Tuberculosis in Pregnancy
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1 Tuberculosis in Pregnant versus non- Tuberculosis in Pregnancy Mark J. Granada, MD Means of Spreading TB bacilli Coughing Sneezing Singing Spitting Laughing Rarely, pregnant TB patient may pass TB to unborn child Tuberculosis in Pregnant versus Non- 2. Pregnancy does not increase rate of infection or reactivation 3. Does not affect rate of progression of LTBI to active disease
2 Tuberculosis in Pregnant versus non- 2. Pregnancy does not increase risk of infection or reactivation. 3. Pregnancy does not affect progression from LTBI to active disease 4. Clinical manifestations are similar Active TB - Signs and Symptoms Unexplained weight loss Coughing for 3-4 months Fever low grade fever a Night sweats Loss of appetite Hemoptysis Chills Fatigue Chest pain Tuberculosis in Pregnant versus Non- 2. Pregnancy does not increase risk of of infection 3. Pregnancy does not affect progression of LTBI to active disease 4. Clinical manifestation is similar 5. Radiographic presentation is similar TB CXR
3 TB CXR Lower Lobe TB TB CXR Lower Lung Field TB
4 Tuberculosis in Pregnant Versus Non- 2. Risk of infection is similar 3. Pregnancy does not affect progression of to active disease 4. Clinical Manifestation is similar 5. Radiographic presentation is similar 6. Management is modified in pregnant woman Active TB and Pregnancy Management 1. Pregnancy does not affect response to treatment for TB 2. Treatment be initiated immediately if active disease is moderately or highly suspected 3. If ATT is started early in pregnancy, outcome is the same in pregnant and non-pregnant 4. Late diagnosis and ATT is associated with 4-fold increase in obstetric morbidity and 9-fold increase in preterm labor in one study Pregnancy and Active TB treatment 1. Before drug sensitivity of TB is known: INH, Rifampin and Ethambutol for two months followed by INH and RM for 7 months in the US 2. If TB is sensitive to all 3 drugs EMB is discontinued Pregnancy and Active TB treatment (cont) 3. Pyrazinamide not routinely used in the US but WHO recommends as part of the initial treatment 4. Pyridoxine is used 5. Steroids in case of meningitis and pericarditis 6. Treatment by DOT and evaluated monthly for toxicity
5 Active TB and Pregnancy Second line drugs if no suitable alternative Cycloserine PAS Ethionamide Flouroquinolone LTBI in Pregnancy Testing for LTBI be done if treatment is considered if the patient has risk factors: 1. Immunocompromised and HIV 2. Exposure to active infectious patient 3. Visit to areas of high incidence of TB 4. Recent immigrants from countries with high incidence of TB Indications for Treatment of LTBI During Pregnancy 1. Immunocompromised and HIV 2. LTBI with recent contact with smear positive TB (No LTBI but with recent contact) at physician s discretion) 3. Recent converter Start treatment after the first trimester LTBI in Pregnancy Treatment of choice a. INH 5 mg/kg up to 300 mg for 9 months b. Pyridoxine is added c. Rifampin is an alternative choice for 4 months 4. Pregnant woman without risk factor - tart treatment 3 months postpartum
6 LTBI in Pregnancy- Follow-up 1. Pregnancy and early postpartum may increase hepatotoxicity 2. Liver enzymes be done monthly 3. Discontinue treatment a. If symptomatic and ALT is 3x normal b. If asymptomatic and ALT is 5x normal 4. LTBI on INH becomes pregnant, continue treatment if patient has risk factors but may discontinue and restart 3 months postpartum if no major risk factors Controlling Transmission - TB and Pregnancy 1. Mother is highly suspect for TB Mother and infant be separated until fully evaluated 2. Mother and infant have active disease both on treatment No need for separation 3. Mother has active TB and infant has LTBI on treatment No need for separation Controlling Transmission (Cont.) 4. Mother has active TB and infant is neither active or LTBI Mother is treated for active TB and infant is treated as LTBI Repeat diagnostic test: if positive, evaluate for active disease; if negative, stop INH for infant 5. Mother is suspected to have drug resistant TB and infant is negative LTBI They should be separated TB and Pregnancy Conclusion For LTBI 1. Diagnostic tests for LTBI be done only with presumption of treatment 2. In the presence of major risk factors, treatment is started 3. Without risk factors can be delayed 3 months postpartum 4. INH is the first choice and RM is an alternative For Active TB 1. Treat early with moderate or high suspicion for active TB 2. Treatment with INH, RM, EMB for 2 months and INH and RM for 7 months Follow-up for Drug toxicity Breastfeeding is not contraindicated
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