International

TUBERCULOSIS IN PREGNANCY

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TUBERCULOSIS IN PREGNANCY
LEARNING OBJECTIVES:
Describe epidemiology of
tuberculosis
Describe effects on mother and
child
Principle of Management
Preventive strategy

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EPIDEMIOLOGY
one-third of world pop. TB infected

8 M new cases each year

4.5 in Asia:
India, China, Bangladesh,

Pakistan, Indonesia, Philippines

Indonesia :

22 High Burden Countries

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1.
2.

India
China

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Bangladesh
Nigeria
Pakistan
South Africa
Philippines
Russia
Ethiopia
Kenya
DR Congo
Viet Nam
UR Tanzania
Brazil
Thailand
Zimbabwe
Cambodia
Myanmar
Uganda
Afghanistan
Mozambique

3. Indonesia

Indonesia 10%

China
15%

Bangladesh 4%

Pakistan 4%

India
30%

Philippines 3%
Nigeria 3%
South Africa 2%
Russia 1%

Other
28%

Penyebab kematian terbanyak penyakit infeksi

(SKRT 1995)

583.000 kasus baru/tahun, 140.000 kematian

/tahun (WHO)

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Natural History of Tuberculosis

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70% NON INFECTED

Exposure 10-30%

Infection
HIV
40-50%

PEOPLE
Infectious

Disease

10%

5% IN 2 YEARS

50% of smear positive

90% NO DISEASE

5% Reactivation TB

Death

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PENYEBAB UTAMA PENINGKATAN BEBAN

MASALAH TBC (1)

Kemiskinan negara sedang berkembang

Kegagalan program TBC selama ini akibat :
Tidak memadainya komitmen & pendanaan
Tidak memadainya organisasi pelayanan TBC
Tidak memadainya tatalaksana kasus
Salah persepsi terhadap hasil vaksinasi BCG
Infrastruktur kesehatan yang buruk
negara mengalami krisis ekonomi / pergolakan
masyarakat

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PENYEBAB UTAMA PENINGKATAN BEBAN

MASALAH TBC ( 2 )
Perubahan Demografik peningkatan penduduk
dunia
Dampak Pandemi HIV/AIDS koinfeksi dengan
HIV akan meningkatkan secara signifikan
risiko menderita TBC

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Hasil Prevalensi Survey 2004

Angka Prevalensi BTA Pos Baru per 100.000 pddk

Prevalence rate turun 4%per thn 1980-2004

% fall cf 1990
1980 survey

Smear+ prevalence/100K

600

1990

500

2004 survey

400
300

28%

35%
200

42%
54%

100
0

Sumatra

Jav a-Bali

KTI (East)

National

1980 surv e y

422

255

433

321

1990

311

146

342

217

2004 surv e y

203

67

246

125

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Situasi TB di Indonesia 2004 & 2005

DOTS strategy
2004

2005*

Country population (in thousands)

216.415

219,142

No. of TB cases notified (all cases)

214,658

253,269

No. of TB cases notified (new ss+)

128,981

154,330

Cure rate (new ss+, one year earlier)

80.7%

n.a

Treatment success rate (new ss+, one year earlier)

88.8%

n.a

Case detection rate (all new ss+)

51.8%

65.8%

DOTS case detection rate (new ss+ under DOTS)

51.8%

65.8%

* annualized

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There were no statistical differences in

duration of gestation, preterm labor, and other
complications of pregnancy, labor, and
puerperium between the pregnancy groups.
There were no congenital anomalies in the
babies born to the groups.
Pregnancy had no effect on the course of TB
as regards sputum conversion, stabilization of
the disease, and non-relapse even after 2-5
years of follow-up and a further delivery in a
few cases.
Tripathy SN, Int J Gynaecol Obstet. 2003 Mar;80(3):247-53

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The small concentrations of TB drugs in breast milk do

not have a toxic effect on nursing newborns, and
breastfeeding should not be discouraged for women
undergoing anti-TB therapy.
Similarly, drugs in breast milk should not be considered
effective treatment for disease or infection in a nursing
infant.
Breast-feeding is not contraindicated when a mother is
being treated. Likewise, the amount of isoniazid provided
by breast milk is inadequate for the treatment of an
infant. Infants whose breast-feeding mothers are taking
isoniazid should receive supplemental pyridoxine.
CDC Fact Sheet : Tuberculosis and Pregnancy
Feb 5 , 2005

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TB in NEWBORN / INFANT
Prevention : BCG Vaccin
Quite serious
Prophylactic: INH

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Diagnosis
PPD skin test (Mantoux)
Chest X-Ray

Sputum

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Management and
Preventive Strategy
Early diagnosis and
effective treatment
Focus antenatal care
Vaccination: BCG

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Canadian TB Standard, 5th ed, 2000

The risk to a pregnant woman

and her fetus is far greater from
untreated TB than it is from the
drugs used in its treatment
The use of INH, RMP & EMB has
been well studied during
pregnancy, and they are safe in
this setting

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Intervention for TB Control & Elimination.

