Meningitis

Meningitis is not a gynaecological illness – and yet the most important step towards preventing it in the newborn is taken in the gynaecological practice: the swab for group B streptococci between weeks 35 and 37 of pregnancy. This page explains what meningitis is, which organisms matter for pregnant women and newborns, and what can be prevented.

What meningitis is

The brain and the spinal cord are surrounded by three membranes, between which cerebrospinal fluid circulates. When these membranes become inflamed, it is called meningitis. If the inflammation spreads to the brain itself, it is called meningoencephalitis.

The decisive distinction is by the causative organism, because everything else depends on it. Viral meningitis is commoner and as a rule runs a mild course; it mostly resolves by itself. Bacterial meningitis is rarer but life-threatening – untreated it is almost always fatal, and even treated it leaves damage in some of those affected.

This distinction cannot be made from the outside. It requires examination of the cerebrospinal fluid, obtained by a puncture in the lower back. Which is why, where meningitis is suspected, the rule is always: straight to hospital, do not wait.

The warning signs

In adults and older children:

• high fever with severe headache
• neck stiffness – the chin cannot be placed on the chest
• sensitivity to light
• nausea and vomiting
• confusion, drowsiness, seizures
• small, pinpoint bleeding into the skin that does not blanch under a glass

The last sign counts as an emergency within the emergency: it points to blood poisoning caused by meningococci, which can become life-threatening within hours. The glass test is simple – press a transparent glass firmly onto the spot; if it stays visible, call the ambulance on 144 immediately.

In newborns and infants these signs are often absent. Instead of neck stiffness what shows are: poor feeding, striking sleepiness or unusual restlessness, shrill crying, a bulging fontanelle, pale or mottled skin, temperature swings in both directions. A newborn that no longer feeds properly and feels different from usual should be assessed without delay – and that applies even where there is no fever.

Group B streptococci: the swab in weeks 35 to 37

This is the part for which gynaecology is directly responsible.

Group B streptococci, GBS for short, are bacteria that occur in the bowel and the vagina of about ten to thirty per cent of all women – without causing symptoms. It is not an illness but a colonisation. For the woman herself it is of no significance.

For the child it is not. During birth the organism can be transmitted, and in a small proportion of cases this leads to a severe infection of the newborn – blood poisoning, pneumonia or indeed meningitis. GBS is the commonest cause of bacterial meningitis in the first week of life in Europe.

The figures put this in context: of a hundred women about twenty carry the organism, and without prevention roughly one child in two hundred of colonised mothers falls ill. That is rare – and at the same time common enough for prevention to be worthwhile, because the individual case weighs so heavily and the measure is so simple.

This is why in Austria a swab from the vagina and the rectum is taken between weeks 35 and 37 of pregnancy. The timing is deliberately late: colonisation fluctuates, and a result from week 30 says little about the situation at the due date.

If the swab is positive, the mother is given an antibiotic into the vein during labour – usually penicillin, starting at least four hours before the birth. That is enough to prevent transmission almost entirely; the frequency of early neonatal infection has fallen by about eighty per cent as a result.

Important for context: a positive result is not an illness, not a reason for a caesarean section and not a reason to take antibiotics before the birth – treatment during pregnancy does not remove the colonisation permanently, it comes back. What counts is solely the administration during labour.

When this window falls in your pregnancy is worked out by the parent-child pass planner – the swab is usually taken at the fifth examination.

Listeria: the infection that comes through food

Listeria monocytogenes is the second organism of particular importance in pregnancy. Pregnant women fall ill about ten to twenty times more often than other adults, because the immune defences are altered in pregnancy.

For the mother listeriosis often runs an unspectacular course: flu-like symptoms, fever, muscle pain, sometimes diarrhoea. In adults outside pregnancy it can cause meningitis – making it one of the few organisms that trigger meningitis through food.

For the child it is dangerous. Listeria cross the placenta and can cause miscarriage, preterm birth or a severe infection of the newborn in which meningitis is part of the picture.

It can be almost entirely prevented through diet. What is avoided:

• raw milk and cheese made from raw milk, especially soft cheese with a rind
• raw and smoked meat, raw sausage, spreadable raw sausage
• raw fish, smoked fish, sushi
• pre-cut salads and delicatessen salads sold loose
• sprouts

The reason for this list: listeria multiply even at refrigerator temperature – unlike most other organisms. This is why chilling is not enough, and this is why it is precisely pre-cut, long-stored foods that are affected. Heating them right through kills them; heated dishes are safe, even if they come from one of the groups named.

How the swab is taken

There are two swabs: one from the lower part of the vagina and one from the rectum. The second regularly comes as a surprise but is the more important – the bowel is the actual reservoir from which the vagina is repeatedly colonised. A swab that covers only the vagina misses some of the positive women.

Taking it lasts seconds and is not painful; a speculum is not needed for it. In some countries women take the swab themselves, with equally good results – ask about that if you would prefer it. The result is available after two to three days, because the bacteria have to be cultured in the laboratory.

Two situations make the swab unnecessary because treatment is given in any case: if group B streptococci have been found in the urine during this pregnancy, and if a previous child had a GBS infection. In both cases the woman counts as positive, regardless of the swab result.

And if labour starts before the swab has been taken – with a preterm birth, for instance – the decision in hospital follows risk factors: fever during labour, membranes ruptured for more than eighteen hours, or a birth before week 37 all lead to antibiotics being given, even without a result.

