Streptococcal Colonization Research Articles

The acceptability of implementation of group B Streptococcus testing: Perspectives from women and health professionals in the GBS3 trial: A qualitative study

ObjectiveTo determine the acceptability of different methods of routine testing for group B Streptococcus (GBS) colonisation to pregnant women and health care professionals (HCPs), and to examine barriers and facilitators to their implementation. DesignQualitative study, embedded in a cluster randomised trial SettingFour NHS maternity units participating in the GBS3 Trial: two conducting routine antenatal enriched culture medium (ECM) testing; and two using routine rapid intrapartum testing.Sample39 women and 25 HCPs purposively sampled to ensure representation of women with various birthing experiences and different professions.MethodsWomen were interviewed approximately 12 weeks postpartum by telephone or online video call, using a semi-structured topic guide. HCPs were interviewed during the testing period of the trial. Interviews were transcribed for thematic analysis and summarised using the framework method. ResultsFour categories of interest emerged: (1) views of routine testing; (2) acceptability of the testing procedure; (3) preferences on the types of test; (4) improving the testing procedure. Routine GBS testing was well received by both women and HCPs. Most participants found the procedure acceptable and were willing to receive the offer of testing in the future. Preferences for different testing methods varied, with participants emphasising the importance of evidence and informed choice. ConclusionsRoutine GBS testing is acceptable to most women and HCPs. Areas for consideration and the practicalities of implementing testing in maternity services are highlighted.

Comparison of qPCR and chromogenic culture methods for rapid detection of group B streptococcus colonization in Vietnamese pregnant women

IntroductionNeonatal infections can rapidly become severe, with delays in treatment often proving fatal. Streptococcus agalactiae (Group B Streptococcus, GBS) is a common cause, typically transmitted from colonized pregnant women to neonates during childbirth. In Vietnam, routine prenatal care lacks standardized GBS screening protocols. This study aims to compare enhanced qPCR methods with the culture method, evaluate the diagnostic accuracy of these qPCR procedures, and assess the frequency of GBS infection in pregnant Vietnamese women during their final trimester. Materials and methodsPregnant women aged 35 weeks gestation or more were recruited. Rectovaginal swabs were collected and analyzed for GBS using chromogenic culture, a commercial real-time PCR kit, and in-house real-time PCR assays targeting the cfb and sip genes. Clinical diagnostic values were calculated, and GBS prevalence was determined. ResultsThe study included 259 pregnant women with a mean age of 30.2 ± 5.0 years. Of these, 96.6 % had gestational ages of 37 weeks or more at delivery. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the cfb-based and sip-based qPCR assays were 94.1/92.7, 99.0/99.5, 97.1/98.5, 97.8/97.3, and 97.6 %, respectively. The Kappa values were excellent (0.940 and 0.939), with results available in under 2 h. GBS prevalence was 24.7 % and 25.5 % by cfb-based and sip-based qPCR assays, aligning with the culture method (25.5 %). ConclusionsBoth direct real-time PCR assays demonstrated high accuracy and were comparable to chromogenic culture in diagnosing GBS. A significant prevalence of GBS colonization was found among Vietnamese pregnant women in their final trimester.

A Validated Calculator to Estimate Risk of Chorioamnionitis in Laboring and Induced Patients at Term.

Chorioamnionitis is associated with neonatal morbidity and infection-related mortality, but our ability to predict intrapartum infection is limited. We sought to derive and validate a prediction model for chorioamnionitis among patients presenting to labor and delivery at term. This was a planned secondary analysis of a large cohort study from 2014 through 2018 at an academic tertiary care center. To derive a prediction model for chorioamnionitis, we limited our analysis to full-term (≥37 weeks) patients with a singleton gestation undergoing labor induction and presenting in labor. Both nulliparous and multiparous patients were included. Patients with a planned cesarean delivery, fever on admission, or missing data were excluded. The model was derived using multivariable logistic regression. Refinement of the prediction model with internal calibration was performed. External validation was performed utilizing a publicly available database (Consortium on Safe Labor) and applying the same inclusion and exclusion criteria. The discriminative power of each model was assessed using a bootstrap, bias-corrected area under the curve. The chorioamnionitis rates in the derivation and external validation groups were: 5% (1,005/19,966) and 5.8% (n = 3,005/52,171), respectively. In multivariable modeling, maternal age, nulliparity, gestational age, smoking status, group B streptococcus colonization, hours ruptured, number of cervical exams, length of labor, epidural use, internal monitoring, and meconium were significantly associated with infection. A calculator was created and externally validated with an area under the curve of 0.82 (95% confidence interval, 0.81-0.82). External validity was further confirmed with a calibration intercept of 0.81. This is the first infection calculator created and validated for the prediction of developing chorioamnionitis in patients undergoing induction of labor at term. This calculator can be used to augment patient counseling and guide intrapartum infection surveillance in laboring patients.

