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Preterm PROM in a group B strep positive woman (query bank)

Published: 17/10/2013

Question

If a patient with known group B streptococcal colonisation on vaginal swab during this pregnancy presents with preterm prelabour rupture of membranes at 32 weeks:

  • what antibiotic treatment is advised
  • how long would it be advisable to wait after antenatal corticosteroids before inducing?

Answer

The following guidelines on preterm prelabour rupture of the membranes (PPROM) and group B streptococcus (GBS) were identified. Evidence levels are quoted in the original guidelines.

  • American College of Obstetricians and Gynecologists. Premature rupture of membranes. (2013)
    The optimal antibiotic regimen is unclear because multiple regimens have demonstrated benefit.
    ... a 7-day course of therapy with a combination of intravenous ampicillin and erythromycin followed by oral amoxicillin and erythromycin is recommended during expectant management of women with preterm PROM who are less than 34 0/7 weeks of gestation.
    ... Women with preterm PROM and a viable fetus who are candidates for intrapartum GBS prophylaxis should receive intrapartum GBS prophylaxis to prevent vertical transmission regardless of earlier treatments.
    For the preterm fetus in the presence of premature rupture of the membranes, the optimal gestational age for delivery is unclear and controversial.
    ...Patients with PROM before 34 0/7 weeks of gestation should be managed expectantly if no maternal or fetal contraindications exist.
  • RCOG. The Prevention of Early-onset Neonatal Group B Streptococcal Disease (2012)
    6.4 How should women with preterm prelabour rupture of membranes be managed to reduce the risk of neonatal GBS disease?
    If these women are known to be colonised with GBS, intrapartum antibiotic prophylaxis (IAP) should be offered.
    7. Which antibiotics should be given to prevent early-onset neonatal GBS disease?
    For women who have accepted IAP, benzylpenicillin should be administered as soon as possible after the onset of labour and given regularly until delivery.
    Clindamycin should be administered to those women allergic to benzylpenicillin.
  • NICE. Antibiotics for early-onset neonatal infection. (2012)
    Recommendations:
    26. Offer intrapartum antibiotic prophylaxis using intravenous benzylpenicillin to prevent early-onset neonatal infection for women who have had:
    • a previous baby with an invasive group B streptococcal infection
    • group B streptococcal colonisation, bacteriuria or infection in the current pregnancy.
    27. If the woman decides to take intrapartum antibiotic prophylaxis, give the first dose as soon as possible and continue prophylaxis until the birth of the baby.
    28. Consider intrapartum antibiotic prophylaxis using intravenous benzylpenicillin to prevent early-onset neonatal infection for women in preterm labour if there is prelabour rupture of membranes of any duration.
    29. Consider intrapartum antibiotic prophylaxis using intravenous benzylpenicillin to prevent early-onset neonatal infection for women in preterm labour if there is suspected or confirmed intrapartum rupture of membranes lasting more than 18 hours.
    30. Offer benzylpenicillin as the first choice for intrapartum antibiotic prophylaxis. If the woman is allergic to penicillin, offer clindamycin unless individual group B streptococcus sensitivity results or local microbiological surveillance data indicate a different antibiotic.
  • Prevention of Perinatal Group B Streptococcal Disease Revised Guidelines from CDC, 2010. (Verani)
    Women with rupture of membranes at <37 weeks and 0 days gestation should be managed according to the algorithm provided. If patient has undergone vaginal-rectal GBS culture within the preceding 5 weeks, the results of that culture should guide management. GBS-colonized women should receive intrapartum antibiotic prophylaxis.
    A recommended regimen is included in this guideline, key components of which are:
    • Penicillin remains the agent of choice for intrapartum antibiotic prophylaxis, with ampicillin as an acceptable alternative.
    • Penicillin-allergic women who do not have a history of anaphylaxis, angioedema, respiratory distress or urticaria following administration of a penicillin or a cephalosporin should receive cefazolin.
  • Society of Obstetricians and Gynaecologists of Canada. Antibiotic therapy in preterm premature rupture of the membranes. 2009 (Yudin)
    5. Antibiotics of choice are penicillins or macrolide antibiotics (erythromycin) in parenteral and/or oral forms. In patients allergic to penicillin, macrolide antibiotics should be used alone.
    6. The following two regimens may be used (the two regimens were used in the largest PPROM randomized controlled trials that showed a decrease in both maternal and neonatal morbidity): (1) ampicillin 2 g IV every 6 hours and erythromycin 250 mg IV every 6 hours for 48 hours followed by amoxicillin 250 mg orally every 8 hours and erythromycin 333 mg orally every 8 hours for 5 days; (2) erythromycin 250 mg orally every 6 hours for 10 days
    7. Amoxicillin/clavulanic acid should not be used because of an increased risk of necrotizing enterocolitis in neonates exposed to this antibiotic. Amoxicillin without clavulanic acid is safe.
    8. Women presenting with PPROM should be screened for urinary tract infections, sexually transmitted infections, and group B streptococcus carriage, and treated with appropriate antibiotics if positive.
  • RCOG. Preterm Prelabour Rupture of Membranes (2006)
    5.2 When is the appropriate time to deliver the baby?
    Delivery should be considered at 34 weeks of gestation.

A Cochrane review of antenatal corticosteroids for women at risk of preterm birth (Roberts) found insufficient information regarding optimal dose to delivery interval. However, additional references have been identified since the publication of this review and although listed in the publication they have not yet been included in the analysis.

References

Search date

October 2013

Classification of evidence levels

  • Ia: Evidence obtained from meta-analysis of randomised controlled trials.
  • Ib: Evidence obtained from at least one randomised controlled trial.
  • IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
  • IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
  • III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
  • IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

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