Approximately 7,600 cases of neonatal group B streptococcal ("GBS") infection occur in newborns each year in the United States. A fetus who is exposed to GBS organisms in utero and develops early-onset infection, can suffer serious complications, including brain damage, pneumonia, meningitis, and a chronic lung disease known as bronchopulmonary dysplasia. GBS is the leading bacterial organism responsible for causing the death of newborns who develop early-onset infection.
Most newborns who develop early-onset GBS infection are born to mothers who have GBS bacteria in the vaginal or rectal areas at or around the time of labor and delivery. When a woman has GBS bacteria, physicians and nurses will describe her as being "colonized" with the bacteria. It is important to emphasize that, even though between 10% and 30% of pregnant women are colonized with GBS bacteria, most of them have no symptoms and do not know that they are colonized. The optimal method for detecting GBS colonization during pregnancy is for clinicians to culture samples from the distal vagina and anorectum.
When pregnant women are colonized with GBS, the organisms can gain access to the amniotic fluid or the birth canal either before or after the membranes rupture. Even if the membranes are intact, when labor begins, contractions can force the bacteria into the birth canal or in the amniotic fluid. The fetus can swallow or inhale the bacteria in the amniotic fluid, or the baby may be delivered through a contaminated birth canal, resulting in colonization or infection of the baby.
Fortunately, not all of the infants who are exposed to the GBS bacteria will become infected. However, because GBS organisms are capable of producing severe consequences, including death and irreversible brain damage, it is imperative that clinicians develop strategies to prevent transmission of GBS organisms to the fetus. Most obstetricians and pediatricians agree that an effective strategy is to administer antibiotics after labor starts, particularly when risk factors known to increase the occurrence of early-onset GBS infection are present.
Prior to May 31, 1996 -- the date that the Center for Disease Control and Prevention ("CDC") in Atlanta issued definitive guidelines concerning the prevention of GBS infections in newborns -- obstetricians, pediatricians and hospitals relied on guidelines that had been issued in 1992 by the American College of Obstetricians and Gynecologists ("ACOG") and by the American Academy of Pediatricians ("AAP"). In its 1992 Technical Bulletin, ACOG acknowledged that the risk of GBS infection in a newborn increases dramatically when the mother is colonized and other risk factors Ð such as prematurity, prolonged rupture of membranes, and maternal fever during labor Ð are also present. ACOG recommended that clinicians treat all colonized mothers who have risk factors. At the time, since many obstetricians did not believe that screening patients was necessary, ACOG indicated that doctors could comply with the standard of care by relying solely on a risk factor approach to prevent GBS infection in the newborn. The AAP, on the other hand, advocated prenatal screening of all pregnant women at 26-28 weeks and treatment of all women who tested positive and had risk factors. Preterm labor or premature rupture of membranes at less than 37 weeks, fever during labor, and rupture of membranes for more than 18 hours at any gestation, were factors considered to significantly increase the risk of early-onset GBS infection.
In 1996, the CDC issued guidelines that were intended to resolve areas of conflict and combine the features of both of the 1992 ACOG and AAP guidelines. The CDC recommended that women be screened at 35 to 37 weeks, not at 26-28 weeks as previously recommended by the AAP. Physicians were given the option of screening pregnant women at 35 to 37 weeks of gestation and administering antibiotics to all pregnant women who tested positive, or of simply administering antibiotics, without prior screening, to all pregnant women who have risk factors such as preterm delivery at less than 37 weeks gestation, prolonged rupture of membranes greater than 18 hours, or maternal fever (greater than or equal to 38° C). The new guidelines is the requirement that physicians inform patients about the different approaches and offer them the option of being screened and/or treated regardless of whether they have risk factors.
Despite these clear directives to doctors and hospitals, cases of early-onset GBS infection still are being reported. When GBS related neonatal death, lung disease or meningitis occurs, it is reasonable for parents to ask questions about whether appropriate screening methods were utilized during the pregnancy, whether risk factors were present prior to delivery, whether antibiotic therapy was started before delivery, and/or whether antibiotics should have been started by the pediatricians at birth or continued promptly after delivery. Since it often takes 24 to 48 hours to get the results of a blood culture, it is important for neonatologists to administer antibiotics to newborns who manifest early signs of infection.
In my next column, I will discuss the antepartum tests that are available to assess fetal well-being and to identify maternal or fetal conditions requiring the clinicians to expedite the delivery.
Dov Apfel is a principal in the law firm of Joseph, Greenwald & Laake, P.A.
6404 Ivy Lane, Suite 400, Greenbelt, Maryland 20770. He can be reached by
phone at 301-220-2200, or by e-mail. Mr. Apfel is contacted by lawyers and
families throughout the United States to assist them with potential medical
malpractice claims involving children who have died, or who sustained
irreversible brain damage. He is the former Co-Chair of the Birth Trauma
Litigation Group of the Association of Trial Lawyers of America and a member
of the Board of the Medical Negligence Section of the Maryland Trial Lawyers
Association.
Please Note:
This web site is not intended as legal advice on cerebral palsy, and is not a substitute for obtaining guidance from your own legal counsel about cerebral palsy litigation. It provides general educational information about the standards of care and causation issues that can arise in obstetrical malpractice and cerebral palsy litigation. Readers of the articles contained within this web site should not act upon the cerebral palsy information without first consulting with a lawyer who is experienced in evaluating and litigating cerebral palsy and obstetrical malpractice cases. Mr. Apfel is admitted to practice law in Maryland and the District of Columbia. When Mr. Apfel is asked to participate in cerebral palsy
litigation filed in other states, he will associate with, and act as co-counsel with, an attorney licensed in that state who is familiar with the local laws and procedures.