Participant Personal Characteristics and Adherence to Oral Capsules: A Secondary Analysis of a Randomized Placebo-Controlled Trial of Antenatal Probiotics.

Adherence to study interventions is critical to the conduct of randomized controlled trials (RCTs). The relationships between participant characteristics and intervention adherence are understudied in pregnant populations. The purpose of this study was to conduct a secondary analysis of adherence to study capsules in a double-masked, placebo-controlled RCT of a probiotic intervention to reduce antenatal Group B Streptococcus colonization, in relationship to participant characteristics. We analyzed the relationship between capsule adherence rates and demographic characteristics among 81 RCT participants. Categorical variables were reported using counts and percentages, and continuous variables were expressed as means along with their standard deviations. For the univariate analyses, we compared demographic variables with adherence scores. A multivariate linear regression model was used to identify predictors of adherence. Average adherence was similar for control and probiotic group participants (P =.86) Univariate analysis showed that average adherence increased directly with age, education, and income. Participants who were partnered or living with others had higher average adherence compared with those who were single and living alone. Asian and White participants had the highest and Black participants had the lowest average, and there was no difference based on Hispanic ethnicity. Adjusting for all the variables in the regression, participants who identified as Black were significantly less likely to adhere to capsules than White participants, and those who were married or living with partners were more likely to adhere than the single participants. Diverse participants are critically important to RCTs. This secondary analysis provides evidence that participant characteristics and the social determinants of health play an important role in adherence to self-administered interventions in RCTs, although more research is needed. Our findings suggest that intentional consideration of RCT participant characteristics may allow for the development and tailoring of strategies to enhance intervention adherence. The study was registered on ClinicalTrials.gov (NCT03696953) on January 10, 2018.

Comparison of Polymerase Chain Reaction Method with Culture Method in Antenatal Group B Streptococcus Screening.

The aim of this study was to investigate the prevalence of Group B Streptococcus (GBS) colonization in pregnancies between 35 and 37 weeks of gestation and to compare the effectiveness of polymerase chain reaction (PCR) method with gold standard technique of culture in antenatal GBS screening. Vaginal and rectal swabs of a total of 106 pregnant women between 35th and 37th weeks of gestation, who were admitted to our clinic between January 2022 and August 2022, were evaluated using culture and PCR method. The prevalence of GBS was estimated. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the PCR method were analyzed. The prevalence of GBS was 10.4% and 21.69% using the culture and PCR method, respectively. Compared to the culture, the sensitivity, specificity, PPV, NPV and accuracy of PCR were found to be 100%, 87%, 47%, 100%, and 88%, respectively. This study results suggest that the PCR method is a simple, effective and fast method with high sensitivity, specificity, PPV, and NPV in antenatal GBS screening.

Group B streptococcus colonization in pregnancy and neonatal outcomes: a three-year monocentric retrospective study during and after the COVID-19 pandemic

Group B streptococcus colonization in pregnancy and neonatal outcomes: a three-year monocentric retrospective study during and after the COVID-19 pandemic

Prevalence of group B Streptococcus colonisation in mother–newborn dyads in low-income and middle-income south Asian and African countries: a prospective, observational study

