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Understanding Group B Strep with Moira Bradfield

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Understanding Group B Strep with Moira Bradfield

Perinatal infection with group B streptococcus (GBS) is a global health issue occurring in approximately 1-4/1000 live births. There is a high mortality for neonates who acquire a group B strep infection following delivery, thus screening is now a standard feature of natal care.

So what role can complementary medicine play in the co-management or prevention of GBS?

Today we are joined by vaginal health expert, and founder of Intimate Ecology, Moira Bradfield, who shares her own clinical experience in supporting women who have been diagnosed with a GBS infection.     

Covered in this episode:

[00:44] Welcoming back Moira Bradfield
[01:58] What is Group B Strep?
[03:45] Why are these commensals becoming a problem?
[04:31] Group B Strep: how can you tell the good from the bad?
[06:19] How do patients present?
[09:22] Identifying Group B strep
[14:32] Antibiotic treatment
[15:59] Statistics of risks
[23:02] Supportive naturopathic interventions
[32:22] Thanks to Moira


Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today again, is Moira Bradfield. She’s a naturopath and acupuncturist who’s been in clinical practice for over 17 years. 

Graduating with a bachelor of naturopathy from Southern Cross Uni in 2001. Moira has worked as a naturopath in a variety of settings with a wide range of health conditions and disease states. In the pursuit of blending naturopathic medicine with oriental modalities, Moira completed a diploma in traditional Thai massage in 2004, and in 2010, completed a Master's degree in acupuncture. 

She's traveled to the United Kingdom, Thailand and China as part of her clinical training and interest in oriental health. She has a passion for considering the energetic principles underpinning nutritional interventions in client prescription and aligning treatment approaches with constitutional considerations. Moira blends this passion with a solid biochemical and pathological framework to create relevant and effective approaches to health and healing. 

Welcome back to FX Medicine, Moira. How are you going? 
Moira: Pretty good. Thanks for having me back. 
Andrew: So now today, we're talking about group B strep infection. And first, when we start off, I think we have to say, well, we're talking about Streptococcus, but which Streptococcus and what group? 
Moira: So, we are talking about streptococcus. And when we look at the divisions of streptococcus, most of us are familiar with some form of streptococcus. And a lot of us talk about group B strep seemingly like we know what we're talking about as well. And you're right. There are these divisions that actually occur because there's a group A to that group B. And when we're talking about group A and group B, they're both groups of Beta-hemolytic Streptococci

So when we talk about hemolytic then, it's the ability to bust open red blood cells essentially. This group A which is similar to group B in some ways, in terms of what it can actually cause in the human body. But in terms of the hemolytic disease, is actually streptococcus pyogene and group B streptococcus agalactiae
Andrew: Concentrating on the group B, beta-hemolytic streptococci, boy, that's a mouthful, are they different serotypes of that one, you know, subset? 
Moira: Yeah, they actually are. And the serotypes… research tells us there's 10 of them, differ in the polysaccharide capsule and that defines their immunologic activities as well. In the research when we look into the different serotypes, they're also associated with aspects of their virulence along which the toxin, the beta-hemolysin toxin. But also, sometimes the resistance to antibiotics might be associated with that serotype. 
Andrew: Now, often, these can be commensals. Why are we so concerned about Group B, Beta-hemolytic strep? 
Moira: Well, you're right. Often they are commensals and the incidence of carriage of group B strep is anywhere between 4% and 40% depending upon the population, where they're in the world, what point they're screened. And that is in pregnancy and also non-pregnant humans. 

So why we concentrate in group B strep is because of the possibility that it can cause early onset neonatal sepsis. So when we're looking at pregnancy and post-partum, obviously, there's a risk for maternal colonisation to be passed on to a neonate during birth, and therefore, that actually can develop into an active infection. 
Andrew: And you mentioned previously that, you know, depending on the serotype, it defines their immunological activity. Is there any effort to tease the different serotypes out so that a pregnant mother might know if they've got the dangerous one or the non-dangerous one. Or do they just go, "You've got group B strep, so we're going to treat you?"  
Moira: At this point, it's more "You have group B strep and we're going to treat you." And there's a whole protocol surrounding that. 

