PREPARED BY:SANGITA SHRESTHA

MANISHA DHUNGANA

Introduction

Pulmonary tuberculosis is an infectious disease of the lungs caused by acid fast bacilli (AFB) known as mycobacterium tuberculosis characterized by low grade fever, loss of weight, chronic cough, etc.

The bacteria gets into the lungs through inhaled air contaminated by the sputum of positive cases.

About 45% of total population is infected by TB of which 60% is adult.

The incidence ranges between 1-2% amongst the hospital deliveries.

Infact in 1993, WHO pronounced tuberculosis “a global health emergency”.

In 2000, WHO showed the emergence of multidrug resistant tuberculosis (MDR-TB) all over the world.

The lung is the major site of involvement, but the lymph gland, meninges, bones, joint, intestine and kidneys can also be infected.

The person becomes infected by inhaling the infectious organisms mycobacterium tuberculosis, which is carried on a droplet nuclei spread by airborne transmission.

The women can remain asymptomatic for long periods of time as the organism may be dormant.

Causative agents:

Mycobacterium Tuberculosis(Human type)Mycobacterium Tuberculosis(Bovine type)

Predisposing factors

Positive family history or past history.Low socio-economic status.Area of high prevalence of tuberculosis.HIV infection.Alcohol addiction.Intravenous drug abuse.

Clinical features:

Evening pyrexia(low grade fever)Loss of weightNight sweating/Sleep sweatsChronic fatigueLoss of appetite, pale and ill lookingChronic coughMalaiseHaemoptysis Breathlessness

Diagnostic evaluation:

Positive family historyClinical featuresX-ray examinations(after 12 weeks)Early morning Sputum for AFB examinationDiagnostic bronchoscopyGastric washing

Tuberculin skin test with purified protein derivates(PPD) montox test when ≥10 mm is considered positive esp. in presence of risk factors.

Extra-pulmonary sites; lymph nodes, bones (rare in pregnancy)

Direct amplification test to detect Mycobacterium tuberculosis.

Congenital tuberculosis is diagnosed by:a. Lesion noted in the 1st week of life.b. Infection of the maternal genital tractor

placenta.c. Cavitating hepatic granuloma diagnosed by

percutaneous liver biopsy at birth.d. No evidence of postnatal transmission.

Effect on pregnancy

MOTHER: Pregnant women with untreated TB are more likely to have pre-

eclampsia, spontaneous abortion, preterm labour, difficult labour and PPH.

Intrauterine fetal death. Anemia

FETUS: Under weight infant Low apgar score Perinatal death IUGR Preterm labour.New born baby is at risk of postnatally acquired TB if mother has still TB

at the time of birth.

Effect of pregnancy on TB:

Higher risk of relapse in the puerperium. This may be due to the disturbed nights, increased work and anxiety for care of a new born.

Prevention

The BCG vaccine has been incorporated into the National immunization policy of many countries, especially the high burden countries, thereby conferring active immunity from childhood. Non-immune women travelling to tuberculosis endemic countries should also be vaccinated. It must, however, be noted that the vaccine is contraindicated in pregnancy.

The prevention, however, goes beyond this as it is essentially a disease of poverty. Improved living condition is, therefore, encouraged with good ventilation, while overcrowding should be avoided. Improvement in nutritional status is another important aspect of the prevention.

Pregnant women living with HIV are at higher risk for TB, which can adversely influence maternal and perinatal outcomes. As much as 1.1 million people were diagnosed with the co-infection in 2009 alone. Primary prevention of HIV/AIDS is, therefore, another major step in the prevention of tuberculosis in pregnancy. Screening of all pregnant women living with HIV for active tuberculosis is recommended even in the absence of overt clinical signs of the disease.

Cont..

Isoniazid preventive therapy (IPT) is another innovation of the World Health Organisation that is aimed at reducing the infection in HIV positive pregnant women based on evidence and experience and it has been concluded that pregnancy should not be a contraindication to receiving IPT. However, patient's individualisation and rational clinical judgement is required for decisions such as the best time to provide IPT to pregnant women.

Most importantly, governments commitments are highly encouraged so that the World Health Organisation and all other international bodies involved in fighting tuberculosis may succeed in chasing this monster out of all communities.

Therapeutic management

The principles of treatment for the pregnant woman with TB are same as in the non pregnant patient.

The treatment of TB in pregnancy is important for two reason.

For serious consequences of untreated TB and the risk of its spread to newborns.

Secondly the effect of the drugs used in its treatment on the fetus.1.Women with positive purified protein derivates (PPD) and

no evidence of active disease (asymptomatic), Isoniazid prophylaxis 300mg/day is started after the first trimester and continued for 6-9 months. Pyridoxine (vit.B6) 50mg/day is added to prevent peripheral neuropathy.

2.Women with active tuberculosis should receive the following drugs orally daily for a minimum period of

9 months.

Drug Daily doses-PO Major side effectsIsoniazid (pyridoxine)

5 mg/kg upto 300mg50mg daily

Hepatitis, peripheral neuropathy, hypersensitivity.