Rectovaginal group B Streptococcus (GBS) colonisation in pregnant individuals at the time of labour is a major risk factor for invasive GBS disease by age 7days (early-onset disease). We aimed to investigate the prevalence of rectovaginal GBS colonisation at the time of labour among pregnant women and vertical transmission to their newborns across selected low-income and middle-income African and south Asian countries. This prospective, observational study was undertaken at 11maternity and obstetric care facilities based in Ethiopia, Kenya, Mozambique, Nigeria, Mali, South Africa, Bangladesh, India, and Bhutan. HIV-negative pregnant women aged 18-45years who were in the early stages of labour and at least 37weeks' gestation were eligible for inclusion. Lower vaginal and rectal swabs and urine were collected from the women, and swabs of the umbilicus, outer ear, axillary fold, rectum, and throat were obtained from their newborns, for GBS culture. Standardised sampling and culture using direct plating and selective media broth for detection of GBS colonisation was undertaken at the sites. Serotyping of GBS isolates was done in South Africa. The primary outcome was the prevalence of rectovaginal GBS among pregnant women, analysed in participants with available data. This study is registered with the South African National Clinical Trials Register, number DOH-27-0418-4989. 6922pregnant women were enrolled from Jan 10, 2016, to Dec 11, 2018, of whom 6514 (94·1%; 759-892per country) were included in the analysis; data from Bhutan were not included in the study due to issues with specimen collection and processing. Overall, the prevalence of maternal GBS colonisation was 24·1% (95% CI 23·1-25·2; 1572of 6514); it was highest in Mali (41·1% [37·7-44·6]; 314of 764) and lowest in Ethiopia (11·6% [9·5-14·1]; 88of 759). Theoverall rate of vertical transmission of GBS from women with rectovaginal GBS colonisation was 72·3% (70·0-74·4; 1132of 1566); it was highest in Mozambique (79·2% [73·3-84·2]; 168of 212) and lowest in Bangladesh (55·8%, 47·5-63·8; 77of 138). The five most common GBS colonising serotypes were Ia (37·3% [34·9-39·7]; 586of 1572), V(28·5% [26·3-30·8]; 448of 1572), III (25·1% [23·0-27·3]; 394of 1572), II (9·2% [7·8-10·7]; 144of 1572), and Ib(6·5% [5·4-7·8]; 102of 1572). There was geographical variability in serotype proportion distribution; serotype VIIwas the third most common serotype in India (8·6% [5·3-13·7]; 15of 174) and serotype VI was mainly identified in Bangladesh (5·8% [3·0-11·0]; eight of 138) and India (5·7% [3·2-10·3]; ten of 174). Our study reported a high prevalence of GBS colonisation in most settings, with some geographical variability even within African countries. Our findings suggest that serotypes not included in current multivalent capsular-polysaccharide GBS vaccines prevail in some regions, so vaccine efficacy and post-licensure effectiveness studies should assess the effect of vaccination on maternal GBS colonisation given the potential for replacement by non-vaccine serotypes. Bill & Melinda Gates Foundation.

Group B Streptococcus colonization status and antibiotic use during labour - a single-centre observational study.

Group B streptococcus (GBS) colonization among pregnant women is the leading cause of neonatal infection. Intrapartum antibiotic prophylaxis (IAP) is the most effective method to reduce the incidents of neonatal sepsis. We describe compliance with GBS management and the implementation of IAP in the context of the long-term effect of antibiotics. The study was conducted among 249 childbearing women hospitalized between January 2022 and February 2022 at University Clinical Center in Gdansk, Poland. The data were obtained from the questionnaire and medical records. We analyzed maternal colonization with GBS, compliance with GBS screening and treatment guidelines, risk factors contributing to GBS colonization, IAP administration, and neonatal congenital infection occurrence. Of all patients, 240 (96.4%) were screened for GBS, 215 (89.6%) between 35-37 weeks of gestation. Fifty (20%) were GBS-positive, 184 (74%) negative, 15 (6%) had unknown GBS status. There were no significant differences between the GBS-positive and GBS-negative groups in maternal age, mode of delivery, gestational age at birth, maternal comorbidities, parity, GBS status in previous pregnancies, and the development of infection among infants of both groups, regardless of IAP administration. Of all the studied women, 158 (63.5%) received antibiotics, 91 (36.5%) did not. The study showed the low positive and the high negative predictive value of the antenatal GBS screening test. We found that compliance with the universal GBS screening is widespread. The management of women with absent or only partial screening test requires assessing the risk factors before administering IAP.

