1. Tuberculosis in Pregnancy Max Brinsmead MB BS PhD May 2015

2. Incidence In 1990 there were 6.6 million cases of TB worldwide In 1990 there were 6.6 million cases of TB worldwide By 2008 this had risen to 9.4 million By 2008 this had risen to 9.4 million 30% of those will be in women 30% of those will be in women And 30% of these will be women of child-bearing age And 30% of these will be women of child-bearing age Pregnancy per se does NOT increase the risk of TB infection Pregnancy per se does NOT increase the risk of TB infection Concomitant HIV infection is the biggest problem Concomitant HIV infection is the biggest problem

3. Diagnosis Can be quite difficult when symptoms are nonspecific Can be quite difficult when symptoms are nonspecific And resources are limited And resources are limited Symptoms of... Symptoms of... Malaise Malaise Fatigue Fatigue Weight loss Weight loss Cough & haemoptysis Cough & haemoptysis Scrofula Scrofula Ascites Ascites Investigate by sputum exam for AFB Investigate by sputum exam for AFB CXR can be negative in ≈1:6 cases pulmonary TB CXR can be negative in ≈1:6 cases pulmonary TB Newer tests such as the Quanti-FERON-TB gold in tube test promising Newer tests such as the Quanti-FERON-TB gold in tube test promising

4. Effect of TB on Pregnancy If adequately treated the prognosis is good and TB per se should not affect outcome If adequately treated the prognosis is good and TB per se should not affect outcome But poor obstetric outcomes are common when socio economic circumstances are taken into account But poor obstetric outcomes are common when socio economic circumstances are taken into account Especially when there is concomitant HIV Especially when there is concomitant HIV There is a risk of mother to child transmission There is a risk of mother to child transmission

5. Mother to Child Transmission of TB Can occur... Can occur... In utero – transplacental In utero – transplacental During labour – ingestion During labour – ingestion From breast feeding with TB breast abscess From breast feeding with TB breast abscess But most occurs by direct exposure to aerosol droplets during postnatal contact But most occurs by direct exposure to aerosol droplets during postnatal contact Newly diagnosed and incompletely treated mothers should be separated from their infants Newly diagnosed and incompletely treated mothers should be separated from their infants And all infants should receive prophylactic Isoniazid And all infants should receive prophylactic Isoniazid

6. Treatment of Mothers with TB Should be the same as for non-pregnant ♀ Should be the same as for non-pregnant ♀ But try to avoid Streptomycin But try to avoid Streptomycin 2 months of... 2 months of... Ethambutal Ethambutal Isoniazid Isoniazid Monitor liver function tests Monitor liver function tests Rifampicin Rifampicin Pyrazinamide Pyrazinamide Follow by 4 months of... Follow by 4 months of... Isoniazid plus Rifampicin Isoniazid plus Rifampicin Compliance is a problem Compliance is a problem Drug resistance is a problem Drug resistance is a problem And the safety of 2 nd line therapy in pregnancy is unknown And the safety of 2 nd line therapy in pregnancy is unknown If there is concomitant HIV try to treat that first if possible If there is concomitant HIV try to treat that first if possible Be aware that drug interactions with HAART occur Be aware that drug interactions with HAART occur

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