But in that, because at this point, it's still culture based. A lot of the testing that is wildly available...they do obviously antibiotic resistance in that testing as well. So in some ways, they're identifying serotypes indirectly. But most of the time, it's just about the ability literally of that organism on a blood agar plate to have that hemolysis effect around. And then there's also another test that they can do where they cross-culture it with staph aureus and there's this beautiful arrow line that occurs around the cross-culture when the two intersect. Based on the hemolytic activity as well of the strep B on the blood plate. 
Andrew: So that's one bacteria interacting with another, causing what? What's this arrow line? 
Moira: Well, the arrow line is, it’s more actually… if you look at pictures of it, it's quite amazing. It's a beautiful geometric shape of an arrow on the intersection of the two microbes, on the blood plate. 

Andrew: Yeah. 

Moira: And it's just an increased or heightened hemolysis of the blood in the blood agar. Because sometimes, the group B strep, even though it has this hemolytic activity, it's not so pronounced that you can actually identify it. So even the current ways that we have identification, there's varying degrees of accuracy in that as well. 
Andrew: So you mentioned, you know, obviously, a major risk with regards to lysis. But what do we see? What does a patient present with and what are we trying to control here? 
Moira: Okay. So what we're trying to control and why group B strep is on everybody's radar, essentially, it is in this at-risk group of neonates. There is obviously group B infection that occurs outside of pregnancy and outside of birth. And that's generally in the elderly and immuno-compromised. And as a microorganism, it has the ability to actually cause infection in a variety of different sites. So everything from pneumonia to meningitis effectively. So it depends on the person and the presentation. 

We know that in pregnancy, there's a variety of different risk factors that they actually will assess in birth around the mother but also the neonate. That would indicate that there's actually something going on. So certainly, for mothers in labour, the presence of fever is indicative that perhaps there's actually an invasive group B infection going on there. So this is outside of carriage. And then in the neonate, we're actually looking for those signs of distress or sepsis. And they can be very subtle obviously depending upon, your child. So there’s this, you know, anywhere from 24 to 48 hours of quite intense observations that goes on. Particularly if the group B carriage status of the mother is known going into labour. 

So they're looking for, obviously, respiratory distress, temperature instability. You know, if there's any sort of unexpected need for resuscitation in the neonate, any sort of apnea at that time, lethargy, seizures, feeding abnormalities, abdominal tension, blood glucose disregulation, blood pressure dropping, metabolic acidosis, and neurological signs. So it's quite a broad list because as a pathogen, it can, obviously, become active and invasive in several sites. And when we're looking at the birthing and where those membranes are actually opened to that bacteria being able to penetrate. That's obviously where that bacteria can get in. 

But in addition to that, we also see that there’s… it's theorised that certainly, we can have the transfer of group B strep to the neonate, in utero. And that actually would intact membranes as well. So certainly, membrane rupture and preterm or rarely rapture of membranes is associated with group B strep, as is preterm labor. But there's now this understanding that it also can actually penetrate through the membrane without rapturing and can cause an infection in the amniotic fluid possibly as well. So then we're exposing neonates in-utero to active infections.  
Andrew: And I guess you'd be looking at foetal distress syndrome in that instance. Would that be correct? 
Moira: Definitely, yes. Foetal distress syndrome, yeah. 
Andrew: So could you assume, not prove, obviously. But could you assume then that if the mother had some symptoms, you were suspecting a group B strep, but the baby seemed fine. That you could assume that the membranes, the amniotic membranes, were intact and that there was little risk for the neonate? I guess where I'm going here is; when do you treat? Most people will treat on parturition and afterwards, correct? 
Moira: Yes, definitely. And I guess we need to define there when we're talking treatment, because a lot of this is very medical. And coming at this from… as a naturopath who has a special interest in vaginas, you know, there's obviously lines that need to be drawn. And my awareness and understanding comes from understanding the medical side and the medical procedure around Group B strep. 

