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Tuberculosis and Pregnancy

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Tuberculosis and Pregnancy Tuberculosis and pregnancy Susanna Capone, MD, MIH University Department of Infectious Diseases and Tropical Medicine WHO Collaborating Center for TB/HIV collaborative activities and for the TB elimination Strategy University of Brescia Brescia, Italy © by author ESCMIDESCMID Postgraduate Education Online Course Lecture Library Infectious Diseases of Pregnant Woman, Fetus and Newborn 29th September 2016 Bertinoro Summary From the mother’s point of From the newborn’s point of view: TB and Pregnancy view: Congenital Tuberculosis 1. Epidemiology 1. Congenital and 2. How pregnancy can perinatal affect TB 2. Epidemiology 3. Diagnosis 3. Diagnosis 4. Active TB © by author4. Treatment Management 5.ESCMID Managment Online of LTBI Lecture Library 6. TB and HIV hints From the mother’s point of view: TB and Pregnancy © by author ESCMID Online Lecture Library Epidemiology Tuberculosis affected an estimated 9.6 million people (3.2 million women and 1 million children) and caused 1.5 million deaths globally in 2014, including about half©‐million by author women and at least 140.000 children. ESCMID Online Lecture Library TB is one of the top killers of women worldwide rd World Health Organization. Global tuberculosis Report 2015 (3 cause). Geneva, Switzerland: WHO, 2016. TB incidence: countries and regions Europe 3% Americas 3% E. Mediterranean 8% South‐East Asia Africa 28% 41% © by author 23% in India 10% each:ESCMID Indonesia & China Online Lecture Library 5% each: Nigeria & Pakistan Prevalence of active TB in pregnant and post partum women <20 cases per 100 000 population per year in LBC >60 cases per 100 000© population by perauthor year in HBC ESCMID Online Lecture Library Mathad & Gupta, CID, 2012: 55 (11): 1532-1549 Prevalence of LTBI in pregnant and post partum women © by author ESCMID Online Lecture Library Mathad & Gupta, CID, 2012: 55 (11): 1532-1549 2. Does Pregnancy influences the TB natural history? M. tuberculosis IRR for TB: Pregnant women 2fold vs First NON pregnant women Re-infection Infection (exogenous) Primary TB Pregnancy Latent ? TB Reactivation © by author(endogenous) ESCMID OnlineProgressive Lecture? LibraryPost-primary TB Primary TB Does pregnancy affect the course of TB? • Pregnancy suppresses the T‐helper 1 (Th1) response, which may mask symptoms while increasing susceptibility to new infection and reactivation of tuberculosis (i.e. M. leprae) • After delivery the Th1 suppression reverses and symptoms exacerbate as in IRIS. • Biologic changes in pregnancy© by author and postpartum ‐ influence TB progression ESCMID Online Lecture Library © by author An upward trend immediately postpregnancy, peaking at 90 days postpartum (IRR,ESCMID 1.74; 95% CI, 0.95–3.19) Online and a gradual Lecture decrease to anLibrary IRR of 1.53 (95% CI, 0.79–2.96) and 1.19 (95% CI, 0.55–2.58) at 180 days and 270 days postpartum, respectively Zenner D et al, Risk of tuberculosis in pregnancy: a national, primary care based cohort and selfcontrolled case series study. Am J Respir Crit Care Med 2012; 185:779–84 Risk of TB during pregnancy • Tuberculosis during pregnancy increases the occurrence of preterm labor, low birth weight, and neonatal mortality • Late diagnosis of tuberculosis in pregnancy may increase the risk of obstetric morbidity by 4‐fold and that© ofby preterm author labor by up to 9‐ fold ESCMID Online Lecture Library 3. Diagnosis of TB during pregnancy • Insidious onset, protean manifestation, non‐specific nature of symptoms • Loss of appetite, tiredness, fatigue, shortness of breath and sweating, can be due to pregnancy • Diagnosis is delayed because of clinicians’ concern to suggest chest X‐ray© during by authorpregnancy ESCMID Online Lecture Library 3. Diagnosis of TB during pregnancy • Bacteriological confirmation and other radiological diagnostics for extra‐pulmonary cases are more difficult to perform during pregnancy • Surgical or endoscopic biopsies for extra‐pulmonary TB may not be feasible in pregnant women because of technical difficulties such as non‐accessibility of the lesions, secondary increased risk of preterm labor and anesthetic© hazbya rdsauthor for the foetus ESCMIDWHO CLINICAL Online APPROACH LectureIN HIGH Library BURDEN HIV/TB COUNTRIES: CURRENT COUGH, FEVER, NIGHT SWEATS, WEIGHT LOSS Active TB diagnosis • In symptomatic and asymptomatic women with a recent contact with a patient with active pulmonary TB, CDC recommends a chest xray, which poses minimal risk to the foetus . If findings are abnormal, sputum samples should be sent for microscopy and culture examination. • Common extra‐pulmonary© by author sites of tuberculosis in pregnancy include lymph nodes, gastro‐intestinal