Tuberculosis in Pregnancy

Prof. M.C.Bansal.MBBS.,MS. MICOG. FICOG.

Founder Principal & Controller ;Jhalwar Medical College And Hospital Jhalawar.

Ex. Principal & Controller;Mahatma Gandhi Medical College And Hospital.

Sitapura, Jaipur

Pulmonary Tuberculosis , already prevalent in India , has shown an increased incidence in recent years worldwide .

WHO has rightly declared it as “ global health emergency “

WHY so ? HIV infection has flared it and more so the TB

bacteria have immersed with more resistance to the available ATT.

30% of world TB is in India and 5% active disease is seen in pregnant women .

Incidence

Most of the tubercular pregnant women are seen IN ANC are known cases and are on ATT.

Some are detected as fresh case of pulmonary Tuberculosis-----

Symptoms are non specific Easy fatigability. Low grade fever. Haemoptysis. Long standing cough not responding to routine

antibiotics and anti tussives.

Suspicion OF TUBERCULOSIS during ANC is first step to diagnose It---as

Women with genital TB are infertile. Pregnancy can occur in extra genital

tubercular patients ; so also in cases of pulmonary TB.

No adverse effects have been reported except pregnancy induced altered hepatic excretion of drugs and clinical hepatotoxicity reported in a few cases.

Maternal malnutrition associated with TB can also lead to anemia, IUGR, prematurity etc.

Effect Of TB on Pregnancy and Child birth

Side effect of ATT on fetus and newborn are to be taken in account ; though placenta provides an effective barrier to the tubercular organisms and congenital tuberculosis is extremely rare.

Transplacental and haematogerous infection to fetus is extremely rare.

The newborn may catch infection from mother if she is sputum positive.

Effect of TB on Pregnancy and Child birth----

Usually pregnancy and childbirth do not alter the course of disease.

During puerperium , stress of labour load of child care can activate the disease.

Puerperal relapses are not uncommon. Pulmonary surgery is rarely needed and

should be postponed, If possible, until after delivery.

Effect of Pregnancy ON TB

Sputum examination .2 samples(spot & morning) in 2 consecutive day.(sensitivity 45-85%)

Sputum culture(for monitoring of drug)

Tuberculin test- 1TU & 5 TU i.d of PPD >10 mm- recent/past infection.

Chest x ray- with abdominal shield Cavitary lesion/LN enlargement mainly involving

upper lobe 15% normal

INVESTIGATION

Adenosine deaminase activity(ADA) test.-high in cases of TB.-related to proliferation & differentiation of

lymphocytes.

ELISA for IgG & IgM in blood & body fluids.

QuantiFERON TB test- measurement of gamma interferon released by sensitized lymphocytes using ELISA technique.

BACTEL 460 TB – detects mycobacterium growth

Symptoms----Cough (75%) , weight loss (10%) , Low grade fever 50% cases.

Signs ---Upper lobe of lung (usual site )-post coughing crepitations, findings suggestive of cavitation ,hydrothorax may be there.

Investigations---Xray chest, CBC , Tuberculine test is safe ,conclusive and should be done.

ESR is raised in pregnancy hence is not a good criteria.

HIV testing should be done , if it is positive special care is needed.

consultation with Chest physician should help in diagnosis as well as control of disease.

Diagnosis

High risk explained. She is to be isolated, mask provided ., if found to be an

open case ---likely to spread to others. Rest High protein diet. Vital(P.R,B.P) charting done. Temperature charting done 6hrly.

Iron sucrose given to correct her HB status. Symptomatic treatment for fever, weakness, cough ,

vomiting etc. TB & chest reference ----Confirmation of diagnosis and

tailoring of ATT therapy( according to requirement of individual case)

Category 1 treatment started under DOTS.

Management Of Tubercular Infection in pregnancy

DRUGS (1st line)

DRUGS DOSE(DAILY)(mg/Kg)

SIDE EFFECET

RIFAMPICIN(R),cat C 10 Hepatotoxic, nephrotoxic,thrombocytopenia

ISONIAZID(H) 5 GI effect, hepatites, peripheral neuropathy

PYRAZINAMIDE(Z) 20-25 hepatotoxic, nephrotoxic, thrombocytopenia

ETHAMBUTOL(E) 15 Retro bulbar neuritis, peripheral neuropathy

Capreomycin Kanamycin Ethinamide. PAS Cycloserin Safety to these drugs are doubtful Termination should be offered to pregnant

women in view of teratogenic effects.

