Obat Anti

tuberkulosis
Pada Ibu Hamil
Saifullah
Fitria Arianty Rasyid Thaha
Annisa Ika Nurrahmayanti Syakir

Supervisor : Dr. dr. Efendi Lukas, SpOG(K)

 TUBERKULOSI
S
Emergensi di bidang kesehatan masyarakat di
Afrika tahun 2005.
● Sekitar 10 juta orang menderita TB aktif di
2018 (WHO)
● 4,2/100.000 ibu di UK
● Co-infeksi dengan HIV meningkatkan
mortalitas 300%

Kruger, Stefanie J.M., Phoswa, Wendy (2021). Association Of TB Treatment With Pregnancy Complications: A Systematic Review And Metaanalysis
Protocol. Research Square. https://doi.org/10.21203/rs.3.rs-274069/v1
 KOMPLIKASI OBSTETRI

ABORTUS SPONTAN
KELAHIRAN PREMATUR
PERTUMBUHAN JANIN
TERHAMBAT
BERAT BAYI LAHIR RENDAH

Kruger, Stefanie J.M., Phoswa, Wendy (2021). Association Of TB Treatment With Pregnancy Complications: A Systematic Review And Metaanalysis
Protocol. Research Square. https://doi.org/10.21203/rs.3.rs-274069/v1
 DIAGNOSIS

Riwayat kontak dengan Riwayat ke daerah Gejala klinis TB

penderita endemis

Chest X-Ray Mantoux Test Sputum BTA

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
 “Untreated tuberculosis represents a far
greater hazard to a
pregnant woman and her fetus than does
treatment of the
disease”

CDC (2020). TB Treatment and Pregnancy. https://www.cdc.gov/tb/topic/treatment/pregnancy.htm

 TERAPI PADA IBU HAMIL

• Terapi untuk TB latent (pasif) • Terapi untuk TB yang berpotensi

dapat ditunda hingga 2-3 bulan untuk menjadi penyakit TB,
post partum untuk menghindari terutama yang menpunyai
pemberian medikasi saat riwayat kontak positif, terapi tidak
kehamilan. boleh ditunda, meski saat
trimester pertama.

CDC (2020). TB Treatment and Pregnancy. https://www.cdc.gov/tb/topic/treatment/pregnancy.htm

 TERAPI PADA IBU HAMIL
Diagnosis Treatment
Latent TB Infection • 6- or 9-month daily regimen of INH (6H or 9H) , with pyridoxine (vitamin
B6) supplementation
• The 3-month weekly INH and rifapentine (3HP) regimen is not
recommended for pregnant women or women expecting to become
pregnant during the treatment period because its safety during pregnancy
has not been studied.
TB Disease • The preferred initial treatment regimen is INH, rifampin (RIF), and
ethambutol (EMB) daily for 2 months, followed by INH and RIF daily, or
twice weekly for 7 months (for a total of 9 months of treatment).
• Streptomycin should not be used because it has been shown to have
harmful effects on the fetus.
• Pyrazinamide (PZA) is not recommended to be used because its effect on
the fetus is unknown.
HIV-Related TB Disease • Treatment of TB disease for pregnant women co-infected with HIV should
be the same as for nonpregnant women, but with attention given to
additional considerations.  
CDC (2020). TB Treatment and Pregnancy. https://www.cdc.gov/tb/topic/treatment/pregnancy.htm
 TERAPI LINI PERTAMA
Bukan kontraindikasi, namun membutuhkan follow-up klinis, dan monitor fungsi liver

ISONIAZID ETAMBUTOL
- INH-induced Retrobulbar neuritis
Hepatotoxicity
- Lewat sawar plasenta
- Piridoxine 50mg/hari

RIFAMPISIN PIRAZINAMID
- Resiko perdarahan -E Ikterus
bayi baru lahir - Drug-induced
- Vit. K 10mg/hari : 4- hepatitis
8 minggu kehamilan - Nyeri sendi
Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
 TERAPI LINI PERTAMA
Kontraindikasi

