HRVP Federica MOGHERINI visits Copenhagen
The disease is a significant contributor to maternal mortality and is among the three leading causes of death among women aged 15—45 years in high burden areas. The exact incidence of tuberculosis in pregnancy, though Tubercolosi Joint Forum readily available, is expected to be as high as in the general population.
Diagnosis of tuberculosis in pregnancy may be challenging, as the symptoms may initially be ascribed to Tubercolosi Joint Forum pregnancy, and the normal weight gain in Tubercolosi Joint Forum may temporarily mask the associated weight loss. Obstetric complications of TB include spontaneous abortion, small for date uterus, preterm labour, low birth weight, and increased Tubercolosi Joint Forum mortality. Congenital TB though rare, is associated with high perinatal mortality. Rifampicin, INH and Ethambutol are the first line drugs while Pyrazinamide use in pregnancy is gaining popularity.
Babies born to this mother should be commenced on INH prophylaxis for six months, after which they are vaccinated with BCG if they test negative. Tuberculosis TB is believed to be nearly as old as human history. Traces of it in Egyptian mummies date back to about years ago, when it was described as phthisis by Hippocrates [ 1 ]. Tubercolosi Joint Forum was declared a public health emergency in the African Region in [ 1 ] and has since continued to be a major cause of disability and death.
About 9. About one-third of the world's population estimated to be about 1. This significantly impairs socioeconomic development, thereby perpetuating the poverty cycle [ 4 ]. Mycobacterium tuberculosis, an aerobic, non-spore-forming, nonmotile bacillus, is one of five members of the Mycobacterium tuberculosis complex, others being M.
Africanum, and M. It belongs to the family Mycobacteriaceae. Other Mycobacterium species that may infect humans include Mycobacterium lepraeM. Intracellulare, and M. Tuberculosis affects almost every organ in the body, but the usual site of the disease is the lungs, accounting for more than 80 percent of tuberculosis cases [ 5 ]. The pattern of the infection in HIV positive patients may, however, be different, with increasing trends towards extrapulmonary spread [ Tubercolosi Joint Forum ].
Almost all tuberculosis infections are caused by inhalation of infectious particles aerosolized by coughing, sneezing, talking, or manipulation of infected tissues.
Other modalities of transmission may, however, include ingestion of unpasteurised milk Tubercolosi Joint Forum direct implantation through skin abrasion or the conjunctiva. Following phagocytosis by pulmonary macrophages, a granulomatous reaction may be initiated, in conjunction with the regional lymph nodes, thereby forming the Ghon's focus.
The bacilli remain in a state of dormancy within the Ghon's focus, from where they may later become reactivated. The wide array of opinion of Medical practitioners on tuberculosis in pregnancy simply reflects the Public Health significance of the condition. It is best described as a doubled-edged sword, one blade being the effect of tuberculosis on pregnancy and the pattern of growth of the newborn, while the other is the effect of pregnancy on the progression of tuberculosis.
Tuberculosis not only accounts for a significant proportion of the global burden of disease, it is also a significant contributor to maternal mortality, with the disease being among the three leading causes of death among women aged Tubercolosi Joint Forum years [ 2 ].
The exact incidence of tuberculosis in pregnancy is not readily available in many countries due Tubercolosi Joint Forum a lot of confounding factors.
It is, however, expected that the incidence of tuberculosis among pregnant women would be as high as in the general population, with possibly higher incidence in developing countries. A recent United Kingdom study, however, quoted an incidence of 4. Researchers from the days of Hippocrates have expressed their worries about the untoward effects that pregnancy may have on preexisting tuberculosis.
Pulmonary cavities resulting from tuberculosis were believed to collapse as a result of the increased Tubercolosi Joint Forum pressure associated with pregnancy. This belief was widely held till the beginning of the fourteenth century! Indeed, a German physician recommended that young women with TB should get married and become pregnant to slow the progression of the disease.
This was practiced in many areas till the 19th century [ 9 ], while in the early 20th century, induced abortion was recommended for these women [ 1011 ].
