Tb in pregnancy

• Incidence of TB in pregnancy
• In 2012 the estimated Global annual incidence of 8.6 million
• Not many studies have been done in this field. In one study done in
some ethnic groups in London it was found to be 1%.
• Tuberculosis cases 2.3 million were estimated to have occurred in
India.(India accounts for 30% of the burden of all TB cases in the
world.)
• 80% of the patients are in the economically productive age group
of 15– 54 years.
Introduction

• Tuberculosis continues to be a major health issue in a country like India

with a large population.
• Management of Tuberculosis in pregnancy continues to be one of the
challenges even to the experienced persons as pregnancy adds many
challenges for effective diagnosis and treatment because of the altered
situations .
• One third of the world population and approximately 50% of the Indian
adults are infected with Mycobacterium Tuberculosis .
• In India two deaths occur every three minutes due to Tuberculosis -
almost 1000 deaths/day
• The causes of maternal mortality
• Infection is via inhalation of Mycobacterium tuberculosis, which
incites a granulomatous pulmonary reaction.
• In more than 90 percent of patients, infection is contained and is
dormant for long periods
• In some patients, especially those who are immunocompromised or
who have other diseases, tuberculosis becomes reactivated to cause
clinical disease.
• TB Bacilli
• It comprises M. tuberculosis hominis
• M. bovis
• M. africanum (atypical Mycobacteria spp.)
• Tuberculosis in humans is mainly caused by bacteria called M.
tuberculosis hominis (occasionally mycobacterium bovis or atypical
tuberculosis organisms are also found).
• Tuberculosis organism is a non-motile obligate aerobe with replicating
cycle of 17-24 hours (slow growing)
• It does not have a capsule.
• It has a property of being acid-fast due to the surface lipids. This
property makes it resistant to common antibacterial agents and lytic
enzymes.
• Manifestations usually include cough with minimal sputum
production, low-grade fever, hemoptysis, and weight loss.
• Various infiltrative patterns are seen on chest radiograph, and there
may be associated cavitation or mediastinal lymphadenopathy.
• Acid-fast bacilli are seen on stained smears of sputum in
approximately two thirds of culture-positive patients.
• Forms of extrapulmonary tuberculosis include lymphadenitis, pleural,
genitourinary, skeletal, meningeal, gastrointestinal, and military or
disseminated
Groups at High Risk for Having Latent
Tuberculosis Infection
• Health-care workers
• Contact with infectious person(s)
• Foreign-born
• HIV-infected
• Working or living in homeless shelters
• Alcoholics
• Illicit drug use
• Anyone can catch TB, but it is possible that pregnant women have a slightly
higher risk of TB.
• Some people are more at risk than others. These include people who:
• Have lived in the same household – or been in prolonged contact – with
someone with TB involving the lung/s
• Have lived, worked or stayed for a long time in a country with a high

• (immunosuppressed) due to illness

• (such as HIV infection) or treatment (such as therapy for cancer)
• Are notably underweight
• Are dependent on drugs and alcohol
symptoms of TB during
pregnancy?
• Cough which persists for more than a few weeks
• Persistent fever (a high temperature)
• Heavy sweating at night
• Loss of appetite
• Unexplained weight loss
• General & unusual sense of tiredness and feeling unwell
• Coughing up blood
• Persistent swellings in the neck glands (or sometimes other glands)
• Low birth weight
• Prematurity
• Congenital TB
• Increased neonatal and maternal mortality
Increased pregnancy complications
• Abortion
• Post partum haemorrhage
• Pre-eclampsia
Consequences of TB in pregnancy
• Pregnant women with pulmonary TB who access early appropriate TB
treatment do not have an increase in maternal or neonatal
complications.
Neonatal Tuberculosis.
• Tubercular bacillemia can infect the placenta, but it is uncommon that
the fetus becomes infected— congenital tuberculosis.
• The term also applies to newborns who are infected by aspiration of
infected secretions at delivery.
• Neonatal tuberculosis simulates other congenital infections and
manifests with hepatosplenomegaly, respiratory distress, fever, and
lymphadenopathy .
Diagnosis of TB

• Pregnant Woman with cough of ≥2 weeks duration with or without

other symptoms.in pregnancy
• Cough of any duration:
– If she is a contact of a sputum smear positive case in the family.
– If she is having haemoptysis.
– If she is a suspected or confirmed extra pulmonary Tuberculosis
case.
– If she is also infected with HIV.
• There are two types of tests to detect latent or active tuberculosis.
• One is the time-honored tuberculin skin test (TST),
• interferon-gamma release assays (IGRAs),
• There are two IGRAs available: QuantiFERON-TB Gold and T-SPOT.TB
tests are recommended by the Centers for Disease Control and
Prevention
• Two samples of sputum (one spot and one in the early morning) are
to be collected and examined for Acid Fast Bacilli (AFB) with Zeil-
Neelson (ZN) stain
Categorization TB Cases