STREPTOMISI
-N TERATOGENIC
- Malformasi janin
- Paralsisi nervus VIII
- Gangguan pendengaran

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
 ISONIAZID
● Kategori A
● Terapi lini pertama
● Dosis : 3-5 mg/kg hingga 300 mg/hari
● Efek samping : ruam, demam, hepatitis (jarang), neuropati perifer (dosis tinggi)
● Efek pada bayi: tidak didapatkan malformasi / restriksi pertumbuhan, aman untuk ibu
hamil, melewati sawar plasenta  demyelinasi suplementasi priridoksin
● Meningkatkan resiko hepatotoksik pada ibu hamil
● Cek fungsi hepar dan monitor gejala saat 2 bulan pertama terapi
● Sebagai kemoprofilaksis pada TB latent untuk yang berisiko sebagai penyakit TB (HIV
co-infeksi / riwayat kontak)

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 RIFAMPISIN
● Kategori C
● Terapi fase intensif
● Dosis : 1—20 mg/kg hingga 600 mg/dibagi dalam 4 dosis perhari
● Efek samping : hepatitis, hipersensitif kutaneus, ganggaun GI, trombositopenic
purpura
● Efek pada bayi : teori : teratogenic  resiko gangguan CNS, ekstremitas,
hipoprotrombinemia dan heamoragic disease of newborn (HDN
● Perdarahan akibat hipoprotrombinemia didapatkan pada ibu dan bayi
● Vitamin K  ibu dan bayi post partum jika rifampisin dikonsumsi di akhir kehamilan

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 ETAMBUTOL
● Kategori A
● Dosis : 15 mg/kg
● Efek samping : optic retrobulbar neurtis, arthralgia
● Efek pada bayi : melewati sawar darah plasenta, namun sedikit EBM pada hewan
tentang teratogenitas, teori  toksisitas okuler

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 PIRAZINAMIDE
● Kategori B2
● Digunakan dengan hati – hati pada ibu hamil
● Dosis : 20– 30 mg/kg
● Efek samping : anoreksia, mual, fotosensitifitas, flushing, hepatotoksik
● Efek pada bayi : tidak ada laporan mengenai teratogenitas / malformasi pada hewan
● Belum ada laporan mengenai malformasi janin  CDC belum memasukkan di
guideline, namun disetujui oleh WHO
● Jika pyrazinamide tidak diberikan  regimen 9 bulan dengan INH & RIF
direkomendasikan, suplementasi dengen E.

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 STREPTOMICIN
● Kategori D
● Dihindari penggunaannya selama masa kehamilan
● Dosis : 12 – 15 mg/kg
● Efek samping : hipersensitivitas kulit, pening, tinnitus, rasa baal, vertigo, ataksia,
ketulian
● Efek pada bayi : melewati sawar plasenta, ototoksik dengan derajat bervariasi

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 TERAPI LINI KEDUA
Sebaikya dihindari pada ibu hamil, menyebabkan otoxicity, neftotoksik, gangguan GIT

FLUOROQUINOLONE STREPTOMYCIN PARA-

S AND AMIKACIN AMINOSALICYLI
C ACID

ETHIONAMIDE AND CYCLOSERINE

PROTHIONAMIDE

AMOXYCILIN / ASAM CAPREOMYCIN

KLAVULANAT
Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 FLUOROQUINOLONES
● Kategori B3  Ciprofloxacin, Moxifloxacin, Norfloxacin
● Resiko abnormalitas pada bayi tidak didapatkan
● Ciprofloxacin pada hewan  kerusakan kartilago articular dan juvenile arthritis,
kerusakan sendi
● Penggunaanya pada wanita hamil dimana menfaatnya lebih banyak disbanding
dengan resikonya.

