1. P R E P A R ED B Y :
S A N G I T A S H R E S T HA
M A N I SH A D H U N G A N A

3. 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.

4. Cont..
 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.

5. Cont..
 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.

6. Causative agents:
 Mycobacterium Tuberculosis(Human type)
 Mycobacterium Tuberculosis(Bovine type)

7. 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.

8. Clinical features:
 Evening pyrexia(low grade fever)
 Loss of weight
 Night sweating/Sleep sweats
 Chronic fatigue
 Loss of appetite, pale and ill looking
 Chronic cough
 Malaise
 Haemoptysis
 Breathlessness

9. Diagnostic evaluation:
 Positive family history
 Clinical features
 X-ray examinations(after 12 weeks)
 Early morning Sputum for AFB examination
 Diagnostic bronchoscopy
 Gastric washing

10. Cont..
 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.

11. Congenital tuberculosis is diagnosed by:
a. Lesion noted in the 1st week of life.
b. Infection of the maternal genital tract or placenta.
c. Cavitating hepatic granuloma diagnosed by
percutaneous liver biopsy at birth.
d. No evidence of postnatal transmission.

12. 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.

14. 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.

15. 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.

16. Cont…
 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.

17. 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.

18. Cont…
 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.

19. 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.

20. 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 effects
Isoniazid
(pyridoxine)
5 mg/kg upto 300mg
50mg 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.

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

22. Obstetrical management
During pregnancy
 Supervision 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.

23. During labour
 Close 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.

24. During postnatal period
 After 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.

25. Cont…
 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.

26. Cont..
 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.

27. 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.

28. Cont…
 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.

29. Cont..
 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.

30. Cont..
 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.

31. Cont..
 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.

32. 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.

33. Cont..
 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.

34. 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.

35. • Oral contraceptives should be avoided when
rifampicin is used.
For Children:
 Ethambutol should not be given to children below 6
years of age.

36. References:
1. K.Park, Park’s textbook of Preventive and Social
Medicine,21st Edition,Pageno:164-175.
2. S.Durga, G.Saraswoti, Midwifery Nursing (Part-1),
2nd Edition, Pageno:379- 382.
3. T.Roshani, Manual of Midwifery I, 8th Edition,
Pageno:313-314.
4. H.L.M.C. Midwifery Manual, 1st Edition, Pageno:
124-125.
5. D.C.Dutta, Textbook of Obstetrics,6th Edition,
Pageno:282-283.
6. www.mayoclinic.com