Urinary Tract Infections with Group B Streptococcus (GBS) During Pregnancy
Thursday, September 03, 2009
Kenneth F. Trofatter, Jr., MD, PhD
Hi - I am getting a little confused about Group B Strep (GBS) and UTI (urinary tract infection) information. Hoping you can help me clarify. I am 7 weeks pregnant and was just diagnosed with a UTI with GBS (asymptomatic - it was done as part of my first visit screen). The nurse called and wants me to start ampicillin (5oo mg 4x/day for 7 days) immediately. I have currently taken no medication (not even a tylenol) during this pregnancy (my first). I keep reading that GBS does not require treatment but then saw that it may with a UTI - I did not know symptomless UTI's were possible. I am very much wanting to not take any medication - your thoughts on this are greatly appreciated.
One of my very first posts here at “Fruit of the Womb” addressed Group B Streptococcus (GBS) infections and pregnancy. This is a topic that is worth revisiting periodically and the questions from today’s reader raise concerns that are shared by many women during pregnancy.
GBS is a bacterium that colonizes the urogenital and lower gastrointestinal tracts in as many as one-third of all healthy reproductive age women. It is the leading cause of serious bacterial infection in newborns and is often transmitted to babies at the time of delivery. Indeed, 8,000-12,000 babies per year in the U.S. will develop complications related to GBS and approximately 2,000 infants will die from their infections. There are several well-known situations in which babies are at increased risk for developing a serious GBS infection including:
• Premature labor or rupture of membranes before 37 weeks
• Prolonged rupture of membranes (18 hr or longer) before delivery
• Fever in labor (100.4F or higher)
• History of GBS urinary tract infection during the pregnancy (4-fold risk)
• Previous baby affected by GBS disease (increases risk 10-fold!!!)
Today’s reader had an asymptomatic UTI with GBS detected at her first prenatal visit during routine screening. We do NOT know why some people carry GBS and others do not, and we are not entirely clear why far more women actually carry the bacterium than are at risk for having a baby with a serious complication related to it, although the maternal immune response to the bacterium probably plays a key role. However, we do know that GBS UTIs place women in one of the highest risk categories for pregnancy complications (preterm labor; premature rupture of membranes; subclinical premature cervical change in the continuum of ‘cervical incompetence’; chorioamnionitis) and for transmission of GBS to the baby at the time of delivery and even prior to the onset of labor (CDC, MMWR May 31, 1996;45:1-24 ). Interestingly, women with GBS UTIs are also at greater risk for hypertensive disorders in pregnancy, anemia, and for babies that are not only premature, but ‘small for gestational age’ (Schieve, et al., Am J Public Health 1994;84:405-410).
UTIs caused by GBS occur in about 5% of women. Many women are asymptomatic or confuse symptoms of pregnancy with subtle symptoms of urinary tract infections (pressure; suprapubic discomfort; frequency; and urgency). However, asymptomatic UTIs can still subject the pregnancy to the risks of the complications mentioned above. Even after treatment, asymptomatic or symptomatic UTIs will recur in as many as one-third of all pregnant women. The source of the ‘reinfection’ is usually the patient’s own lower gastrointestinal tract in which antibiotic therapy of the UTI is ineffective at eradicating colonization. Women with GBS UTIs are usually considered to be more heavily colonized and are at greater risk for persistent and recurrent GBS infections (CDC, MMWR August 16, 2002;51:1-22). They are also at greater risk for developing significant bladder and kidney infections (pyelonephritis), the latter of which may occur in as many as 50% of women who begin with an untreated ‘asymptomatic’ UTI and can be life-threatening, leading to sepsis, adult respiratory distress syndrome (ARDS), and even death during pregnancy. It is the current recommendation that women with symptomatic or asymptomatic GBS UTIs detected during pregnancy should be treated at the time of diagnosis (CDC, MMWR May 31, 1996;45:1-24).