Sexual activity, vaginal symptoms, maternal perineal hygiene behavior, and constipation on ano-vaginal colonization of group B streptococcus in near term pregnancy

BackgroundMaternal Group B Streptococcus (GBS) colonization is influenced by many factors but results are inconsistent. Consideration of antenatal risk factors may help inform decision making on GBS microbiological culture screening where universal screening is not standard of care. We sought to identify independent predictors of GBS colonization at 34–37 weeks gestation incorporating vaginal symptoms, perineal hygiene measures, sexual activity, and a potential novel factor, constipation.MethodsIn this prospective cross-sectional study, 573 women at 34–37 weeks gestation had an ano-vaginal swab taken and sent for selective culture for GBS. Women were asked about vaginal bleeding, discharge, irritation and candidiasis, antibiotic use during pregnancy, ano-vaginal hygiene practices such as douching and perineal cleansing after toileting, sexual intercourse related activities, and a potential novel factor for GBS carriage, constipation. Maternal basic demographics and obstetric-related characteristics were also collected. Bivariate analyses were performed to identify associates of GBS colonization. All variables with p < 0.05 found on bivariate analysis were then included into a model for multivariable binary logistic regression analysis to identify independent risk factors for GBS colonization.ResultsGBS colonization was found in 235/573 (41.0%) of participants. Twenty six independent variables were considered for bivariate analysis. Eight were found to have p < 0.05. Following adjusted analysis, six independent predictors of GBS colonization were identified: ethnicity, previous neonatal GBS prophylaxis, antenatal vaginal irritation, antibiotic use, recent panty liner use, and frequency of sexual intercourse. Vaginal discharge and perineal cleansing were not associated after adjustment. Recent douching and constipation were not associated on bivariate analysis.ConclusionThe identification of independent predictors of GBS colonization in late pregnancy may inform the woman and care provider in their shared decision making for microbiological screening at 35–38 weeks gestation in locations where universal GBS screening is not standard of care.Ethics oversightThis study was approved by the Medical Ethics Committee of University Malaya Medical Centre (UMMC) on August 9, 2022, reference number 2022328-11120.

Prevalence of Group B Streptococcus Colonization in Pregnant Women in Iran: A Systematic Review and Meta-Analysis

Introduction: Group B Streptococcus (GBS) or Streptococcus agalactiae is one of the main causes of invasive infections such as meningitis and septicemia in infants. Genital colonization with group B streptococci has been related to increased risk of premature delivery, and premature infants are at greater risk of disease. There is limited information about the prevalence of rectovaginal GBS colonization in pregnant women in Iran. The aim of the present study was investigating the prevalence of group B streptococcus colonization in pregnant women in Iran. Methods: Information of this study was attained by searching on databases including PubMed, Google Scholar, Scopus, Web of Science and SID using relevant keywords and without time limit. Then, the studies containing the inclusion criteria were reviewed. The data were analyzed using Comprehensive MetaAnalysis software (Biostat V3). Heterogeneity between studies was investigated with the I2 index and based on the results of heterogeneity, the random effect model was implemented in order to determine the prevalence of GBS in pregnant women. Results: Out of 231 articles, 15 articles were included in the study. The analysis of 15 studies showed that the prevalence of GBS in Iranian pregnant women was 12.2% (95% CI: 9.9-15.1). Conclusion: In order to prevent the invasive neonatal disease, screening for GBS colonization is recommended for pregnant women in 35–37 weeks of gestation. Regarding the lack of preventive strategies for GBS infections in Iran, national guidelines should be established to guide the obstetricians, midwives, and nurses on the prevention of GBS infections.

Significant Correlation Between Cutaneous Abundance of Streptococcus and Psoriasis Severity in Patients with FBXL19 Gene Variants.

Psoriasis results from both genetic predisposition and environmental triggers, such as Streptococcal infections. This study aimed to explore the correlation between the abundance of the Streptococcus genus on the skin and psoriasis severity in individuals carrying specific psoriasis-associated genetic variants. Studying 39 chronic plaque psoriasis patients, the elbow skin microbiome and 49 psoriasis-related single nucleotide polymorphisms (SNPs) were analysed using a MiSeq instrument for 16S rDNA sequencing, and CLC Genomic Workbench for processing and analysis. Through multivariate linear regression analysis, a positive correlation was found between Streptococcus genus abundance and psoriasis severity in patients with certain FBXL19 gene-related heterozygous SNPs (rs12924903, rs10782001, rs12445568). Conversely, a negative association was observed in patients with homozygous genotypes. Moreover, we identified an association between Streptococcus abundance and psoriasis severity in patients with genetic variants related to IL-22, ERAP1, NOS2, and ILF3. This is the first study highlighting a positive association between Streptococcus skin colonization and psoriasis severity in patients with heterozygous genotypes within the FBXL19 gene region. FXBL19 targets the IL-33/IL1RL1 axis, crucial in infectious diseases and innate immunity promotion. These novel results suggests an intricate interaction among host genetics, Streptococcus skin colonization, and psoriasis inflammation, offering potential avenues for novel treatment approaches.