So they certainly have protocols of treatment and intervention and risk assessment. Which is a very.. quite global but do vary in Australia from state to state. We don't necessarily employ the same universal screening in every state in Australia. Or every territory in Australia. Which is very interesting as well, as I do, I work obviously, on the Gold Coast. Which we have a border to NSW, very close. So there's some interesting things when you have clients coming to you from both New South Wales and from Queensland where they have quite different prenatal care and screening going on. And the autonomy in their own healthcare is different for each of those different clients.  
Andrew: Wow. Look, I can remember working a hospital, a hospital within a state and you had different procedures that were accepted. So, you know, CSSD, the Central Sterilization and Supply Department. Would have different procedures for certain infections. Now, whether that was because of proven sensitivity to a bug in that particular hospital, I don't know. But I just thought it was rather...let's say it was quizzical. 
Moira: Yeah. Well, we do see that as well. So even though I say there’s differences state to state. Within each of those states, it's actually, so it seems...and as I said, my main experience is with New South Wales and Queensland. But from state to state, from care provider to care provider, they actually have the choice to implement one, well, there’s actually three, but one of two main protocols surrounding group B strep. 

So, again, it's dependent upon the care provider that your client is actually seeing and what they're actually required to do in their antenatal journey in terms of are they required to have a swab? Which is, the universal screening procedure is to swab from 35 to 37 weeks. And then if they're positive group B, positive at that time, then when they labor, they're actually given prophylactic antibiotics at labor. So they don't treat it beforehand because your status can change. And even if you were to clear it, you could actually have it come back again. 
Andrew: Reinfect. 
Moira: Yes. So they're just looking to have that essentially, sterility of that microbe around the birthing procedure through the birth canal itself. 
Andrew: With regards to the swabbing process, does it matter if it's a lower or high vaginal swab? 
Moira: No. And a lot of these... Well, yes. But a lot of the swabbing that is actually adopted now is patients self-swabbing. So they know that there's actually three sites that they will swab. And depending upon whether it's medical provider swab, or whether it’s self-swabbing, they can apply that how they like. 

So there’s certainly a vaginal… it doesn't necessarily have to be a high vagina, although in the hospital setting, it often will be. And then there's a perivaginal and then a rectal swab or an anal swab. So I know with clients who… and myself included, in pregnancy was given a kit to go home with, it was a perivaginal and an anal swab. In that order obviously, both swabs. 

And then what they actually know is that there's… so group B carriage is obviously like some microbes do, move from rectum to vagina to urinary tract. So they know that there's actually a higher sensitivity rectally to swab it than there is in the other site essentially. But it depends on the instruction you’re actually given. Because certainly I know, that you know, sometimes I see it where it’s just the perineum swab. Sometimes, it's the vagina swab. Sometimes it's vagina to anus. And sometimes it's all three and it's done in rooms. 

So, you know, there's a great variability just in the swabbing itself and therefore, the collection. And when we look at data, because there is a great amount of data of the universal screening procedure. Because it is essentially universal. There's a lot of countries that have adopted this particular procedure at 35 to 37 weeks and then initiating treatment from that. That there's huge variances in how that's actually applied as well. So there's a lot of things that actually go into this. 
Andrew: And treatment with antibiotics, IV? 
Moira: Yes, IV, and the caveats around that are you need at least four hours before birth for them to have effect. So the judgment then is made on do we have a four-hour window? So certainly things like cervical dilation are taken into account as well before we can implement it. And then it's an IV every four hours essentially, through the labouring process. So that's with the group B strep positive mother. And then once the baby’s born, then they go into observation. And then if they show any of those signs then they’re on antibiotics as well. 
Andrew: If it's IV, do you see more ampicillin being used or do you find that they're going for the bigger guns nowadays because of fears of antibiotic resistance like, you know, your vancomycin and clindamycin? 
Moira: So certainly, the standard is benzyl penicillin. 

Andrew: Benzyl, yep. 

Moira: Yeah, and then clindamycin and vancomycin are there if on culture it's identified as being resistant. Or...and then obviously we need to consider obviously penicillin analogy and everything else that goes on with that. 
Andrew: Yep. 
Moira: So that's the kind of protocol that I'm aware of in Queensland. So obviously, that's where I'm dealing with this mostly. Yeah, IV definitely. Which obviously then can place some restrictions on birthing and movement and all sorts of things. 
Andrew: Let's talk about naturopathic medicine and management. And I think to start off with, we need to answer the medico-legal issue. Do you 'treat' it at all? 
Moira: Do you treat it all? So, in Australia, there is some variability in protocol which gives us some variability in terms of how we approach it. 

