The weird and wonderful world of GBS… Tasveer Singh O&G Registrar Blacktown Hospital

Meet Jane Doe… A 34 year old woman first pregnancy booked in with an Obstetrician at 9 weeks gestation. Negative antenatal serology B Positive blood group Immune to Rubella Routine screening tests at booking Normal. 10 year history of PCOS treated with Metformin Spontaneous conception

Jane has profound fear of having blood drawn from her Refused a first trimester screen and the FGTT at 28 weeks Normal morphology US No smoking, alcohol or illicit drug use in the pregnancy Had several ANC appointments, and an uneventful antenatal run until 34 weeks

At 34 weeks… Presented for usual ANC appointment Reported reduced foetal movements for the last 1 day Foetal heart unable to be detected on ultrasound…FDIU diagnosed Emotional support provided Delivery expedited in the next couple of days with prostaglandins. Delivered a female foetus, weight 1770g

FDIU Screen Normal HbA1C Negative thrombophilia screen Negative TORCH screen Negative Kleihauer test No other positive tests results on usual FDIU bloods

Post Mortem Baby: Placenta: Moderate to severely macerated female baby Weight and length consistent with 32-33 week size Normal morphology Placenta: Weight 303g (25-50% for 33 weeks) Overcoiled cord 0.4 coils/cm (normal: 0.1-0.3) Marginal cord insertion

Microbiology GBS GBS GBS Blood culture: Stomach Contents: Streptococcus agalactiae (GBS) isolated form aerobic and anaerobic bottles E coli isolated from aerobic bottle Stomach Contents: Modertae growth of GBS Light growth of E coli Placenta subamniotic swab: Moderate growth of GBS GBS GBS GBS

Most likely cause of death Infection with GBS and E coli Degree of maceration indicated baby died in 33rd week of gestation Baby was not SGA

Several days post delivery… Presented to hospital with acutely sore right hip Radiology was suggestive of a small joint effusion Indicating transient synovitis Ultrasound guided aspiration of the right hip done Pain settled Aspiration was culture negative

3 days after initial aspiration Hip pain returned worse than before Arthroscopic joint aspiration and washout was done Thick straw colored exudative fluid was aspirated This aspirate grew GBS sensitive to amoxycillin She received 2 weeks of IV antibiotics followed by 4 weeks of orals and recovered well without further complications

A rare case of GBS associated septic arthritis following an FDIU caused by the same organism in a young immuno-competent woman.

GBS… gram positive cocci in chains

Discussion Role of GBS in Obstetric practice and neonatal sepsis is well documented in literature Prophylactic IV antibiotics in labour is protocol in every obstetric hospital 3 to 8 per 1000 live births result in stillbirths in developed countries GBS has been linked to 4-10% of stillbirths across in Europe and USA The most likely spread is by ascending route across the membranes

GBS rarely causes invasive infection, however haematogenous and trans-fallopian routes have been reported as well. Gibbs & Roberts, Boston, 2007 foetal death in-utero was due to invasive GBS sepsis of the foetus, in a woman with intact membranes who presented in labour at term with an FDIU. diagnosis also made from autopsy and cultures

Septic arthritis is a orthopaedic emergency and GBS is isolated as the cause in 10-20% of cases Although uncommon, if misdiagnosed can severely damage the involved joint GBS seen usually in the elderly population and the immunocompromised. Few reported cases of septic arthritis in young women who have suffered an adverse pregnancy outcome or instrumentation of the uterus.

Imam et al in 2012 reported a case of a Sri Lankan housewife who developed septic Arthritis of the shoulder and Sacroiliac joints from GBS only 12 hours post-partum. McKenna & O’ Brien reported sacroiliitis from GBS following mid-trimester dilation &curettage in a 37 year old undergoing medical termination of pregnancy in the USA

Conclusion GBS is a commonly encountered commensal of the female genital tract Invasive infection from GBS is rare, but few cases documented leading to adverse pregnancy outcome GBS not a common cause of septic arthritis Handful of cases in literature of invasive infection from GBS during pregnancy causing FDIU and septic arthritis

Thank you