There are 5 major serotypes of GBS (Ia, Ib, II, III, and V). All are capable of causing both maternal and neonatal disease. Babies born to women who do not have antibodies to types II and III seem to be at greater risk for complications. Indeed, at some point, this may be one of the primary factors we can use to differentiate pregnancies at risk from those which are less so. A recent study has shown that serotypes V, Ia, and III are most often associated with asymptomatic and symptomatic UTIs (Ulett, et al., J Clin Microbiol. 2009;47:2055-60). About two-thirds of serious GBS infections are apparent at the time of delivery and 90% of babies who will develop complications do so within the first 48 hr after delivery. This is generally referred to as “early-onset” GBS infection and technically is used to define disease occurring in the first week of life. “Late-onset” disease, frequently associated with serotype III, affects another 10% of newborns, often presents as meningitis with septicemia, and rarely occurs after one month of age. Up to one-third of the survivors of GBS meningitis will develop long-term physical and/or neurological handicaps and in 1 of every 8 of these babies, the handicaps will be severe.
Unless you are in one of the high risk groups noted above, the goal of prophylactic antibiotic therapy during labor in those who are found to be colonized with GBS during their pregnancies is to deliver antibiotics to the mother early enough in the course of labor that sufficient drug can be transferred across the placenta to achieve protective levels in the baby prior to birth. That means, the antibiotic selected must not only be able to kill GBS, but it must also be able to cross the placenta. Fortunately, GBS has not yet been found to have developed resistance to the antibiotic of choice, penicillin G, and this drug also readily crosses the placenta. It also has a long and proven safety record for the baby. Ideally, antibiotic therapy is begun, intravenously, at least 4 hr prior to delivery so that at least one or two doses can be administered before the baby is born. If a woman has a serious allergy to penicillin, other options for therapy exist and the risks and benefits of these are discussed in our previous post on this subject.
The important things are that your doctors did the right thing by screening you, they have identified a potential problem, and there is a well-proven means of significantly reducing the risks from that problem for both you and your baby during your pregnancy and at the time of your labor and delivery. Thanks for reading and for the good questions. Best wishes for the rest of your pregnancy!
Dr T
Labels: GBS and pregnancy, Group B Strep, urinary tract infection, UTI
12 Comments:
At Tue Sep 08, 03:42:00 AM 2009,
Anonymous said…
It is common during early pregnancy to be infected with uti.It should be treated.Ampicillin is a medication that be used safely during pregnancy.It does not cause any damage to the foetus.
At Wed Sep 09, 09:01:00 AM 2009,
Anonymous said…
hi, i've been very worried about my body and whats going on with it. i went to the emergency room thursday night with a horrible bladder infection and found ou that i was 13 weeks pregnant, friday night i passed a big dark red thing while i was urinating and it felt slimy on the tissue. i had been having sharp pains in the vaginal area going straight up and down for the past four days and he pains were getting worser. so i went back to the tri lakes medical center where doctor haley told me i was threatening a miscarriage in which he gave me wo types of pain pills and some ifection pills. he told me to make an appointment with dr. davis the comming up tuesday to be checked. meanwhie at home was still huting and stil passing red slimy thigs some ere bright red but a great majority was dark red. at one point hen i wipped i saw only blood and at another i saw none. i was still passing slimy red things that looked like mucous and only once i passed some that was clear.when i wen to dr. he told me the baby was fine, he said i as fine and i didn't have a bladder infection and he saw no vaginal bleeding not a drop! but that day he did not do a urine sample and he didn't give me an ultrasound. he only did a wet mouth during the pap. I DON'T KNOW WHAT TO DO! I NEED HELP! WHATS GOING ON WITH ME! i'm having abdominal pains and cramping, back pains, urinating still hurts, ut no vaginal bleeding like a minstrual period
At Sat Sep 12, 07:17:00 AM 2009,
Anonymous said…
Dr. T-
I don't know if you will see this post since it doesn't connect exactly to your original article and your last article on Inc. Cervix is almost a year old. However, I was wondering if you could give us some advice. My wife and I lost our first child at 21 weeks after her water broke at 20 weeks and she was found to have no measurable cervical lenght. We are pregnant again and had a McDonald stitch in place starting with week 14. At 18 weeks my wife's cervix measured 3.4. At 22 weeks her cervix measured 1.4 with some funnelling. There has been no evidence of contracions or PTL (except for one painless contraction caught on an u/s about three weeks ago). They have monitored for contractions and tested for infection. Both were negative except she has a mild yeast infection that seems to have started this week. The doctor has put my wife on hospital bedrest and indomethacin. We start P17 shots in two days. Is there anything else we should be doing? Should I be preparing for the worst or is there reason to still be hopeful?
Thanks,
Anxioushusband
At Wed Oct 07, 01:50:00 PM 2009,
Lin said…
Dear Dr.
