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