As far as I'm aware and the experiences that I've had with pregnancy now is that there's still autonomy in this decision as well. So regardless of what state you're in and what protocol is being applied, there is still the right of refusal to swab, if it's a universal procedure. And then they tend to move into then the risk-based protocol. And the risk-based protocol is if there are maternal risk factors in play. And that includes previous GBS pregnancies, previous early onset GBS infection in the neonate, rapture of membranes as being for more than 18 hours. And a earlier UTI in pregnancy, that has been positive for GBS as well. So those are the things that put that maternal risk factor in play at actually birth itself. 

So if you refuse and then you go into a labor and then it appears that there are risk-based complications, then medically, they will employ that flowchart essentially of antibiotics or no antibiotics. And that applies as well for the neonate, on birth. So there is autonomy in that you can actually refuse swabbing. And, you know, so not actually knowing status. Because certainly statistics tell us that, you know, certainly the infection of GBS in a neonate is devastating and has quite a high mortality rate. So depending on what you read again, it can be up 50% of neonates with active infections, can die. 

So, but the statistic of carriage in neonates to conversion to active infection is actually not as high statistic as you would actually expect. So when we look at 40% to 50% of babies born to colonised mothers... Sorry, 40% to 50% of babies who are born to colonised mothers will actually have GBS carriage or colonisation. And then only about 1% to 2% of those will convert into an infection. 
Andrew: So to me, it's kind of like the risk of Listeria monocytogenes. And that is that the risk in reality is pretty low, but if you're that low risk, you're the one, it's devastating. 
Moira: It's devastating. That's right. And that's what they're doing is they have a universal protocol that has been shown to, you know, decrease neonatal mortality, in some aspects. So there are some interesting statistics about what the screening has done. So that certainly, there's an agreement that the prophylaxis or the treatment at birth has improved outcomes. But the screening doesn't necessarily has changed that statistic at all, which is very interesting. And then there's a whole array of factors around who they're researching and the fact that they're looking at a population that has had universal screening applied. So you can't really tease out the data that you need to tease out. 

Andrew: The bias. Yeah. 

Moira: So, yeah, certainly, it is devastating for the... You know, 1 in 1,000 child, essentially, will have this active infection. And the mother and then all of the complications that obviously come out of that. But we also need to weigh up the risk of what we know antibiotics do to the infant microbiome. And the array of unknown in that very early, you know, three months, of what can actually occur in terms of the programming essentially. And in-utero as well obviously. The programming of the setup for the rest of that particular person's life. 

So, you know, the antibiotics that they used with group B strep...and there have been studies done on the infant microbiome post this prophylaxis intervention. Shows that between anywhere from three to six months that there's been a restoration of the microbiome compared to other infants who haven't received that. But that’s certainly, only seen in those that are breastfed. And those that aren't breastfed, that, you know, return to a norm is prolonged much longer past a year. And then again, you know, all of that early programming in terms of metabolic and interaction and immunity, that's the unknown. You don't know what you've done essentially. And that's something, I guess, from a naturopathic perspective if we're looking at preventative medicine, that's where our intervention is. Is what can I do to avoid this even being a factor in this particular person's life. You know, if you're going to have the universal screening, lets make sure you get a negative, not a positive, and then this isn't an issue. 

Andrew: Yeah, yeah. 

Moira: And then, let's use our common sense in the hospital settings if that child shows signs of distress or sepsis, intervene, because that's lifesaving. And certainly, I mean, I have a lot of friends luckily that are midwives and we've been able to have these discussions is that, you know, the approach is that they're observed anyway. Let's just observe them essentially, and they make those decisions in the hospital setting. 

It's also quite interesting though, along that observational line, is that a lot of the early infections, so there's early and late onset group B strep infections. And the early, is 0 to 7 days, and the late is anywhere from 7 to 90 days. So there's a big window there. The late onset infection is far less fatal than the early onset. And the early onset, most of that will occur within the first 24 hours, post birth. So there's that observation window. 