Researchers like Hedvall [ 12 ] and Schaefer [ 7 ], however, demonstrated no net benefit or adverse effect of pregnancy on the progression of TB. Frequent, consecutive pregnancies may, however, have a negative effect, as they may promote recrudescence Tubercolosi Joint Forum reactivation of latent tuberculosis. It is, however, important to note that the diagnosis of tuberculosis in pregnancy may be more challenging, Tubercolosi Joint Forum the symptoms may initially be ascribed to the pregnancy.
The weight loss associated with the disease may also be temporarily Tubercolosi Joint Forum by the normal weight gain in pregnancy. The Tubercolosi Joint Forum of TB on pregnancy may be influenced by many factors, including the severity of the disease, how advanced the pregnancy has gone at the Tubercolosi Joint Forum of diagnosis, the presence of extrapulmonary spread, and HIV Tubercolosi Joint Forum and the treatment instituted. The worst prognosis is recorded in women in whom a diagnosis of advanced disease is made in the puerperium as well as Tubercolosi Joint Forum with HIV coinfection.
Failure to comply with treatment also worsens the prognosis [ 13 ]. Other obstetric complications that have been reported in these women include a higher rate of spontaneous abortion, small for date uterus, and suboptimal weight gain in pregnancy [ 1415 ]. Others include preterm labour, low birth weight and increased neonatal mortality [ 13 ].
Late diagnosis is an independent factor, which may increase obstetric morbidity about fourfolds, while the risk of preterm labour may be increased ninefolds [ 15 — 18 ]. Congenital tuberculosis is a rare complication of in utero tuberculosis infection [ 19 ] while the risk of postnatal transmission is significantly higher [ 20 ]. Congenital tuberculosis may be as a result of haematogenous spread through the umbilical vein to the foetal liver or by ingestion and aspiration of infected amniotic fluid [ 21 ].
A primary focus subsequently develops in the liver, with involvement of the peri-portal lymph nodes. Congenital tuberculosis may be difficult to distinguish from other neonatal or congenital infections from which similar symptoms may arise in Tubercolosi Joint Forum second to the third week of life.
These symptoms include hepato-splenomegaly, respiratory distress, fever, and lymphadenopathy. Radiographic abnormalities may also be present but these generally appear later [ 13 ]. The diagnosis of neonatal tuberculosis may, however, be facilitated by employing a set of diagnostic criteria developed by Cantwell et al. The possibility of postnatal transmission must be excluded by a thorough investigation of all contacts, including hospital staffs and attendants.
As much as half of the neonates delivered with congenital tuberculosis may eventually die, especially in the absence of treatment [ 723 — 26 ]. To diagnose this condition, Tubercolosi Joint Forum of exposure to individuals with chronic cough or recent visit to areas endemic with tuberculosis should be obtained. History of symptoms, which Tubercolosi Joint Forum likely to be the same as in nonpregnant women, is also essential.
Caution must, however, be exercised, as these symptoms may be nonspecific in pregnancy [ 2728 ]. These symptoms include night sweat, evening pyrexia, haemoptysis, Tubercolosi Joint Forum weight loss, and chronic cough of over 3 weeks duration. There may also be a history of ineffective attempts at antibiotics therapy [ 2729 ]. In pregnant women with suggestive symptoms and signs of TB, a tuberculin skin test should be carried out. This has since been accepted to be safe in pregnancy [ 2130 ].
The debate, however, is about the sensitivity of Tubercolosi Joint Forum test during pregnancy. Earlier reports suggested diminished tuberculin sensitivity in pregnancy [ 31 ], while recent studies revealed no significant differences in the pregnant and nonpregnant populations [ 2732 — 35 ].
This test utilises an instrument with multiple needles that are dipped in a purified form of the TB bacteria called old tuberculin OT. The skin is pricked with these needles and the reaction is analysed 48—72 hours later. It is, however, no longer popular except in large population screening.
A single-needle intradermal injection of 0. It is a more accurate and reproducible test than the Tines test. False-positive results may be obtained in individuals who had previously been vaccinated with Tubercolosi Joint Forum BCG vaccine, those with previously treated tuberculosis, as well as in people with infection from other Mycobacterium species. False negatives on the other hand are commonly due to a compromised immune system and technical errors [ 36 ].