My first baby was delivered vaginally and developed GBS-sepsis shortly after birt. It was a big scare to us, but she had a quick recovery and no late effects from a troubled start of life.
In my second pregnancy, I was scared and worried alot because of GBS. I was not screened during pregnancy as the docs said I would get prophylaxis during birth no matter what. Anyhow, I had two (unsymptomatic) UTI's both caused by GBS in the weeks 33-36 treated with two different antibiotics. (Ampicillin and Trimethoprim) I gave birth by a planned CS (because he was in breech) at week 38, and was given IV antibiotics prior to CS. Still, my son soon became septic with major breathing problems and fought for his life on an oscillating vent for a week.
I never received a valid explanation for how he caught the infection during our stay in NICU, but in retrospect I know remember that I lost the mucous plug the day before CS. Is it likely that he was infected in the womb just before birth? Or can the transmission happen during the C-section in it self?
My son started having symptoms shortly after birth (even though he had triple 10 on Apgar, but had negative infectionparameters on bloodworks for the first 24 h. He started IV-antibiotics at 6 hours, but declined rapidly, despite early intervention.
I don't dare to become pregnant again. It would be a nignhtmare, and I have no faith in me being able to produce healthy kids. And since not even a C-Section could prevent infection, what on earth could do it then? If I was your patient what would your monitoring regime be as to prevent GBS infection? I have not yet discussed this with my OB gyn, as I am not considering a new pregnancy, just because of these horrifying bacterias.
I hope you will answer this question. Thanks in advance.
At Fri Oct 09, 09:45:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sep 9: From what you have told me, I cannot tell if the bleeding and the pain are coming from your bladder, your uterus, or even your rectum. It is also possible that there are DIFFERENT causes for each related to threatened abortion, a bladder infection or, perhaps, irritability and spasm, or even constipation or other lower gastrointestinal problem. If bot keep up, please return to your doctor for further evaluation! Good luck.
Dr T
At Fri Oct 09, 09:47:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anxioushusband: Some thought should be given to placing another cerclage. The first might have torn into the cervix and become looser with time. Another option is to uses a pessary. Your doctor can explain what that is/does. Best wishes.
Dr T
At Fri Oct 09, 09:51:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lin Oct 7: You are probably one of those people who, for unexplained reasons, has an inadequate immune response to GBS so that you not only have trouble controlling your own infections with it, but your babies also do not receive protective immunity while they are in the uterus. GBS can and does cause ascending infections in the absence of ruptured membranes, especially in women with recurrent GBS urinary tract infections. In your case, if you become pregnant again, I would suggest not only treatment of any acute UTIs, but also suppressive therapy for the duration of the pregnancy. Thank you for writing.
Dr T
At Wed Oct 14, 05:11:00 PM 2009,
Anonymous said…
Dr. T,
I have what I think are two separate issues going on and was hoping for some advice. I am 34 years old and this is my third pregnancy. My 2 prior pregnancies were uneventful and I was Strep B negative both times. During this pregnancy, I tested postive for a GBS UTI during my initial prenatal visit (asymptomatic) and I was treated with a course of penicillin. My urine has not been recultured. Then, during my nuchal scan at 12 wks, 5 days, my nt measurement (2.3) and HCG (1.05 MOM)were normal but my PAPP-A was low (.44 MOM). I was given a 1 in 144 chance of DS and I have an amnio scheduled in 2 weeks. Between these two issues, I have been so worried that my odds of having a perfectly healthy baby are greatly reduced. Here are my specific questions:
1. Do you think there is any correlation betwen the GBS UTI and the low PAPP-A?
2. Does the fact that I had two prior healty pregnancies without any GBS issues work in my favor? I find it odd that I have never tested positive for GBS yet now I am "heavily colonized." Wouldn't this be unusual?
3. I know that a GBS UTI increases my odds of the baby becoming infected in the womb and/or at birth, but assuming I am treated appropriately now and during labor, are there any statistics as to how great that risk is? I am terrifed of this.
4. This is probably a ridiculous question - do you think the amnio can in any way increase the likelihood of the baby acquiring GBS in-utero? I ask because I know the amnio is breaching the baby's environment.
5. Is there any other advice you would give me going forward? Do you think I still have a good chance that all will work in my favor and my baby will be ok?
Thank you so much for taking the time to answer these questions. Emma.