Early and late neonatal infection

With group B streptococci two forms are distinguished, and the difference explains why prevention covers only part of the problem.

The early form appears in the first week of life, mostly in the first 24 hours. It arises through transmission during birth and shows itself as blood poisoning or pneumonia, less often as meningitis. It is precisely this form that the antibiotic during labour prevents – and very effectively at that.

The late form appears between the second week of life and the third month of life. It more often involves meningitis and cannot be prevented by the measures taken during labour, because infection occurs later and from other sources.

For parents a practical sentence follows from this: a negative swab and an uncomplicated birth do not exclude a later infection. Which is why the rule stands that a newborn that feeds poorly, is strikingly sleepy or unusually restless should be looked at the same day.

Tick-borne encephalitis: the viral form that counts in Austria

Among the viral forms of meningitis one has particular significance in Austria: tick-borne encephalitis, TBE for short (in German: Frühsommer-Meningoenzephalitis, FSME). It is transmitted by ticks, and Austria is among the countries with the highest prevalence in Europe.

The course is typically in two phases. After one to two weeks flu-like symptoms appear, which subside. In some of those affected a second phase follows after a symptom-free interval, with high fever, headache, neck stiffness and in severe cases involvement of the brain and spinal cord. Lasting paralysis and difficulties with concentration occur; there is no treatment directed at the cause.

It can be prevented by a vaccination which is offered throughout Austria. It is an inactivated vaccine, and from that follows the piece of information decisive for this page: it can in principle be used in pregnancy. The licensing texts are cautiously worded because systematic studies in pregnant women are lacking; where the risk of exposure is high – with occupational work in forests or in a high-risk area, for instance – it is given after weighing things up.

Anyone planning the basic course anyway is best placing it before a pregnancy. Three doses are needed for it, the third after five to twelve months; after that boosters every three to five years depending on age. That span of time is hard to fit into a pregnancy and easy to fit in before one.

The organisms that vaccination can prevent

A considerable proportion of bacterial meningitis can be prevented by vaccination. Four organisms stand in the foreground, and against three of them vaccination is given in Austria in childhood.

The effect of these vaccinations can be read off the figures. Before the introduction of the Hib vaccination, Haemophilus influenzae type b was the commonest cause of bacterial meningitis in small children; today it is a rarity. The same holds for the pneumococcal conjugate vaccination.

The last two rows of the table are the gynaecological ones: where no vaccination exists, care in pregnancy takes its place.

Why protection from the mother is not enough here

The mother's antibodies cross to the child in the last third of pregnancy and carry it through the first months of life. With several illnesses this works well – with whooping cough it is even the express purpose of a vaccination in pregnancy.

With the organisms causing meningitis it is different. The protective antibodies are directed against the sugar coats of the bacteria, and against such structures an adult who has not been vaccinated often does not form high levels. For group B streptococci there is no vaccine that could change this – one that would allow pregnant women to be vaccinated has been worked on for years, but none has been licensed so far.

So it remains with the swab and the antibiotic during labour. It is a more cumbersome solution than a vaccination, and it works.

What meningitis can leave behind

Even when treated, bacterial meningitis leaves consequences in some of those affected. The commonest is hearing loss – it arises because the inflammation spreads to the inner ear, and it is the reason why a hearing test is routinely carried out after meningitis in childhood. Impaired hearing recognised early can be treated; overlooked, it delays the development of speech.

Less often, seizures, difficulties with concentration and learning, or movement disorders remain. After meningococcal blood poisoning the disturbance of the circulation can cause tissue damage extending to the loss of limbs.

This list is not here to frighten but to put two things in context. First, it explains why treatment is given immediately and without delay where meningitis is suspected – every hour really does count. Second, it explains why vaccination is given against these organisms even though the illnesses are rare: it is not about how often they occur but about the scale of what is at stake in the individual case.

How it is treated

Where bacterial meningitis is suspected, nobody waits for results. Blood cultures are taken, then a high-dose antibiotic is given immediately into the vein, in adults together with corticosteroids, which lower the frequency of hearing damage. The lumbar puncture follows as quickly as possible; treatment is adjusted as soon as the organism is known.

For close contacts of a case of meningococcal disease a preventive antibiotic is provided for, usually within 24 hours. It concerns members of the household and people with close contact with secretions – not the whole school class. Suitable preparations exist for pregnant women; the public health authority determines who receives them.

With viral meningitis, treatment is mostly for relief of symptoms. An exception is the herpes viruses, against which an effective medicine is available – another reason why identifying the organism cannot be dispensed with.

With a newborn in whom infection is suspected, the same principle is followed, only with an even shorter fuse: take blood cultures, start an antibiotic, examine the cerebrospinal fluid as soon as the circulation permits. If the suspicion is not confirmed, treatment is stopped again after two to three days. This willingness to start a treatment and then discontinue it is not a sign of uncertainty but the only approach that does justice to the pressure of time.

What happens next

The swab for group B streptococci is part of routine antenatal care and does not have to be asked for specially. A positive result belongs in the parent-child pass and must be known to the maternity unit – so carry the pass with you to every appointment and to the birth. Arranging an appointment.

Where meningitis is suspected, in Austria call the ambulance on 144 or the health line 1450. This practice is not an emergency department.