It is concerning however when we see practices in some of the hospitals where they're now sending parents home. It’s concerning, but also encouraging in other areas, where they send them home after four hours. 
Andrew: Right. 
Moira: So that observation obviously disappears and is left then to the parents or the caregivers of that particular child. 
Andrew: But we would have seen spikes in, you know, hemolysis at home if we had a real issue there, wouldn't we? 
Moira: Well, not necessarily. Because the symptoms are not neccesarily, you know, evidently hemolysis. They are, you know, fever and things like that. And again, you know, you've been a new parent, it's all very worrying. 
Andrew: True, very true. 
Moira: And unknown and then people telling you that's normal. You know, I mean I'm sure that, you know, the symptoms generally are. But if the symptoms are crying and apnea and things like that, that you might not necessarily be able to pick up on. Then there's possibly a risk there. So certainly, if you get a choice, my recommendation if there was any consideration of risk in the mother, would be at least a night in hospital. You know, get some sleep then go home. 
Andrew: There’s a big one. Get some sleep now. So with regards to naturopathic medicine, at the risk of sounding prescriptive, and I don't like that. But it just seems like maybe there's a case that for, you know, let's say a month, that women, especially if they weren't going to breastfeed, receive some colostrum, some bovine colostrum. 

It's been shown to be active against a wide host of pathogens. It's pretty innocuous. It's a sort of active immune system for the bubba. It's safe, unless you’ve got a milk allergy, a true IGE allergy. 
Moira: So, I mean, any of those tools we have available that are safe in pregnancy, that can reestablish vaginal microbiome, that can support immunity, that can, you know, have those effects that we want in terms of beneficial outcomes in pregnancy, those are the preventative outcomes. You know, there certainly has been research on Lactobacilli strains of bacteria in group B strep positive women. But what that research actually tells us...and the statistics are significant enough that we know that it's quite a promising intervention. It's not complete, so in 49 women… this was a was a Taiwanese study. 49 women in the active probiotic groups in a randomised, controlled trial that were receiving, you know, a two strain in lactobacilli. 21 of them had a reversion back to negative. 
Andrew: Right. 
Moira: And this was the 35 to 37 weeks. So this is generally the agreement at that time is that whilst it can some natural reversion to negative, that that was statistically significant enough. But they were using...that was an oral intervention. They were using two of them a day. And the time period that they actually had that in play was a little bit longer. 

So it was 28 to 60 days, depending upon at what time period they swabbed them and then picked them up and therefore when they delivered. Because they measured them at birth, which is when they retested. Because we saw an Australian pilot study which used the same probiotics from my knowledge,well, slightly different strains. And they did a much shorter time frame. So 14 to 21 days and did not see that trend at all. 
Andrew: Gotcha. 
Moira: So what we actually need to consider is that this is perhaps something we should employ as general, you know, natal care. Is that we need to consider that regardless of whether this person is going to swab themselves for group B strep, that we need to consider that that is a bacteria that can exist in the genitourinary tract, in the rectum, and that perhaps, we need to diminish that count and get rid of altogether. And so probiotics, etc. 
Andrew: Yeah, I think there's real facility. You know, like, it's basically, you know, set in stone. That women should receive at minimum folic acid supplement. I would say not just the folic acid supplement because of the issue with covering up B12 deficiency if you give folic acid. And you don't know. So I would say the minimum B12 plus folate, but I would prefer a multi. 

It's basically “ok’d”, you know, by government to say, "Give that. It's good for women to do that." And when you look at the cost-benefit, it's worth it. I really think we're getting to the stage now where probiotics, they're safe in pregnancy, they're safe for babies, for neonates. There's a real facility for their use. The issue is the time that you take them. In all studies. So start early.

Moira: Yeah, definitely. 

Andrew: And then if you need to...maybe some colostrum as an additive, you know, call it an ‘immune booster’ if you like. An immune insurance. How's that? 
Moira: Yeah, definitely. It's certainly part of my ongoing protocol, is that we introduce them, you know, if not from the beginning, then at least from the second trimester. And that they are carried through. Because we have so many other risks, not just with group B strep, but, you know, certainly, you want to prevent urinary tract infections. 

Andrew: Yes.

Moira: And you want to, you know, improve immune status in offspring. And you know, we want full-term labors so that we avoid those other risks. And we want to do vaginal deliveries if we can and inoculation if we can. So it certainly is a really important part of that type of protocol. And if we do happen to get positive universal swab and there is the timeframe as well to be addressing that, it goes in there, in my clinical practice, in much higher basis and intravaginally. In addiction to some other things, that are a little bit more traditional in nature in terms of the research to backs them. Because it's interesting there’s..., you know, for example, the vaginal use of garlic which we've talked about before…

Andrew: Right. 

Moira: …Is something that, you know, anecdotally, across the internet is, very effective in group B strep. In a petri dish effect, within group B strep, there's been no research around it that I know of. I did find a clinical trial that was more about case collection and things like that. But there’s no results for that. 

