Tuberculosis in Pregnancy

Abstract

Tuberculosis (TB) in pregnancy poses a substantial risk of morbidity to both the pregnant woman and the fetus if not diagnosed and treated in a timely manner. Assessing the risk of having Mycobacterium tuberculosis infection is essential to determining when further evaluation should occur. Obstetrician-gynecologists are in a unique position to identify individuals with infection and facilitate further evaluation and follow up as needed. A TB evaluation consists of a TB risk assessment, medical history, physical examination, and a symptom screen; a TB test should be performed if indicated by the TB evaluation. If a pregnant woman has signs or symptoms of TB or if the test result for TB infection is positive, active TB disease must be ruled out before delivery, with a chest radiograph and other diagnostics as indicated. If active TB disease is diagnosed, it should be treated; providers must decide when treatment of latent TB infection is most beneficial. Most women will not require latent TB infection treatment while pregnant, but all require close follow up and monitoring. Treatment should be coordinated with the TB control program within the respective jurisdiction and initiated based on the woman's risk factors including social history, comorbidities (particularly human immunodeficiency virus [HIV] infection), and concomitant medications.

Fig. 1.

High-burden tuberculosis (TB) countries as reported by the World Health Organization. ^aIndicates countries that are included in the list of 30 high TB burden countries on the basis of severity of their TB burden (ie, TB incident cases/100,000 population/year), as opposed to the top 20, which are included on the basis of their absolute number of incident cases per year. MDR-TB, multi-drug-resistant tuberculosis; TB/HIV, tuberculosis and human immunodeficiency virus co-infection. © World Health Organization 2018. Available at https://reliefweb.int/sites/reliefweb.int/files/resources/9789241565646-eng.pdf.

Fig. 2.

Evaluation for tuberculosis (TB) in pregnancy. *Evaluation for active TB disease includes a medical history and physical examination, chest radiograph, sputum smears for acid-fast bacilli, cultures, nucleic acid amplification testing, and other diagnostics as clinically indicated. ^†If immunosuppressed, may still choose to perform a chest radiograph at the discretion of the provider, even if the interferon gamma release assay or tuberculin skin test result is negative. If a pregnant woman is a contact to a person with infectious TB, a repeat test should be performed 8 weeks after the last exposure. ^‡Chest radiograph should be performed as soon as possible regardless of trimester if woman is immunocompromised but may be delayed until the second or third trimester based on epidemiologic risk factors and clinical judgment for all other pregnant women. Chest radiograph in pregnancy should be performed with a lead abdominal shield. ^§Baseline laboratory tests include liver function tests if treating with isoniazid and includes a complete blood count if using rifampin. ^‖Latent TB infection treatment should be started at the discretion of the provider based on risk factors, local epidemiology, and other individual factors.