Tuberculosis

and its effect in

pregnancy
 Introduction
▪ Pulmonary tuberculosis is an infectious disease
of the lungs caused by acid fast bacilli (AFB)
known as mycobacterium tuberculosis
characterized by low grade fever, loss of
weight, chronic cough, etc.
▪ The bacteria gets into the lungs through inhaled
air contaminated by the sputum of positive
cases.
▪ About 45% of total population is infected by TB
of which 60% is adult.
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 Cont..
▪ The incidence ranges between 1-2%
amongst the hospital deliveries.
▪ In fact in 1993, WHO pronounced
tuberculosis “a global health emergency”.
▪ In 2000, WHO showed the emergence of
multidrug resistant tuberculosis (MDR-TB) all
over the world.

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 Cont..
▪ The lung is the major site of involvement, but
the lymph gland, meninges, bones, joint,
intestine and kidneys can also be infected.
▪ The person becomes infected by inhaling
the infectious organisms mycobacterium
tuberculosis, which is carried on a droplet
nuclei spread by airborne transmission.
▪ The women can remain asymptomatic for
long periods of time as the organism may be
dormant.
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 Causative agents:
▪ Mycobacterium Tuberculosis(Human type)
▪ Mycobacterium Tuberculosis(Bovine type)

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 Predisposing factors
▪ Positive family history or past history.
▪ Low socio-economic status.
▪ Area of high prevalence of tuberculosis.
▪ HIV infection.
▪ Alcohol addiction.
▪ Intravenous drug abuse.

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 Clinical features:
▪ Evening pyrexia(low grade fever)
▪ Loss of weight
▪ Night sweating/Sleep sweats
▪ Chronic fatigue
▪ Loss of appetite, pale and ill looking
▪ Chronic cough
▪ Malaise
▪ Hemoptysis
▪ Breathlessness
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 Diagnostic evaluation:
▪ Positive family history
▪ Clinical features
▪ X-ray examinations(after 12 weeks)
▪ Early morning Sputum for AFB examination
▪ Diagnostic bronchoscopy
▪ Gastric washing

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 Cont..
▪ Tuberculin skin test with purified
protein derivatives (PPD)
Montoux test when ≥10 mm is
considered positive esp. in
presence of risk factors.
▪ Extra-pulmonary sites; lymph
nodes, bones (rare in
pregnancy)
▪ Direct amplification test to detect
Mycobacterium tuberculosis.
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 Congenital tuberculosis is
diagnosed by:
a. Lesion noted in the 1st week of life.
b. Infection of the maternal genital tract or
placenta.
c. Cavitating hepatic granuloma diagnosed by
percutaneous liver biopsy at birth.
d. No evidence of postnatal transmission.

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 Effect on pregnancy MOTHER:
▪ Pregnant women with untreated TB are more
likely to have pre- eclampsia, spontaneous
abortion, preterm labor, difficult labor and PPH.
▪ Intrauterine fetal death.
▪ Anemia

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 Effect on pregnancy FETUS:
▪ Under weight infant
▪ Low Apgar score
▪ Perinatal death
▪ IUGR
▪ Preterm labor.
New born baby is at risk of postnatally acquired TB
if mother has still TB at the time of birth.
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 Effect of pregnancy on TB:
 Higher risk of relapse in the puerperium. This
may be due to the disturbed nights,
increased work and anxiety for care of a new
born.

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 Prevention
▪ The BCG vaccine has been incorporated into the National
immunization policy of many countries, especially the high
burden countries, thereby conferring active immunity from
childhood. Non-immune women travelling to tuberculosis
endemic countries should also be vaccinated. It must,
however, be noted that the vaccine is contraindicated in
pregnancy.
▪ The prevention, however, goes beyond this as it is essentially
a disease of poverty. Improved living condition is, therefore,
encouraged with good ventilation, while overcrowding should
be avoided. Improvement in nutritional status is another
important aspect of the prevention.
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 Cont…
▪ Pregnant women living with HIV are at higher risk
for TB, which can adversely influence maternal
and perinatal outcomes. As much as 1.1 million
people were diagnosed with the co-infection in
2009 alone. Primary prevention of HIV/AIDS is,
therefore, another major step in the prevention of
tuberculosis in pregnancy. Screening of all
pregnant women living with HIV for active
tuberculosis is recommended even in the absence
of overt clinical signs of the disease.
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 Cont..
▪ Isoniazid preventive therapy (IPT) is another
innovation of the World Health Organization that
is aimed at reducing the infection in HIV positive
pregnant women based on evidence and
experience and it has been concluded that
pregnancy should not be a contraindication to
receiving IPT. However, patient's individualization
and rational clinical judgement is required for
decisions such as the best time to provide IPT to
pregnant women.
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 Cont…
▪ Most importantly, governments commitments
are highly encouraged so that the World
Health Organization and all other
international bodies involved in fighting
tuberculosis may succeed in chasing this
monster out of all communities.

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 Therapeutic management
▪ The principles of treatment for the pregnant woman with TB
are same as in the non pregnant patient.
▪ The treatment of TB in pregnancy is important for two reason.
• For serious consequences of untreated TB and the risk of
its spread to newborns.
• Secondly the effect of the drugs used in its treatment on
the fetus.
1.Women with positive purified protein derivatives (PPD) and
no evidence of active disease (asymptomatic), Isoniazid
prophylaxis 300mg/day is started after the first trimester and
continued for 6-9 months. Pyridoxine (vit.B6) 50mg/day is
added to prevent peripheral neuropathy.
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 2.Women with active tuberculosis should receive
the following drugs orally daily for a minimum period
of 9 months.
Drug Daily Doses-PO Major Side Effects
Isoniazid 5 mg/kg up to 300mg Hepatitis, peripheral neuropathy,
(pyridoxine) 50mg daily hypersensitivity.
Rifampicin 10 mg/kg up to 600mg Nausea, vomiting, hepatitis,
orange discoloration of urine and
secretion, febrile reaction.
Ethambutol 15 mg/kg up to 2.5 gm Skin rash, optic neuritis,
decreased visual activity.