So it certainly is something...you know, inserting a clove that's been bruised or crushed or pierced and then using a vaginal probiotic at the other end of the day. That in my experience, when you have had somebody who retested, you know, if they're in a care facility that agrees to retest based on the second result when they go into labour, that we've seen a reversion to a negative status.  
Andrew: And no caveats with the use of garlic with, you know, methosulphur compounds and burning or anything like that? 
Moira: Ahh, well, yes. Certainly, my experience with the burning...so we are, you know, asking them to crush...I tend to get them to pierce rather than to crush. 

Andrew: Right. 

Moira: Because obviously then you've got more of a mucous membrane contact if you're crushing, which you may obviously need. But the burning is also higher when the epithelium is a little bit inflamed. Which is more trending towards things like bacterial vaginitis. It can coexist, you know?

There is some suggestion that group B strep, even though it's commensal, when we start seeing it being problematic, we are obviously in a dysbiotic vagina, if that’s the membrane we're actually looking at. 

Andrew: Yep.

Moira: So there is a possibility that other, you know, opportunistic anaerobic organisms are existing at the same time at the levels that they shouldn’t be. So the inflammation there is usually surrounding those other organisms at that time. 

So I haven't had that negative feedback. And, you know, generally there's not even the requirement, in my experience, to thread a string through it, it just pops out in the morning. 
Andrew: Got you. So insert that over night? So the other end of the day when the lady inserts the next garlic clove, they're doing the probiotic? 
Moira: Yeah. 
Andrew: Because the garlic would kill the probiotic as well, wouldn't it? 
Moira: It depends, doesn't it, really? I mean, what we find is that certainly, not all antimicrobials are antimicrobial against everything. 
Andrew: Yeah, true. 
Moira: So you're obviously wiping out an opportunistic pathogen and allowing others to take its place in terms of beneficial microbes. And, you know, there's a whole other array around that vaginal dysbiosisthat we might need to consider in terms of intervention. But it just depends on the clinical presentation. 

So at the very basic level, probiotic, possibly garlic...I mean we see in that research that probiotics alone, convert in, you know, nearly 50% of the time. But for me, you obviously want a better than 50% conversion. 
Andrew: Fifty-percent is a flip of the coin. I wouldn't be comfortable with that. 
Moira: No. definitely not. So, you know, and because...what that means if you go into birth and you’re still positive, that’s certainly not amazing for anyone involved. And the repercussions of that obviously, emotionally, but also in things like breastfeeding and, you know, touch time with the neonate etc. So, it’s quite widespread in what can actually happen if that's the track that you end up down. 
Andrew: And obviously, continue the probiotic afterwards to recover from antibiotic therapy as well? 
Moira: Definitely, yeah. 
Andrew: You spoke about three to six months. Do you continue for that long? 
Moira: Possibly, not always that long. And again, it depends on the individual situations. What's going on? Has there been mastitis? You know, and that obviously dictates as well, what strains you might use. 

We know that, you know, interventions in probiotics in neonates, you know, really affect the bifidobacteria at the offset because it's what they have a lot of in the beginning. So you might want to be choosing strains that can be passed and then going from there. But also prebiotic therapy as well. You know, how can we actually get this to come up in the individual naturally, because again, you know, probiotics, they're fantastic. But in many ways, there still a stop-gap. You know, you need to encourage the person, the organism, the human, to be able to foster their own community. Otherwise it's always going to be symptomatic on one level. 
Andrew: Moira, every single time we podcast, I learn so much from you and you bring out clinical pearls to make us all think more about what we're doing with our patients, to help our patients always receive a better outcome. Thank you so much for joining us and talking to us about group B Strep today on FX Medicine. 
Moira: My pleasure, thank you for having me. 
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Additional Resources

Moira Bradfield
Intimate Ecology

Research explored in this podcast

Ho M, Chang YY, Chang WC, et al. Oral Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 to reduce Group B Streptococcus colonization in pregnant women: A randomized controlled trial. Taiwan J Obstet Gynecol. 2016 Aug;55(4):515-8 

Olsen P, Williamson M, Traynor V, et al. The impact of oral probiotics on vaginal Group B Streptococcal colonisation rates in pregnant women: A pilot randomised control study. Women Birth. 2018 Feb;31(1):31-37


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