Rifampicin 10 mg/kg upto 600mg. Nausea, vomiting, hepatitis, orange discoloration of urine and secretion, febrile reaction.

Ethambutal 15 mg/kg upto 2.5 gm Skin rash, optic neuritis, decreased visual activity.

Pyrazinamide 15-30mg/kg upto 2gm. Hepatotoxicity, skin rash, arthralgias, hyperuricemias, G.I. upset.

3.Surgical management should be withheld, if possible, but if deemed necessary should be restricted for first half of pregnancy beyond 12 weeks.

Obstetrical management

During pregnancySupervision and joint care with obstetrician and chest

physician is necessary.In the first trimester anti-TB drug should be

continued. The choice of drug and the dosage may have to be modified. Morning sickness may pose some difficulties.

In 2nd and 3rd trimester, the status should be reviewed. Women will need advice regarding workload, diet and rest.

Treatment with iron, folic acid and vitamin is necessary to improve general condition/health.

During labourClose monitoring of pulse and respiratory rate are

necessary especially in pulmonary TB.Normal vaginal delivery is routine for women with

tuberculosis and low forcep may be used to short the 2nd stage of labour.

Spinal or epidural anesthesia are preferred than inhalation anesthesia for fear of contamination.

During postnatal periodAfter delivery the women with active disease must

stay in hospital or transferred to a hospital for two or three weeks to allow them a period of rest before they return to their house hold duties.

Breast feeding is not contraindicated when a woman is taking anti-tuberculosis drugs. Breast feeding should be avoided if the infant is also

taking the drugs (to avoid excess drug level) In active lesion, not only is breast feeding

contraindicated but the baby is to be isolated from the mother following delivery.

Baby should be given prophylactic isoniazid 10-20mg/kg/day for 3 month when the mother is suffering from the active disease.

If the mother is on effective chemotherapy for at least 2 weeks, there is no need to isolate the baby. BCG should be given to the baby as early as possible.

Pregnancy is to be avoided until quescence is assured for about two years. Oral contraceptives should be avoided when

rifampicin is used. Due to accelerated drug metabolism, contraceptive

failure is high. Puerperal sterilization should be considered if the

family is completed.

Nursing management

Review the woman's history for risk factors such as immuno-compromized status, recent immigration status, homeless, over crowded living conditions and injectable drug use.

At antepartum visits, be alert for clinical manifestation of TB including fatigue, fever or night sweats, non productive cough, slow weight loss, anemia, haemoptysis and anorexia.

If the TB is suspected or the woman is at risk for developing TB, anticipate screening with purified protein derivative (PPD) administered by intradermal injection. If the client has been exposed to TB, a reddened

induration will appear within 72 hours. If the test is positive anticipate a follow up chest

x-ray with lead shielding over the abdomen and sputum culture to confirm the diagnosis.

Complaining with the multidrug therapy is critical to protect the woman and her fetus from progression of TB.

Provide education about the disease process, the mode of transmission, prevention, potential complications, and the importance of adhering to the treatment regimen.

Stressing the importance of health promotion activities throughout the pregnancy is important. Some suggestion might include;

Avoiding crowded living conditions. Avoiding sick people. Maintaining adequate hydration. Eating a nutritious well balanced diet. Keeping all prenatal appointments to evaluate fetal

growth and well being. Getting plenty of air by going outside frequently.

Determining the woman's understanding of her condition and treatment plan is important for compliance.

Breast feeding is not contraindicated during the medication regimen and should be encouraged

Management of the newborn of a mother with TB involves preventing transmission by teaching the parent not to sneeze, cough or talk directly into the newborns face.

How do you manage the newborn ?

If the mother is non-infectious, she can handle her baby. Ordinary BCG vaccination is given to protect the baby.

If the mother is infectious, the baby must be separated from the mother until she becomes non-infectious. The baby must Be given a dose of BCG vaccine. The infectious mother can handle her baby only after successful BCG vaccination i.e. after a period of eight weeks.

If the separation of mother and baby is not practicable, the baby may be given protective dose of isoniazide as prophylactic:10-20 mg/kg/day for 3 months.

Points to be remember:During pregnancy,Streptomycin can cause permanent deafness

in the baby, so ethambutol should be used instead of streptomycin.

Isoniazid, rifampicin, pyrazinamide and ethambutol are safe to use.

Second-line drugs such as fluroquinolones, ethionamide and protionamide are teratogenic, and should not be used.

• Oral contraceptives should be avoided when rifampicin is used.

For Children:Ethambutol should not be given to children

below 6 years of age.

References:

1. D.C.Dutta, Textbook of Obstetrics,6th Edition, Pageno:282-283.

2. H.L.M.C. Midwifery Manual, 1st Edition, Pageno: 124-125.

3. K.Park, Park’s textbook of Preventive and Social Medicine,21st Edition,Pageno:164-175.

4. S.Durga, G.Saraswoti, Midwifery Nursing (Part-1), 2nd Edition, Pageno:379- 382.

5. T.Roshani, Manual of Midwifery I, 8th Edition, Pageno:313-314.