Paris : IUAT-LD , 2002

Pregnant women with TB do not

pose particular problem for
treatment
INH, RMP , EMB, PZA & THZ are
safe in pregnancy, and are not
reported to have teratogenic or
other adverse effects on the fetus

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Treatment of TB, Guidelines for National

Programme. Geneve : WHO , 1997

Most anti TB drugs are safe for use in

pregnant woman
The exception is streptomycin which is
ototoxic to the fetus, should not be used
in pregnancy and can be replaced by
ethambutol
All the anti TB drugs are compatible with
breastfeeding

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Pregnant women with TB must be given adequate

therapy as soon as TB is suspected. The preferred
initial treatment regimen is isoniazid, rifampin,
and ethambutol
- Because the 6-month treatment regimen cannot be
used, a minimum of 9 months of therapy should be
given
CDC Fact Sheet : Tuberculosis and Pregnancy
Feb 5 , 2005

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Risiko TB-kehamilan

Risk

Low birth weight (<2.5 kg)

Prematurity (<37 weeks)
Small for dates
Pre-eclampsia
Vaginal bleeding
Perinatal death
Fetal death (16 to 28 weeks)
Maternal death

Rate per 100. 000 pregancies

pregnancy with
normal
TB
16.500
34.200
11.100
22.800
7.900
20.200
4.700
7.400
2.200
4.400
1.600
10.100
230
2.010
12,2
No data

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Risiko ESO dalam 100.000

Isoniazid-induced hepatitis

1.600

Rifampicin-induced hepatitis

1.100

Hepatitis with standard TB

treatment

2.700

Fatal hepatitis

9,4-14

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PENANGGULANGAN TBC
Di seluruh dunia menggunakan
STRATEGI DOTS (Directly Observed

Treatment Shortcourse)

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PENANGGULANGAN TBC
DENGAN STRATEGI DOTS

5 komponen DOTS:
1. Komitmen
2. Penegakan diagnosa mikroskopis
basil tahan asam positif
3. Pengobatan dengan RHZE+S
dengan Pengawasan menelan obat
oleh PMO (Pengawas Menelan
Obat)
4. Kepastian persediaan OAT pada
saat penderita membutuhkan
5. Pencatatan pelaporan terintegrasi
menggunakan format baku

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Short-course Chemotherapy Treatment for

New Tuberculosis Cases, Adult >50kg

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JENIS TABLET FDC

Untuk sementara ada 2 macam FDC:

4FDC, Setiap tablet mengandung:

- 75 mg Isoniasid (INH)
- 150 mg Rifampisin
- 400 mg Pirazinamid
- 275 mg Etambutol.
Utk pengobatan HARIAN tahap Intensif dan Sisipan.

2FDC, Setiap tablet mengandung:

- 150 mg Isoniasid (INH).
- 150 mg Rifampisin
Untuk pengobatan 3 KALI SEMINGGU tahap lanjutan.

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KEMASAN OBAT FDC

- Tablet 4FDC dikemas dalam blister @ 28 tablet.
- Tablet 2FDC dikemas dalam blister @ 28 tablet.
- Tablet Etambutol 400 mg dikemas dlm blister @
28 tablet.
- Streptomisin vial @ 750 mg
- Aquabidest vial @ 5 ml dan
- Disposable syringe .

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Disamping itu,
Tersedia obat lain untuk melengkapi paduan obat
kategori 2, yaitu:

Tablet Etambutol @ 400 mg,

Streptomisin injeksi, vial @ 750 mg.
Aquabidest.

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KATEGORI PENGOBATAN

Kategori 1 (2HRZE/4H3R3):
- penderita baru TBC Paru BTA positif
- penderita baru TBC Paru BTA negatif/Rontgen
positif (ringan atau berat)
- penderita TBC Ekstra Paru (ringan atau berat).

Kategori 2 (2HRZES/HRZE/5H3R3E3):
- penderita TBC BTA positif Kambuh
- penderita TBC BTA positif Gagal
- penderita TBC bekas defaulter yang kembali
dengan BTA positif.

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DOSIS KATEGORI 1 (2HRZE/4H3R3):

BERAT
BADAN

TAHAP INTENSIF
TIAP HARI
SELAMA 2 BLN

TAHAP LANJUTAN
3 KALI SEMINGGU
SELAMA 4 BLN

30 - 37 Kg

2 Tab 4FDC

2 Tab 2FDC

38 - 54 Kg

3 Tab 4FDC

3 Tab 2FDC

55 - 70 Kg

4 Tab 4FDC

4 Tab 2FDC

> 70 Kg

5 Tab 4FDC

5 Tab 2FDC

KETERANGAN: 1 BULAN = 28 HARI.

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DOSIS KAT 2 (2HRZES/HRZE/5H3R3E3)

BERAT
BADAN

TAHAP INTENSIF
SELAMA 3 BULAN
TIAP HARI
TIAP HARI
2 BULAN
1 BULAN

TAHAP
LANJUTAN
3 X SEMINGGU
SELAMA 5 BULAN

30 - 37 Kg

2 Tab 4FDC
+ 2 ml Strepto

2 Tab 4FDC

2 Tab 2FDC
+ 2 Tab Etamb

38 - 54 Kg

3 Tab 4FDC
+ 3 ml Strepto

3 Tab 4FDC

3 Tab 2FDC
+3 Tab Etamb

55 - 70 Kg

4 Tab 4FDC
+ 4 ml Strepto

4 Tab 4FDC

4 Tab 2FDC
+4 Tab Etamb

> 70 Kg

5 Tab 4FDC
+ 4 ml Strepto

5 Tab 4FDC

5 Tab 2FDC
+5 Tab Etamb

KETERANGAN: 1 BULAN = 28 HARI

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MODIFIED DOTS - REGIMEN

In Indonesia:

INH 300 mg daily

Rifampicin 600 mg daily
6 months

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DRUG RESISTANT TB

Resistant to INH & Rifampicin MDR

DOTS Plus
Need other drugs
Cost

MDR-TB is harder to cure

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100

all TB

MDR-TB

Treatment success (%)

80
60
40
20

Russia

Dominican Rep.

Korea

Peru

Hong Kong

Espinal MA et al. JAMA 2000; 283:2537-2545

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