A chest radiograph with abdominal lead shield may be Tubercolosi Joint Forum after the tuberculin skin testing, though pregnant women are more likely to experience a delay in obtaining a chest X-ray Tubercolosi Joint Forum to concerns about fetal health [ 27 ]. Microscopic examination of sputum or other specimen for Acid-fast bacilli AFB remains the cornerstone of laboratory diagnosis of TB in pregnancy. Three samples of sputum should be submitted for smear, culture, and drug-susceptibility testing.
Light-emitting diode LED fluorescent microscopy Tubercolosi Joint Forum recently been introduced to improve diagnosis [ 37 ]. The staining techniques may, therefore, not sufficient for the diagnosis of TB, as smear-negative cases will be missed [ 37 ]. The traditional culture on Lowenstein-Jensen's medium may take 4—6 weeks to obtain a result.
This may, however, still be useful in cases of diagnostic doubts and management of suspected drug-resistant tuberculosis [ 38 ].
Newer diagnostic tools are Tubercolosi Joint Forum available to facilitate diagnosis, including the liquid Bactec culture medium, which has been endorsed by WHO. Other culture media that could be used include the modified Lowenstein's medium, Petragnani medium, Trudeau Committee medium, Peizer's medium, Dubos Middlebrook media, Tarshis blood agar, Middlebrook's 7-H3, Middlebrook's 7-H9, and Middlebrook's 7H media [ 38 ].
It may, therefore, be differentiated from other mycobacterium species using these features. Others include reduction of nitrates and its isoniazide sensitivity, which may, however, not be reliable in cases of INH resistance.
Molecular Line Probe Assay LPA as well as the use of polymerase chain reaction PCR are presently facilitating the specific identification of the tubercle bacilli [ 37 ].
The management of tuberculosis in pregnancy is a multidisciplinary approach, with the team comprising the obstetrician, communicable disease specialty personnel, neonatologists, counselling unit, and public health officials. This therapy entails the use of combination therapy for at least 6 months, depending on the combination of antituberculous agents that are available. This combination includes isoniazide and rifampicin compulsorily, supported by ethambutol and pyrazinamide [ 40 — 44 ].
Treatment is done on out-patient basis, unless otherwise indicated [ 37 ]. The use of these first-line antituberculous drugs in pregnancy are considered safe for the mother and the baby by The British Thoracic Tubercolosi Joint Forum, International Union Against Tuberculosis and Lung Disease, and the World Health Organisation [ 1645 ].
INH is safe during pregnancy even in the first trimester, though it can cross the placenta [ 11 ]. The women must, however, be followed up because of the possibility of INH-induced hepatotoxicity.
The retrobulbar neuritis that may complicate the use of this drug in adults generated the fear that it may interfere with ophthalmological development when used in pregnancy but Tubercolosi Joint Forum has not been demonstrated when the standard dose is used.
This was also confirmed in experimental studies on some abortuses [ 47 ]. The use of pyrazinamide in pregnancy was avoided by many physicians for a long time due to unavailability of adequate data on its teratogenicity. There are no reports of significant adverse events from the use of this drug in the treatment of TB in pregnant women despite its use as part of the standard regimen in many countries [ 48 ].
Its use is particularly indicated in women with tuberculous meningitis in pregnancy, HIV coinfection, and suspected INH resistance [ 49 — 52 ]. Breastfed infants of mothers on antituberculous therapy should, however, be monitored for jaundice, which may suggest drug-induced hepatitis, as Tubercolosi Joint Forum as joint pains resulting from drug-induced hyperuricaemia.
The drug has been proven to be potentially teratogenic throughout pregnancy. It causes fetal malformations and eighth-nerve paralysis, with deficits ranging from mild hearing loss to bilateral Tubercolosi Joint Forum. Many centres are against the use of this drug in pregnancy [ 495354 ]. They may sometimes require treatment with second-line drugs, including cycloserine, ofloxacin, amikacin, kanamycin, capreomycin, and ethionamide.