Diet influences community dynamics following vaginal group B streptococcus colonization.

The vaginal microbiota plays a pivotal role in reproductive, sexual, and perinatal health and disease. Unlike the well-established connections between diet, metabolism, and the intestinal microbiota, parallel mechanisms influencing the vaginal microbiota and pathogen colonization remain overlooked. In this study, we combine a mouse model of Streptococcus agalactiae strain COH1 [group B Streptococcus (GBS)] vaginal colonization with a mouse model of pubertal-onset obesity to assess diet as a determinant of vaginal microbiota composition and its role in colonization resistance. We leveraged culture-dependent assessment of GBS clearance and culture-independent, sequencing-based reconstruction of the vaginal microbiota in relation to diet, obesity, glucose tolerance, and microbial dynamics across time scales. Our findings demonstrate that excessive body weight gain and glucose intolerance are not associated with vaginal GBS density or timing of clearance. Diets high in fat and low in soluble fiber are associated with vaginal GBS persistence, and changes in vaginal microbiota structure and composition due to diet contribute to GBS clearance patterns in nonpregnant mice. These findings underscore a critical need for studies on diet as a key determinant of vaginal microbiota composition and its relevance to reproductive and perinatal outcomes.IMPORTANCEThis work sheds light on diet as a key determinant influencing the composition of vaginal microbiota and its involvement in group B Streptococcus (GBS) colonization in a mouse model. This study shows that mice fed diets with different nutritional composition display differences in GBS density and timing of clearance in the female reproductive tract. These findings are particularly significant given clear links between GBS and adverse reproductive and neonatal outcomes, advancing our understanding by identifying critical connections between dietary components, factors originating from the intestinal tract, vaginal microbiota, and reproductive outcomes.

Timing of exposure assessment in studies on Group B streptococcus colonization and preterm birth

Timing of exposure assessment in studies on Group B streptococcus colonization and preterm birth

Intrapartum prophylactic efficacy of ampicillin versus clindamycin in preventing vertical transmission of group B Streptococcus.

To compare the prophylactic efficacy of ampicillin and clindamycin against vertical transmission of group B Streptococcus from mothers to their infants by evaluating the rates of group B Streptococcus colonisation. We retrospectively extracted data for mothers who delivered at Showa University Northern Yokohama Hospital between 1 October 2017 and 31 March 2021 and tested positive for antepartum group B Streptococcus, and their infants. The chi-square test was used to compare the rates of group B Streptococcus colonisation, sepsis, and meningitis. We conducted a multivariate logistic regression analysis, including the time interval between membrane rupture and delivery, chorioamnionitis, and maternal intrapartum fever (≥38.0°C). Two hundred fifty-nine mothers and their infants were eligible. Ampicillin and clindamycin were administered to 150 and 109 mothers, respectively. In the ampicillin and clindamycin groups, 12.0% (18/150) and 37.6% (41/109) infants were group B Streptococcus positive, respectively. The rate of group B Streptococcus colonisation among infants was significantly lower in the ampicillin group (p < 0.001). Multivariate regression analysis showed similar results (p < 0.001). No sepsis or meningitis cases were observed in either group. Prophylactic efficacy of clindamycin against the vertical transmission of group B Streptococcus is lower than that of ampicillin.

