Tasveer SinghO&G Registrar
Blacktown Hospital
Meet Jane Doe…A 34 year old womanfirst pregnancy booked in with an Obstetrician at 9 weeks
gestation.Negative antenatal serologyB Positive blood groupImmune to RubellaRoutine screening tests at booking Normal.10 year history of PCOS treated with MetforminSpontaneous conception
Jane has profound fear of having blood drawn from her
Refused a first trimester screen and the FGTT at 28 weeks
Normal morphology USNo smoking, alcohol or illicit drug use in the
pregnancyHad several ANC appointments, and an
uneventful antenatal run until 34 weeks
At 34 weeks…Presented for usual ANC appointmentReported reduced foetal movements for the
last 1 dayFoetal heart unable to be detected on
ultrasound…FDIU diagnosedEmotional support providedDelivery expedited in the next couple of days
with prostaglandins.Delivered a female foetus, weight 1770g
FDIU ScreenNormal HbA1CNegative thrombophilia screenNegative TORCH screenNegative Kleihauer testNo other positive tests results on usual FDIU
bloods
Post MortemBaby:
Moderate to severely macerated female babyWeight and length consistent with 32-33 week
sizeNormal morphology
Placenta:Weight 303g (25-50% for 33 weeks)Overcoiled cord 0.4 coils/cm (normal: 0.1-0.3)Marginal cord insertion
MicrobiologyBlood culture:
Streptococcus agalactiae (GBS) isolated form aerobic and anaerobic bottles
E coli isolated from aerobic bottleStomach Contents:
Modertae growth of GBSLight growth of E coli
Placenta subamniotic swab:Moderate growth of GBS
GBS
GBS
GBS
Most likely cause of deathInfection with GBS and E coliDegree of maceration indicated baby died in
33rd week of gestationBaby was not SGA
Several days post delivery…Presented to hospital with acutely sore right
hipRadiology was suggestive of a small joint
effusion Indicating transient synovitisUltrasound guided aspiration of the right hip
donePain settledAspiration was culture negative
3 days after initial aspirationHip pain returned worse than beforeArthroscopic joint aspiration and washout
was doneThick straw colored exudative fluid was
aspiratedThis aspirate grew GBS sensitive to
amoxycillinShe 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
DiscussionRole of GBS in Obstetric practice and neonatal
sepsis is well documented in literature Prophylactic IV antibiotics in labour is
protocol in every obstetric hospital3 to 8 per 1000 live births result in stillbirths
in developed countriesGBS 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
ConclusionGBS is a commonly encountered commensal
of the female genital tractInvasive 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