At Thu Oct 15, 05:33:00 PM 2009,
Anonymous said…
Dr. T,
I have what I think are two separate issues going on and was hoping for some advice. I am 34 years old and this is my third pregnancy. My 2 prior pregnancies were uneventful and I was Strep B negative both times. During this pregnancy, I tested postive for a GBS UTI during my initial prenatal visit (asymptomatic) and I was treated with a course of penicillin. My urine has not been recultured. Then, during my nuchal scan at 12 wks, 5 days, my nt measurement (2.3) and HCG (1.05 MOM)were normal but my PAPP-A was low (.44 MOM). I was given a 1 in 144 chance of DS and I have an amnio scheduled in 2 weeks. Between these two issues, I have been so worried that my odds of having a perfectly healthy baby are greatly reduced. Here are my specific questions:
1. Do you think there is any correlation betwen the GBS UTI and the low PAPP-A?
2. Does the fact that I had two prior healty pregnancies without any GBS issues work in my favor? I find it odd that I have never tested positive for GBS yet now I am "heavily colonized." Wouldn't this be unusual?
3. I know that a GBS UTI increases my odds of the baby becoming infected in the womb and/or at birth, but assuming I am treated appropriately now and during labor, are there any statistics as to how great that risk is? I am terrifed of this.
4. This is probably a ridiculous question - do you think the amnio can in any way increase the likelihood of the baby acquiring GBS in-utero? I ask because I know the amnio is breaching the baby's environment.
5. Is there any other advice you would give me going forward? Do you think I still have a good chance that all will work in my favor and my baby will be ok?
Thank you so much for taking the time to answer these questions. Emma.
At Fri Oct 30, 02:04:00 PM 2009,
Anonymous said…
My 13 year old daughter has been rather ill for the last several months. Her symptoms are flu like with fever coming and going as it pleases. She does not have any itching, swelling, or any discomfort in the southern regions. S
Last April she had the same symptoms for several weeks before Strep B was found in her urine. After a round of antibiotics she was fine. Until now.
She has had a slew of blood work done and CT scans. But, all appears normal. She is undergoing evaluation with an immunologist, a neurologist and soon a rheumatologist. Last week, I thought, "Duh! they need to test for Strep B again." So, they did and found it at 50,000-100,000. She started antibiotics yesterday.
The question then is, can a non-pregnant female have such reactions to Strep B -- the flu like symptoms but no negative reactions in the vaginal area? If so, how is this possible? What type of medical specialist is needed to help her? The doctors we are currently visiting with know very little on the subject.
She is so sick that this school year she has missed 65% of school. She has had a few okay days, but the last time she can remember feeling great was in early August.
Please help.
At Sun Nov 01, 08:44:00 PM 2009,
jpenmar said…
My 13 year old daughter has been rather ill for the last several months. Her symptoms are flu like with fever coming and going as it pleases. She does not have any itching, swelling, or any discomfort in the southern regions.
Last April she had the same symptoms for several weeks before Strep B was found in her urine. After a round of antibiotics she was fine. Until now.
She has had a slew of blood work done and CT scans. But, all appears normal. She is undergoing evaluation with an immunologist, a neurologist and soon a rheumatologist. Last week, I thought, "Duh! they need to test for Strep B again." So, they did and found it at 50,000-100,000. She started antibiotics yesterday.
The question then is, can a non-pregnant female have such reactions to Strep B -- the flu like symptoms but no negative reactions in the vaginal area? If so, how is this possible? What type of medical specialist is needed to help her? The doctors we are currently visiting with know very little on the subject.
She is so sick that this school year she has missed 65% of school. She has had a few okay days, but the last time she can remember feeling great was in early August.
Please help.
At Tue Nov 10, 05:45:00 AM 2009,
hobbes said…
Dr T, I hope you see this in time to help me. I am 40.5 years old and will be 41.2 by the time I deliver. We have conceived with some difficulty following a miscarriage after an IUI conception last year. This conception was natural.
I had my nuchal screening test at 12 weeks 6 days and my dr said the results are very good for my age, less than 1 in 10000 for both t21 and t18. Exact results are
CRL 65.7 mm, NT 18mm, 107 MoM
PappA 3.74 mIU/ML 110 COR MoM
Free b-HCG 11.2 mg/ml 0.21 COR MoM
I know I shd be reassured by my results but I cannot get the risks of a late-age pregnancy out of my mind and am still wondering whether I shd get an amnio. What is your advice?
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