This document discusses pulmonary tuberculosis in pregnant women. It notes that 30% of global TB cases are in India, and 5% of pregnant women have active TB disease. It outlines symptoms of TB in pregnancy like fatigue, fever, and cough. It discusses evaluating and treating TB in pregnancy, including using directly observed therapy. Side effects on the fetus are considered minimal. Vaginal delivery is generally safe while avoiding certain drugs. Breastfeeding is also generally recommended while taking precautions if the mother has active TB.

1. Prof. M.C.Bansal.
MBBS.,MS. MICOG. FICOG.
Founder Principal & Controller ;
Jhalwar Medical College And Hospital Jhalawar.
Ex. Principal & Controller;
Mahatma Gandhi Medical College And Hospital.
Sitapura, Jaipur

2. 
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Pulmonary Tuberculosis , already prevalent in
India , has shown an increased incidence in
recent years worldwide .
WHO has rightly declared it as “ global health
emergency “
WHY so ?
HIV infection has flared it and more so the TB
bacteria have immersed with more resistance
to the available ATT.
30% of world TB is in India and 5% active
disease is seen in pregnant women .

3. 
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Most of the tubercular pregnant women are seen
IN ANC are known cases and are on ATT.
Some are detected as fresh case of pulmonary
Tuberculosis----Symptoms are non specific
Easy fatigability.
Low grade fever.
Haemoptysis.
Long standing cough not responding to routine
antibiotics and anti tussives.

4. 
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Women with genital TB are infertile.
Pregnancy can occur in extra genital
tubercular patients ; so also in cases of
pulmonary TB.
No adverse effects have been reported except
pregnancy induced altered hepatic excretion
of drugs and clinical hepatotoxicity reported
in a few cases.
Maternal malnutrition associated with TB can
also lead to anemia, IUGR, prematurity etc.

5. 
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Side effect of ATT on fetus and newborn are
to be taken in account ; though placenta
provides an effective barrier to the tubercular
organisms and congenital tuberculosis is
extremely rare.
Transplacental and haematogerous infection
to fetus is extremely rare.
The newborn may catch infection from
mother if she is sputum positive.

6. 
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Usually pregnancy and childbirth do not alter
the course of disease.
During puerperium , stress of labour load of
child care can activate the disease.
Puerperal relapses are not uncommon.
Pulmonary surgery is rarely needed and
should be postponed, If possible, until after
delivery.

7. 
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Sputum examination .2 samples(spot & morning)
in 2 consecutive day.(sensitivity 45-85%)
Sputum culture(for monitoring of drug)
Tuberculin test- 1TU & 5 TU i.d of PPD
>10 mm- recent/past infection.
Chest x ray- with abdominal shield
Cavitary lesion/LN enlargement mainly involving
upper lobe
15% normal

8. Adenosine deaminase activity(ADA) test.
-high in cases of TB.
-related to proliferation & differentiation of
lymphocytes.
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ELISA for IgG & IgM in blood & body fluids.
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QuantiFERON TB test- measurement of gamma
interferon released by sensitized lymphocytes
using ELISA technique.
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BACTEL 460 TB – detects mycobacterium growth

9. 
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Symptoms----Cough (75%) , weight loss (10%)
, Low grade fever 50% cases.
Signs ---Upper lobe of lung (usual site )-post
coughing crepitations, findings suggestive of
cavitation ,hydrothorax may be there.
Investigations---Xray chest, CBC , Tuberculine
test is safe ,conclusive and should be done.
ESR is raised in pregnancy hence is not a good
criteria.
HIV testing should be done , if it is positive
special care is needed.
consultation with Chest physician should help in
diagnosis as well as control of disease.

10. 
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High risk explained.
She is to be isolated, mask provided ., if found to be
an open case ---likely to spread to others.
Rest
High protein diet.
Vital(P.R,B.P) charting done.
Temperature charting done 6hrly.
Iron sucrose given to correct her HB status.
Symptomatic treatment for fever, weakness, cough ,
vomiting etc.
TB & chest reference ----Confirmation of diagnosis
and tailoring of ATT therapy( according to
requirement of individual case)
Category 1 treatment started under DOTS.

11. DRUGS
RIFAMPICIN(R),cat C
ISONIAZID(H)
DOSE(DAILY)
(mg/Kg)
10
5
PYRAZINAMIDE(Z)
20-25
ETHAMBUTOL(E)
15
SIDE EFFECET
Hepatotoxic, nephrotoxic,
thrombocytopenia
GI effect, hepatites, peripheral
neuropathy
hepatotoxic, nephrotoxic,
thrombocytopenia
Retro bulbar neuritis,
peripheral neuropathy

12. 
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Capreomycin
Kanamycin
Ethinamide.
PAS
Cycloserin
Safety to these drugs are doubtful
Termination should be offered to pregnant
women in view of teratogenic effects.