Second line

CATEGORY OF PATIENT

TYPE OF PATIENT INTENSIVE PHASE

CONTINUTION PHASE

1(red)

-New sputum smear positive- New Sputum smear negative-New Extra pulmonary

2(HRZE)3 4(HR)3

2(blue)

-smear positive relapse.-smear positive failure.-Smear positive treatment default, failure

2(HRZES)3 OR2(HRZE)3

5(HRE)3

REVISED TREATMENT

Drug-resistant  by at least the two antibiotics, isoniazid (INH) and rifampicin(R).

TREATMENT

MDR-TB(DOTS PLUS)

INTENSIVE PHASE(9months)

CONTINUTION PHASE(18months)

kanamycin ofloxacin

ofloxacin Ethinamide

Ethambutol cycloserine

Pyrazinamide Ethambutol

Ethinamide

Resistant to at least 1st line drugs(isoniazid &

rifampicin) 3 or more 2nd line drugs

TREATMENT INTENSIVE(6-12 months)

Amoxicillin/clavulanate.

CONTINUATION(18) months-PAS,Moxifloxacin,Isoniazid,ClofazimineLinezolid, Amoxicillin/clavulanate

EXTENTED(XDR –TB)

Termination of pregnancy on account of the disease is not justified. The woman should be antitubercular drugs.

Streptomycine is ototoxic to the fetus and newborn while Ethambutol is occular toxic . Therefore these drugs are to be avoided.

Vaginal delivery is safe and should be prefferred. LSCS can be perfoemed only on obstetrical

grounds . Epidural anaesthesia is safer than general

anaesthesia.

Obstetrical Management of TB patient.

Most relapses occur in this period , decreased body resistance , super added sepsis in genital tract and tenting effect of enlarged uterus on diaphragm is no more and hence the lung expands and infection may flare up. A sputum negative mother can breast feed her child with mask on her mouth and nose.

If she is sputum +vet for T.bacilli , newborn should be separated and breast feeding in poor country like ours can be allowed with the mother wearing a mask.

Puerperium

American Academy of Pediatrics recommends that women with TB who have been treated for 2 weeks or more/not contagious may breast feed.

But RNTCP recommends breast feeding of neonates regardless of mother’s TB status

Anti tuberculosis drugs are excreted into breast milk but dose is less compared with therapeutic dose for infants.

The newborn should be vaccinated with o.1ml of BCG vaccine (developed from isonex resistant bacillus—strain ). It can be postponed if newborn is under weight (< 2.5 Kg)/ ill or Mother is HIV +ve.

Infants Should receive Isoniazid 20mg /kg body weight of therapeutic dose.

New born &TREATMENT OF TB in LACTATING WOMEN

Very small quantity of ATT secreted in mothers milk.

No toxicity has been reported from this small concentration in breast milk.

Mother may take medication immediately after feed & and need not a bottle feeding.

Pyridoxine supplementation should be given to infants on INH /whose mother is taking the drug.

In the absence of congenital tuberculosis, isoniazid (20mg/Kg/day) should be commenced at birth and continued for next 6 months.

The tuberculin skin test & chest X rays are done at 6 weeks,12 weeks, and 6 months.

Baby is revaccinated with BCG at 6 months and isonizid is continued if these test are negative.

Congenital tuberculosis in newborn is manifested by the 2nd / 3rd week after birth.

Baby develops fever , feeding problems and irritable , no weight gain .

Respiratory distress and jaundice may also develop. Liver & spleen are enlarged., indicating transplacental spread of infection. Prognosis is poor.

RNTCP GUIDELINES, 18 MARCH 2013

BY GOVT. OF INDIA

STOP TB IN MY LIFETIME

● Early detection and treatment of at least 90% of estimated

all type of TB cases in the community, including Drug resistant and HIV associated TB.

● Successful treatment of at least 90% of new TB patients,

and at least 85% of previously-treated TB patients

● Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%

Objectives---

● Offer of HIV Counseling and testing for all TB patients and linking HIV-infected TB patients to HIV care and support;

● Extend RNTCP services to patients diagnosed and treated in the private sector.

● Initial screening of all re-treatment smear-positive till 2015 and all Smear positive TB patients by year 2017 for drug-resistant TB and provision of treatment services for MDR-TB patients.

Objectives----