tract and bones . ESCMID Online Lecture Library Additional diagnostic testing (eg, biopsy)should be pursued if clinical suspicion is high. 4. Active TB management “Untreated tuberculosis represents a far greater hazard to a pregnant woman and her foetus than does TB treatment” © by author ESCMID Online Lecture Library Centre for Disease Control, “Treatment of tuberculosis,” MMWR, vol. 52, no. RR‐11, pp. 1–77, 2003. When mother is smear positive • Immediate maternal treatment for TB; • If the mother has received tuberculosis treatment for <2 months before delivery or remains potentially infectious, the child should be given IPT. • In the newborn,© in byabsence author of evidence of congenital TB, isoniazide (10mg/kg/day) ESCMIDshould be commenced Online Lecture at birth and Library continued for six months When the mother is smear positive • In endemic countries, WHO recommends BCG vaccination in infants born to mothers with active tuberculosis, after completion of infant IPT, as INH seems to inhibit vaccine efficacy • BCG vaccination is not recommended in HIV‐ infected infants because of the risk of disseminated BCG© by disease author ESCMID Online Lecture Library TB and breastfeeding • The CDC encourages breastfeeding if a woman has been on first‐line ATT and is no longer infectious • There has been no documented cases of tuberculosis transmission via breast milk since the development of ATT • Women with tuberculosis mastitis should breastfeed from the unaffected© breast.by author • Small concentrations of ATT are secreted into the ESCMIDbreast milk, posing Online minimal Lecture risk to the Library infant. Active TB Treatment © by author ESCMID Online Lecture Library Jyoti S. Mathad and Amita Gupta Tuberculosis in Pregnant and Postpartum Women: Epidemiology, Management, and Research Gaps; CID 2012;55(11):1532–49 Rifampicin • Safe: pregnancy category C • There is an increased risk of haemorrhagic disorders due to secondary hypoprothrombinaemia in the woman and in her newborn particularly in case of RIF use in late pregnancy © by author • Vitamin K should be administered to the ESCMIDmother and Onlineat birth to Lecture her infant Library • Dose: 10 mg/kg/die Isoniazid • Safe: pregnant category A • The women must be followed up because of the possibility of INH‐induced hepatotoxicity (liver function each 15 days for the 1st 2 months and then monthly). • Pyridoxine supplementation© by author is recommended for all pregnant women taking INH because of ESCMIDa higher risk Online of its deficiency Lecture during Library pregnancy. • Dose: 5 mg/kg/die Ethambutol • Safe: pregnancy category A • 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 this has not been demonstrated when© by the author standard dose is used. ESCMID Online Lecture Library • Dose: 15 mg/kg/die Pyrazinamide • Safe: pregnancy category B2 • The use of pyrazinamide in pregnancy was avoided by many physicians for a long time due to unavailability of adequate data on its teratogenicity. • Actually no report on any secondary foetal malformations. • Presently, CDC does not recommend but IUALT, WHO, QH and other organizations recommend it. • Its use is particularly ©indica byted author in women with TB meningitis, HIV coinfection, and suspected INH resistance. • If PZA/Z is not used, a nine‐month regimen containing INH ESCMIDand RIF is recommended, Online supplemented Lecture by LibraryETH until drug susceptibility results are available. • Dose: 25 mg/kg/die Streptomycin • Not recommended!!! • The drug has been proven to be potentially teratogenic throughout pregnancy. • It can cause foetal malformations and VIII nerve paralysis, with deficits ranging from mild hearing loss© to by bilateral author deafness. ESCMID Online Lecture Library Second line drugs The management of drug‐resistant cases and the use of second‐line agents (both generally and during pregnancy) should only be considered after consultation with an expert in TB management. Teratogenicity has been described with© aminoglycosides, by author capreomycin and ethionomide and patients taking these ESCMIDagents should Online be advised Lecture to take Library measures to avoid pregnancy. Flurochinolones • Pregnancy category: B3 (cipro, moxi, norflo). • Animal studies of ciprofloxacin suggest a risk of damage to articular cartilage , subsequent juvenile arthritis with short courses , possibility of joint damage with longer ones. • No reports on foetus abnormalities in pregnant women having taken© byflurochinolones author • Should only been used when the benefits outweigh ESCMIDthe risks Online Lecture Library Amikacin • Pregnancy category D: not reccomended! • All aminoglycosides are potentially nephrotoxic and ototoxic to the foetus and • The use of aminoglycosides in pregnancy
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