Pyrazinamide 15-30mg/kg up to 2gm Hepatotoxicity, skin rash,

arthralgias, hyperuricemias, G.I.
upset.
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 Cont..
3. Surgical management should be withheld, if
possible, but if deemed necessary should be
restricted for first half of pregnancy beyond
12 weeks.

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Obstetrical management During pregnancy
▪ Supervision and joint care with obstetrician and
chest physician is necessary.
▪ In the first trimester anti-TB drug should be
continued. The choice of drug and the dosage may
have to be modified. Morning sickness may pose
some difficulties.
▪ In 2nd and 3rd trimester, the status should be
reviewed. Women will need advice regarding
workload, diet and rest.
▪ Treatment with iron, folic acid and vitamin is
22 necessary to improve general condition/health.
 During labor
▪ Close monitoring of pulse and respiratory rate
are necessary especially in pulmonary TB.
▪ Normal vaginal delivery is routine for women
with tuberculosis and low forceps may be used
to short the 2nd stage of labor.
▪ Spinal or epidural anesthesia are preferred than
inhalation anesthesia for fear of contamination.

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 During postnatal period
▪ After delivery the women with active disease must
stay in hospital or transferred to a hospital for two or
three weeks to allow them a period of rest before
they return to their house hold duties.
▪ Breast feeding is not contraindicated when a
woman is taking anti-tuberculosis drugs.
▪ Breast feeding should be avoided if the infant is
also taking the drugs (to avoid excess drug level)
▪ In active lesion, not only is breast feeding
contraindicated but the baby is to be isolated from
24 the mother following delivery.
 Cont…
▪ Baby should be given prophylactic isoniazid 10-
20mg/kg/day for 3 month when the mother is
suffering from the active disease.
▪ If the mother is on effective chemotherapy for at
least 2 weeks, there is no need to isolate the
baby. BCG should be given to the baby as early
as possible.

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 Cont..
▪ Pregnancy is to be avoided until quiescence
is assured for about two years.
▪ Oral contraceptives should be avoided when
rifampicin is used.
▪ Due to accelerated drug metabolism,
contraceptive failure is high.
▪ Puerperal sterilization should be considered
if the family is completed.

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 Nursing management
▪ Review the woman's history for risk factors such
as immuno-compromised status, recent
immigration status, homeless, over crowded
living conditions and injectable drug use.
▪ At antepartum visits, be alert for clinical
manifestation of TB including fatigue, fever or
night sweats, non productive cough, slow
weight loss, anemia, hemoptysis and anorexia.

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 Cont…
▪ If the TB is suspected or the woman is at risk for
developing TB, anticipate screening with purified
protein derivative (PPD) administered by intradermal
injection.
▪ If the client has been exposed to TB, a reddened
induration will appear within 72 hours.
▪ If the test is positive anticipate a follow up chest x-ray
with lead shielding over the abdomen and sputum
culture to confirm the diagnosis.

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 Cont..
▪ Complaining with the multidrug therapy is critical
to protect the woman and her fetus from
progression of TB.
▪ Provide education about the disease process,
the mode of transmission, prevention, potential
complications, and the importance of adhering to
the treatment regimen.

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Cont..
▪ Stressing the importance of health promotion activities
throughout the pregnancy is important. Some
suggestion might include;
▪ Avoiding crowded living conditions.
▪ Avoiding sick people.
▪ Maintaining adequate hydration.
▪ Eating a nutritious well balanced diet.
▪ Keeping all prenatal appointments to evaluate fetal
growth and well being.
▪ Getting plenty of air by going outside frequently.
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 Cont..
▪ Determining the woman's understanding of her
condition and treatment plan is important for
compliance.
▪ Breast feeding is not contraindicated during the
medication regimen and should be encouraged
▪ Management of the newborn of a mother with TB
involves preventing transmission by teaching the
parent not to sneeze, cough or talk directly into the
newborns face.
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How do you manage the newborn ?
▪ If the mother is non-infectious, she can handle
her baby. Ordinary BCG vaccination is given to
protect the baby.
▪ If the mother is infectious, the baby must be
separated from the mother until she becomes
non- infectious. The baby must Be given a dose
of BCG vaccine. The infectious mother can
handle her baby only after successful BCG
vaccination i.e. after a period of eight weeks.

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 Cont..
 If the separation of mother and baby is not
practicable, the baby may be given protective
dose of isoniazide as prophylactic:10-20
mg/kg/day for 3 months.

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 Points to be remember:
▪ During pregnancy,
 Streptomycin can cause permanent deafness in
the baby, so ethambutol should be used instead
of streptomycin.
 Isoniazid, rifampicin, pyrazinamide and
ethambutol are safe to use.
 Second-line drugs such as fluroquinolones,
ethionamide and protionamide are teratogenic,
and should not be used.

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 Cont...

 Oral contraceptives should be avoided when

rifampicin is used.
 For Children: Ethambutol should not be
given to children below 6 years of age.

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 THANKS!
Any questions?

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