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TB developed during pregnancy can be successfully treated without harm to the developing fetus if diagnosed early enough. By Dr Ian Cropley.

 

Barbara, a twenty-five year old mother of two small children was 4 months pregnant with her third child. Everything had gone well with her previous pregnancies and there had been no problems with her current pregnancy so far. However, over the next couple of weeks she started to become more tired than she had remembered being in her previous pregnancies. She saw her doctor who told her it was probably just her pregnancy, but he arranged to see her again two weeks later. By then Barbara was convinced something was seriously wrong. She had started getting sweats at night and her abdomen was becoming bloated in a way she was convinced was very different from her previous pregnancies. She was admitted to hospital and, after many tests, a diagnosis of abdominal tuberculosis was eventually made. She started treatment and quickly made a good recovery. The remainder of the pregnancy was normal and she gave birth to a healthy baby boy two days before her expected date of delivery. This story illustrates a number of features of tuberculosis in pregnancy, particularly the problems in recognising the early stages of the illness, which may be outside the lung (as in the non-pregnant individual) and may present with symptoms difficult to differentiate from those of a normal pregnancy. It also illustrates that tuberculosis developing during pregnancy can be successfully treated without harm to the developing fetus. Inevitably with a disease as common and as widespread as tuberculosis, some of those infected will be pregnant. For centuries it was not clear whether tuberculosis had a beneficial or harmful effect on pregnancy. Prior to 1850 there were those who believed that any young woman with tuberculosis should become pregnant to improve her outcome. Between 1850 and the 1920s it was felt that tuberculosis was more harmful to the mother during pregnancy, and termination of pregnancy was recommended. Now, since the advent of modern anti-tuberculous medication it appears that tuberculosis in pregnancy can be safely treated with a successful outcome for both mother and fetus, provided that the illness is diagnosed before the mother is seriously unwell. However there is probably an increased risk of miscarriage and to the health of the mother if she becomes severely ill with the tuberculosis. It remains unclear whether pregnant women are more at risk of developing tuberculosis, and if they do, whether the tuberculosis is more likely to be in organs other than the lungs. One of the main problems of diagnosing tuberculosis in pregnancy is the vague, non-specific nature of the symptoms. Fatigue, shortness of breath, sweating and tiredness can be all too easily attributed to the pregnancy. There is also the reluctance of health care professionals to perform a chest X ray on a pregnant woman for fear of harming the fetus. This often leads to a delay in diagnosis, particularly if the diagnosis is not considered. Other means of diagnosis are the same as for non-pregnant individuals and include sputum examination and culture and scans. Contrary to popular belief, the Heaf and Mantoux skin tests are probably as reliable as in non-pregnant women.

 

Combination anti-tuberculous therapy in pregnancy was established as safe and effective in the mid 1970s. It is now believed that there is no increase in congenital malformations or fetal damage when rifampicin, isoniazid and ethambutol are used in combination. In the UK and Europe pyrazinamide is also considered to be a safe drug in pregnancy, but is only just starting to gain acceptance for use during pregnancy in the USA. Streptomycin, however, has been shown to cause fetal sensorineural deafness when used at any stage in pregnancy and must therefore be avoided. Although pregnancy is usually advised against, women who become pregnant whilst on anti-tuberculous therapy while using rifampicin, isoniazid, ethambutol and pyrazinamide can be reassured that there appears to be no increased risk to their baby, and that they should complete their treatment course. The situation may be different for women on second line agents for multi-drug resistant tuberculosis, however, and the risks should be assessed on an individual basis.

Breast feeding also appears to be safe when the mother is taking standard anti-tuberculous medication. If the mother is taking isoniazid, pyridoxine supplementation should be given to the child as a small amount of isoniazid is present in breast milk. It is usually unnecessary for the child to receive treatment unless the mother is diagnosed with open (infectious) pulmonary tuberculosis at the time of delivery, or contact tracing (which should be performed promptly) reveals that the child has had contact with another infectious member of the family. Very rarely the child can be infected in the uterus if the mother has had miliary tuberculosis, tuberculosis of the placenta or uterus, or has advanced HIV.

Treatment requires a coordinated multidisciplinary approach from all those involved in the care of the mother and child, including obstetrician, TB physician, midwives, TB nurses, health visitors and paediatricians to ensure that the best management is offered and that compliance with medication is maintained.

Screening for tuberculosis in pregnancy is not now generally performed in the UK because of the reluctance to do chest X rays on pregnant women, and with other forms of screening being less effective. However there remains a need for health care professionals to be aware of the possibility of tuberculosis during pregnancy and to think of the diagnosis early, particularly in high risk groups, although it may , of course, occur in any group. Early diagnosis can prevent the increased morbidity (and infectivity in pulmonary disease) associated with advanced tuberculosis

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