• Tuberculosis patients are categorized as per RNTCP guidelines as

category I (New cases) or category II (Retreatment cases) depending
upon the history of previous Anti-tuberculosis treatment received.
• Pregnant women with Tuberculosis who are taking Anti-tuberculosis
treatment for the first time or who have taken Anti-tuberculosis
treatment for less than 1 month previously are categorized as new
cases
First-line treatment
• This guideline endorses the recommendation of the use of standard
first-line drug regimens in pregnant women with TB.
• Isoniazid,
• rifampicin,
• pyrazinamide and
• ethambutol are not contra-indicated in pregnancy, but treatment
during pregnancy requires close clinical follow-up, with the
monitoring of at least monthly liver function tests due to the higher
risk of hepatotoxicity.
• Currently, an intermittent regimen (thrice weekly on alternate days)
under the DOTS strategy of RNTCP is being increasingly used world-
wide for the pregnant women having TB.
• ATT should be started promptly as untreated disease presents a
hazard to the mother and foetus.
• The same regimens are recommended for use in pregnancy as for the
non-pregnant state except for witholding of Streptomycin.
• Sputum was smear positive
Isoniazid

• Cat A
• Bacteriostatic
• Dosage: 5mg/Kg ,10mg/Kg(DOTS) max 900mg

• Hepatitis: 2% incidence of drug-induced hepatitis. LFT to be done

fortnightly atleast during intensive phase.
• Neuropathy
• Seizures and psychosis

• Pyridoxine (vitamin B6) should be used .

RIFAMPICIN

• Cat C
• Bacteriocidal
• Dosage:10 mg/Kg
• Red/orange colour discolouration of body fluids
• • Cytochrome P450 induction can result in clearance of contraceptive
hormones and unplanned pregnancy.
Ethambutol

• Cat A
• Bacteriostatic
• Dosage: 15mg/kg, 30mg/Kg(DOTS)
• Visual acuity and colour vision to be tested as it may cause
retrobulbar neuritis.
PZA

• Cat B2
• Bacteriocidal
• Dosage: 25mg/Kg,35mg/Kg(DOTS) max-3g
• May cause GI upset , hyperuricemia and arthralgia.
• No studies of safety in pregnancy:- Extensive clinical experience
supporting it’s safety
• WHO recommends the routine use of PZA in pregnancy
Streptomycin

• Injectable : IM
• Dosage : 15 mg/Kg max – 1g
• Nephrotoxic , neurotoxic and ototoxic.
• Cat D
Cat 1
• Category I-Needs DOTS regimen (Directly Observed Treatment and
short course)
• 2H3R3Z3E3 / 4H3R3
• H-INH (Isoniazid) R- Refampicin, Z- pyrazinamide,
E- Ethambutol S- Streptomycin.
Intensive phase

• For first two months:

• Rifampicin 450 mg
• INH 600 mg
• Pyrazinamide 1500 mg
• Ethambutol 1200 mg
• An additional dose of Rifampicin of 150 mg is to be added if pt crosses wt
>60 kg.
• Fixed drug combination (FDC) are available now : according to wt category.
Cat 2

• Retreatment cases who have taken Anti-tuberculosis treatment

earlier for at least 1 month.
• The intensive phase is of 3 months duration and the continuation
phase is of 5 months.
• The patient is regularly followed up by the treating doctor
• – In pulmonary - follow up sputum smear examinations are done
regularly
• – Extra Pulmonary - assessed by regular clinical examination.
• A woman under Anti Tuberculosis treatment can breast feed her
infant taking the precaution of cough hygiene i.e she should cover her
mouth and nose with a cloth while breast feeding.
Multi Drug Resistant Tuberculosis

• defined as resistance to isoniazid and rifampicin with or without

resistance to othe
• Extensively Drug Resistant (XDR) TB: defined as resistance to
isoniazid and rifampicin ( i.e MDRTuberculosis) + resistance to any of
the fluoroquinolones and any one of the second line injectable drugs
(Amikacin, Kanamycin or Capreomycin)r anti-tuberculosis drugs.
Options for treatment of DR-TB
during pregnancy
• Need to consider risks and benefits for the mother and fetus.
–Option 1: Stop or delay MDR-TB treatment
–Option 2: Terminate the pregnancy
–Option 3: Continue treatment while pregnant
Basic RNTCP regimen for MDR TB
• 6(9) Km Lvx Eto CS Z E /18 Lvx Eto CS E [Reserve / substitute drugs:
PAS, Mfx, Cm]
• (Km – Kanamycin, Lvx- Levofloxacin, Eto- Ethionamide, Cs–
Cycloserine, Z- Pyrazinamide, E- Ethambutol, PAS- Paraamino
salicylic acid, Mfx –Moxifloxacin, Cm-Capreomycin)
Management of MDR TB during Pregnancy

• If GA is <20 weeks, the women is advised MTP,

• For not willing for MTP or if GA is >20 weeks the risk to the mother and
the Fetus needs to be explained before starting the treatment.
• For patients with GA <12 weeks, Km and Ethionamide are omitted & PAS
is added.
• For patients with GA >12 weeks, Km is replaced with PAS, and after
delivery, PAS may be replaced with Km and continued until the end of
Intensive phase.
• Duration of treatment: At least 6 months of intensive phase treatment
(IP) may be extended up to 9 months in patients who have a positive
culture result at 4th month of treatment.
• Minimum 18 months of continuation phase treatment (CP) should be
given following IP.
• Thank you