Risk factors for infection and outcomes in infants with neonatal encephalopathy: a cohort study

BackgroundTo determine the association between early infection risk factors and short-term outcomes in infants with neonatal encephalopathy following perinatal asphyxia (NE).MethodsA retrospective population-based cohort study utilizing the National Neonatal Research Database that included infants with NE admitted to neonatal units in England and Wales, Jan 2008–Feb 2018. Exposure: one or more of rupture of membranes >18 h, maternal group B streptococcus colonization, chorioamnionitis, maternal pyrexia or antepartum antibiotics. Primary outcome: death or nasogastric feeds/nil by mouth (NG/NBM) at discharge. Secondary outcomes: organ dysfunction; length of stay; intraventricular hemorrhage; antiseizure medications use.Results998 (13.7%) out of 7265 NE infants had exposure to early infection risk factors. Primary outcome (20.3% vs. 23.1%, OR 0.87 (95% CI 0.71–1.08), p = 0.22), death (12.8% vs. 14.0%, p = 0.32) and NG/NBM (17.4% vs. 19.9%. p = 0.07) did not differ between the exposed and unexposed group. Time to full sucking feeds (OR 0.81 (0.69–0.95)), duration (OR 0.82 (0.71–0.95)) and the number of antiseizure medications (OR 0.84 (0.72–0.98)) were lower in exposed than unexposed infants after adjusting for confounders. Therapeutic hypothermia did not alter the results.ConclusionsInfants with NE exposed to risk factors for early-onset infection did not have worse short-term adverse outcomes.ImpactRisk factors for early-onset neonatal infection, including rupture of membranes >18 h, maternal group B streptococcus colonization, chorioamnionitis, maternal pyrexia or antepartum antibiotics, were not associated with death or short-term morbidity after cooling for NE.Despite exposure to risk factors for early-onset neonatal infection, infants with NE reached oral feeds earlier and needed fewer anti-seizure medications for a shorter duration than infants with NE but without such risk factors.This study supports current provision of therapeutic hypothermia for infants with NE and any risk factors for early-onset neonatal infection.

Antimicrobial Resistance Profile of Group B Streptococci Colonization in a Sample Population of Pregnant Women from Romania.

Group B Streptococcus (GBS) represents one of the leading causes of life-threatening invasive disease in pregnant women and neonates. Rates of GBS colonization vary by region, but studies on maternal GBS status are limited in Romania. This study aims to identify the prevalence of colonization with GBS and whether the obstetrical characteristics are statistically associated with the study group's antimicrobial susceptibility patterns of tested GBS strains. This observational study was conducted between 1 May and 31 December 2021 at The Department of Obstetrics and Gynecology at Elias University Emergency Hospital (EUEH) in Bucharest, Romania. A total of 152 samples were positive for GBS and included in the study according to the inclusion criteria. As a result, the prevalence of colonized patients with GBS was 17.3%. GBS isolated in this population had the highest resistance to erythromycin (n = 38; 25%), followed by clindamycin (n = 36; 23.7%). Regarding the susceptibility patterns of tested strains to penicillin, the 152 susceptible strains had MIC breakpoints less than 0.06 μg/μL. The susceptibility patterns of tested strains to linezolid indicated three resistant strains with low levels of resistance (MICs ranging between 2 and 3 μg/μL). Multidrug resistance (at least three antibiotic classes) was not observed. In conclusion, although GBS naturally displays sensitivity to penicillin, the exact bacterial susceptibility testing should be performed in all cases where second-line therapy is taken into consideration for treatment. We acknowledge the need for future actions to limit multidrug-resistant bacteria.

Neighborhood Socioeconomic Disadvantage and Group B Streptococcus Colonization in Pregnancy

Neighborhood Socioeconomic Disadvantage and Group B Streptococcus Colonization in Pregnancy

Oral Probiotic Supplementation in Pregnancy to Reduce Group B Streptococcus Colonisation (OPSiP trial): study protocol for a double-blind parallel group randomised placebo trial

IntroductionGroup B streptococcus (GBS), or Streptococcus agalactiae, remains a leading cause of neonatal morbidity and mortality. Canadian guidelines advise universal maternal screening for GBS colonisation in pregnancy in conjunction with...

Prevalence of group B streptococcus colonization in pregnant women and the correspondence of its virulence genes with adverse pregnancy outcome

Prevalence of group B streptococcus colonization in pregnant women and the correspondence of its virulence genes with adverse pregnancy outcome

Prevalence of Recto-Vaginal Group B Streptococcus Colonization in the Third Trimester of Pregnancy in a Tertiary Hospital in Nepal: A Cross-Sectional Study

Prevalence of Recto-Vaginal Group B Streptococcus Colonization in the Third Trimester of Pregnancy in a Tertiary Hospital in Nepal: A Cross-Sectional Study