1. Tang Phing Phing
Tan Ian Zing

2. 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

3.  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.

4.  Impression?

5.  Impression: PROM in latent phase of labour in a GBS
carrier mother

6. Group B Streptococcus infection
 Why the concern?

7. Group B Streptococcus infection
 Why the concern?
 Most frequent cause of severe early onset infection in
neonates

8.  Neonatal mortality ~10%
 Term infants 6%
 Preterm infants 16%

9.  Is routine screening and the presription of antepartum
prophylaxis recommended?

10.  Is routine screening and the presription of antepartum
prophylaxis recommended?
 No
 Not found to be beneficial overall as yet, and may
increase unnecessary intervention

11.  Who should we screen?

12.  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

13.  How do we isolate this miscroorganism (namely
Streptococcus agalactiae)?

14.  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

15.  Who should we treat?

16.  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

17.  What is the recommended treatment?

18.  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

19.  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)

20.  What happens to the baby?

21.  Her 3.425 kg baby boy was admitted to the Nursery for
presumed sepsis due to maternal GBS status.

22.  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.

23. Definition, Incidence and Natural
History 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

24. 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

25. 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

26. PPROM - The Dilemma
 Is the use of antibiotics justified?

27. Results of the Oracle -1 and -2
studies
 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

28. 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.

29. 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

30. ORACLE children study
Results 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

31. ORACLE children study
Results for women without PPROM
 There is also an unexpected increase in number
children with cerebral palsy in those who were given
either antibiotic

32. ORACLE children study
Results 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.

33. ORACLE children study
Results for women without PPROM
 Neither erythromycin or co-amoxiclav made any clear
differences to child’s functioning

34. 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.

35. 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.

36.  Thank you

37. 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.