international collaborations in order to identify predictors of relapse and to improve the quality of counselling of these women. & References 1 Cauldwell M, Nelson-Piercy C. Re: Subsequent reproductive outcome among women with peripartum cardiomyopathy: a nationwide study. BJOG 2018;125:1039–40. 2 Guldbrandt HM, Johansen M, Vejlstrup N, Gustafsson F, Damm P, Ersboll AS. Subsequent reproductive outcome among women with peripartum cardiomyopathy: a nationwide study. BJOG 2018;125:1018–25. 3 Hilfiker-Kleiner D, Haghikia A, Masuko D, Nonhoff J, Held D, Libhaber E, et al. Outcome of subsequent pregnancies in patients with a history of peripartum cardiomyopathy. Eur J Heart Fail 2017;19:1723–8. 4 Elkayam U, Tummala PP, Rao K, Akhter MW, Karaalp IS, Wani OR, et al. Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. N Engl J Med 2001;344:1567–71. 5 Ersboll AS, Johansen M, Damm P, Rasmussen S, Vejlstrup NG, Gustafsson F. Peripartum cardiomyopathy in Denmark: a retrospective, population-based study of incidence, management and outcome. Eur J Heart Fail 2017;19:1712–20. Maria Guldbrandt Hauge, a Marianne Johansen, a Niels Vejlstrup, b Finn Gustafsson, b Peter Damm, a,c & Anne S Ersbøll a,c a Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen Ø, Denmark b Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen Ø, Denmark c Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N, Denmark Accepted 19 January 2018. DOI: 10.1111/1471-0528.15143 Re: Prevention of early-onset group B streptococcal disease. Green-top Guideline No. 36 Sir, The recent article by Hughes et al. 1 on the revised Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on the prevention of early-onset group B streptococcal (GBS) disease recommends significant changes in clinical practice. The incidence of early-onset GBS sepsis is increasing in UK in spite of having guidelines to prevent the disease since 2003. The exact reason for the increasing incidence is not known but there is evidence of missed opportunities to pre- vent infection for various reasons, such as not adhering to guidelines to give intrapartum antibiotic prophylaxis (IAP) and failing to communicate/access the results from the laboratory about GBS. 2 IAP reduces 80% of early onset disease and we give IAP based on risk factors in UK. Prolonged rupture of membranes for more than 18 hours is a significant risk factor at any gestation and the odds of getting early-onset dis- ease is 25 times higher when there is rupture of membranes for more than 18 hours. 3 In spite of two revisions of the RCOG guidelines, the RCOG recommen- dations for IAP for prolonged rupture of membranes for more than 18 hours are still not clear and are open to interpreta- tion, particularly at term gestation. The guidelines on prevention of early onset GBS infections from the USA, Canada, Australia and New Zealand clearly recommend giving IAP if GBS status is not known and the woman has ruptured membranes for greater than 18 hours at term. It would be useful if RCOG also clearly recommended IAP for prolonged rupture of members of more than 18 hours. A recent meta-analysis of randomised trials on antibiotic prophy- laxis for term or near term premature rupture of membranes has shown not only a reduction in neonatal sepsis, but also a significant reduction in maternal chorioamnionitis and endometritis when the latency was longer than 12 hours. 4 At Sunderland, we noticed that our rate of early-onset infections was high and found prolonged rupture of membranes to be the major risk factor from our audit in 2011. We implemented our recom- mendations to give IAP at any gestation if the GBS status is not known for prolonged rupture of membranes of more than 18 hours. We managed to achieve a 50% reduction in the incidence of the infections 5 years later in 2016. We also noticed a reduction in mortality (14% versus 7%) and morbidity (31% versus 0%) in the follow up of babies who had early-onset sepsis after we imple- mented our recommendations. It is pos- sible to reduce the GBS disease burden if we follow the guidelines correctly and give intrapartum antibiotic prophylaxis appropriately. & References 1 Hughes RG, Brocklehurst P, Steer PJ, Heath P, Stenson BM, on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention of early-onset neonatal group B streptococcal disease. Green-top Guideline. No. 36. BJOG 2017;124:e280–305. 2 Vergnano S, Embleton N, Collinson A, Menson E, Russell AB, Heath P. Missed opportunities for preventing group B streptococcus infection. Arch Dis Child Fetal Neonatal Ed 2010;95:F72–3. 3 Oddie S, Embleton N. Risk factors for early onset neonatal group B streptococcal sepsis: case control study. BMJ 2002;325:308–12. 4 Saccone G, Berghella V. Antibiotic prophylaxis for term or near-term premature rupture of membranes: meta-analysis of randomized trials. Am J Obstet Gynecol 2015;212:627.e1–9. Ruppa Mohanram Geethanath Sunderland Royal Hospital, Sunderland, UK Accepted 21 November 2017. DOI: 10.1111/1471-0528.15160 Authors’ reply Sir, We thank Dr Geethanath for his comments 1 on the latest RCOG guide- lines on the prevention of early-onset group B streptococcal (GBS) disease. 2 The issue of the best management of ruptured membranes at term is con- troversial. The multicentre TERM- PROM study by Hannah et al. in 1996 3 reported that although shorten- ing the duration of prelabour rupture ª 2018 Royal College of Obstetricians and Gynaecologists 1041 BJOG Exchange