13. CATEGORY
OF PATIENT
1(red)
2(blue)
TYPE OF PATIENT
-New sputum smear
positive
- New Sputum smear
negative
-New Extra pulmonary
-smear positive relapse.
-smear positive failure.
-Smear positive treatment
default, failure
INTENSIVE
PHASE
CONTINUTIO
N PHASE
2(HRZE)3
4(HR)3
2(HRZES)3
OR
2(HRZE)3
5(HRE)3

14. 
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Drug-resistant by at least the two
antibiotics, isoniazid (INH) and rifampicin(R).
TREATMENT
INTENSIVE PHASE(9months)
kanamycin
CONTINUTION
PHASE(18months)
ofloxacin
ofloxacin
Ethinamide
Ethambutol
cycloserine
Pyrazinamide
Ethambutol
Ethinamide

15. 
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Resistant to
at least 1st line drugs(isoniazid & rifampicin)
3 or more 2nd line drugs
TREATMENT
INTENSIVE(6-12 months)
Amoxicillin/clavulanate.
CONTINUATION(18) months
-PAS,Moxifloxacin,Isoniazid,Clofazimine
Linezolid, Amoxicillin/clavulanate
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16. 
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Termination of pregnancy on account of the
disease is not justified. The woman should be
antitubercular drugs.
Streptomycine is ototoxic to the fetus and
newborn while Ethambutol is occular toxic .
Therefore these drugs are to be avoided.
Vaginal delivery is safe and should be prefferred.
LSCS can be perfoemed only on obstetrical
grounds .
Epidural anaesthesia is safer than general
anaesthesia.

17. 
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Most relapses occur in this period , decreased
body resistance , super added sepsis in
genital tract and tenting effect of enlarged
uterus on diaphragm is no more and hence
the lung expands and infection may flare up.
A sputum negative mother can breast feed
her child with mask on her mouth and nose.
If she is sputum +vet for T.bacilli , newborn
should be separated and breast feeding in
poor country like ours can be allowed with
the mother wearing a mask.

18. 
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American Academy of Pediatrics recommends that
women with TB who have been treated for 2 weeks
or more/not contagious may breast feed.
But RNTCP recommends breast feeding of
neonates regardless of mother’s TB status
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Anti tuberculosis drugs are excreted into breast
milk but dose is less compared with therapeutic
dose for infants.
The newborn should be vaccinated with o.1ml of
BCG vaccine (developed from isonex resistant
bacillus—strain ). It can be postponed if newborn is
under weight (< 2.5 Kg)/ ill or Mother is HIV +ve.
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Infants Should receive Isoniazid 20mg /kg body
weight of therapeutic dose.
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19. 
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Very small quantity of ATT secreted in mothers
milk.
No toxicity has been reported from this small
concentration in breast milk.
Mother may take medication immediately after
feed & and need not a bottle feeding.
Pyridoxine supplementation should be given to
infants on INH /whose mother is taking the drug.
In the absence of congenital tuberculosis,
isoniazid (20mg/Kg/day) should be commenced
at birth and continued for next 6 months.

20. 
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The tuberculin skin test & chest X rays are
done at 6 weeks,12 weeks, and 6 months.
Baby is revaccinated with BCG at 6 months
and isonizid is continued if these test are
negative.
Congenital tuberculosis in newborn is
manifested by the 2nd / 3rd week after birth.
Baby develops fever , feeding problems and
irritable , no weight gain .
Respiratory distress and jaundice may also
develop. Liver & spleen are enlarged.,
indicating transplacental spread of infection.
Prognosis is poor.

22. STOP
TB IN
BY GOVT. OF INDIA
MY LIFETIME

23. 
● Early detection and treatment of at least 90% of estimated
all type of TB cases in the community, including Drug
resistant and HIV associated TB.
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● Successful treatment of at least 90% of new TB patients,
and at least 85% of previously-treated TB patients
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● Reduction in default rate of new TB cases to less than 5%
and re-treatment TB cases to less than 10%

24. 
● Offer of HIV Counseling and testing for all TB patients and
linking HIV-infected TB patients to HIV care and support;
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● Extend RNTCP services to patients diagnosed and treated
in the private sector.
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● Initial screening of all re-treatment smear-positive till 2015
and all Smear positive TB patients by year 2017 for drugresistant TB and provision of treatment services for MDR-TB
patients.