromycin or co-amoxiclav made any clear differences to child’s functioning
Conclusion Erythromycin has some short term but not long term benefits for children whose mothers have PPROM Antibiotics should not be given to women who are showing signs of going into preterm labour but do not have rupture of membranes or obvious infection.
Conclusion These findings do not mean that antibiotics are unsafe in pregnancy. When there is obvious infection, antibiotics can be life saving for both mother and baby. If there it is not certain whether or not the membrane has ruptured, it is probably more beneficial to delay the initiation of antibiotics.
References Kenyon S, Pike K, Jones DR, et al. Childhood outcomes after prescription of antibiotics to pregnant women with preterm rupture of the membranes: 7-year follow-up of the ORACLE I trial. Lancet 2008;372:1310–8. Kenyon S, Pike K, Jones DR, et al. Childhood outcomes after prescription of antibiotics to pregnant women with spontaneous preterm labour: 7-year follow-up of the ORACLE II trial. Lancet 2008;372:1319–27. Original Oracle trial papers Lancet 2001; 357: 979 -88 and 989-94.