تعليقEpidemiological information on TB in pregnancy is scarce. In the United Kingdom, women in early postpartum were twice as likely to develop TB as non-pregnant women (63).
A recent population study in Mozambique evaluated the prevalence of TB in pregnancy and found that it was similar to that of the general population, although it was higher in women living with HIV (64). The TB prevalence was 505 (95% CI: 242–926) per 100 000 pregnant women and 297 (95% CI: 61–865) per 100 000 postpartum women. Among pregnant women who were HIV-positive, TB prevalence was 1626 per 100 000 (95% CI: 782–2970) and among postpartum women who were HIV-positive, TB prevalence was 984 per 100 000 (95% CI: 203–2848).
In addition to the TB-related risks to the mother, TB during pregnancy has been associated with high perinatal mortality, small size for gestational age, preterm and low birth weight neonates (65). Maternal TB disease is associated with poorer neonatal outcomes, in part because of social deprivation and other factors that are associated with a higher risk of TB during pregnancy (66). Disseminated TB in the mother can cause congenital TB in the infant, but this is a rare condition (67). Diagnosis of TB is often delayed during pregnancy, because of its nonspecific symptoms and overlapping presentation with other infectious diseases. Adverse perinatal outcomes are even more pronounced in women with advanced disease, late diagnosis, and incomplete or irregular drug treatment. Many antenatal clinics are unprepared to diagnose TB (68). Because pregnancy is usually considered an exclusion criterion, there is a lack of data from clinical trials including this important category of patients. Standard treatment for DS-TB is considered safe in pregnancy and outweighs the grave risks posed by untreated TB. Measurement of liver function before the start of treatment is useful and, if the function is found to be abnormal, appropriate management is undertaken (69, 70). Core issues related to the management of treatment during pregnancy relate to the safety of the child before and after birth, considering both the risk of transmission (i.e. mother-to-child) and the potential teratogenic effect of anti-TB drugs.
Neonatal TB is most commonly due to inhalation of tubercle bacilli. As long as the mother has received at least 2 weeks of treatment for DS-TB, isolation of the infant is not required (71). This is particularly relevant because of the importance of breastfeeding for child health. Early diagnosis and treatment help to ensure the best possible outcome of TB in pregnancy for both mother and infant.
Pregnant women are usually treated with the standard 6-month 2HRZE/4HR regimen. Evidence on the use of the 4-month 2HPMZ/2HPM regimen during pregnancy is lacking (1). Experts have suggested using pyridoxine to complement the anti-TB regimen in pregnancy, because deficiency is more likely to occur than in the general population (72).
Implementation considerations
- The isolation needs of the mother should be reduced to the minimum necessary to prevent transmission to the child, to ensure that breastfeeding is not interrupted.
- Health education on the basics of infection control, with a special focus on personal protection and ventilation, is an important component of the management of treatment of DS-TB during pregnancy
- Although the drugs used to treat DS-TB are generally well tolerated and are unlikely to cause adverse events to the mother and the child, monitoring of adverse events is important to ensure rapid notification and prompt management.
- Management of patients listed in this section (i.e. pregnant women and others) involves a multidisciplinary approach; a TB consilium to support the management of people with TB that is difficult to treat may be of help (62, 73)
- Coordination of the NTP with antenatal clinics and HIV services is important, to ensure rapid diagnosis and effective treatment of TB in pregnancy