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 STREPTOMYCIN DAN AMIKACIN
● Kategori D
● Aminoglikosida  potensial untuk nefrotoxic dan ototoxic pada fetus  tidak
direkomendasikan untuk ibu hamil
● Penggunaan pada ibu hamil sebaiknya menjadi pilihan terakhir

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 CAPREOMYCIN
● Kategori C
● Penelitian pada hewan  teratogenic
● Kontraindikasi pada kehamilan dan hanya diberikan setelah menimbang manfaat dan
kerugiannya

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 ETHIONAMIDE DAN
PROTHIONAMIDE
● Kategori N/A
● Penelitian pada hewan  teratogenic
● Tidak direkomendasikan pada ibu hamil

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 CYCLOSERINE
● Not listed
● Penelitian pada hewan  belum ada EBM
● Hanya diberikan setelah menimbang manfaat dan kerugiannya

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 PARA-AMINOSALICYLIC ACID
● Kategori N/A
● Data yang terbatas (hewan dan manusia)
● Resiko gangguan ekstremitas dan telinga

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 AMOXYCILIN / CLAVULANIC ACID
● Kategori B1
● Belum ada data teratogenitas pada hewan.
● Terapi profilaksis pada prolonged rupture of membrane pada akhir kehamilan  tidak
ada efek samping

Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in pregnant women and newborn infants
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
 MULTIDRUG-RESISTANT TB (MDR-
TB)

Cycloserine, ofloxacin, Ethionamide : retardasi - Menunda terapi

amikacin, pertumbuhan, CNS, dan hingga trimester kedua.
kanamycin, gangguan tulang. – Kombinasi terapi lini
capreomycin, and kedua sesuai dengan
ethionamide pasien
Terapi Lini Tidak Individualised
Kedua direkomendasikan Treatment
Regimen (ITR)
Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
 TERAPI PADA MASA NIFAS

Sputum BTA : Positif MDR-TB

2 minggu post partum Isolasi

Ibu nifas Resiko transmisi

< 2 minggu terapi Ibu  bayi

Tuberculin Bacille Calmette-Guerin

Profilaksis (BCG)
test
Isoniazid 5mg + Pada Tuberculin test : Negatif dan stop
6 – 12 minggu profilaksis. Jika Tuberculin test : Positif
Piridoksin 5-14 mg/kg
Terapi hingga 6 bulan
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
WHO (2010). Treatment of Tuberculosis Guidelines.
 TERAPI PADA IBU MENYUSUI

Terapi lini Sekresi dosis Defisisensi

pertama rendah Piridoxine
>2 minggu terapi boleh Dosis di asi <20% dari Supplementasi pyridoxine
breasfeeding dosis terapi INH untuk untuk bayi yang konsumsi
bayi INH / ibunya yang
mendapat terapi
Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–
171
Public Health England. (2019). Pregnancy and Tuberculosis (TB). Information for clinicians
WHO (2010). Treatment of Tuberculosis Guidelines.
DAFTAR PUSTAKA

● Kruger, Stefanie J.M., Phoswa, Wendy (2021). Association Of TB Treatment With

Pregnancy Complications: A Systematic Review And Metaanalysis Protocol. Research
Square. https://doi.org/10.21203/rs.3.rs-274069/v1
● Loto, O. M., & Awowole, I. (2012). Tuberculosis In Pregnancy: A Review. Journal of
pregnancy, 2012, 379271. https://doi.org/10.1155/2012/379271
● CDC (2020). TB Treatment and Pregnancy.
https://www.cdc.gov/tb/topic/treatment/pregnancy.htm
● Queensland Department of Health (2015). Guideline Treatment of Tuberculosis in
pregnant women and newborn infants
● Mahendru, A., Gajjar, K., Eddy, J. (2010). Diagnosis and management of
tuberculosis in pregnancy. The Obstetrician & Gynaecologist 2010;12:163–171
● WHO (2010). Treatment of Tuberculosis Guidelines.
● Public Health England. (2019). Pregnancy and Tuberculosis (TB). Information for
clinicians
TERIMA
KASIH
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