Pregnancy and Tuberculosis. Effect of Tuberculosis on Pregnancy

The most common form of tuberculosis is the process in the lungs. In 50 % of women it proceeds asymptomatically, in others the main manifestations of the disease are a subfebrile condition, cough, perspiration and a slight weight gain. Other forms of tuberculosis, such as meningitis, affection of kidneys, bones are encountered in pregnant women extremely rarely. Genital tuberculosis is accompanied by female sterility.

The incidence of tuberculosis during pregnancy depends on prevalence of disease in the given population and region.

Effect of Tuberculosis on Pregnancy. Usually tuberculosis does not produce any appreciable effect on the course of pregnancy. However at subcompensated and compensated forms a complicated course of pregnancy is marked. Thus, the first place by frequency is taken by miscarriages and premature birth. They are mainly observed at severe forms of tuberculosis accompanied by expressed intoxication. The reason of premature birth is specific infection, intoxication, hypoxia. A constant strain at bad cough, general weakness of organism also contribute to occurrence of premature birth.

Late and early gestoses in pregnant with tuberculosis are observed much more often than in healthy pregnant women, and frequency of severe forms among them (preeclampsia of II and III degree) is high. The transition of tuberculous bacilli from mother to fetus through placenta is rarely observed. However due to intoxication of mother’s organism, disturbances of uteroplacental blood flow an intrauterine hypoxia and hypotrophy of the fetus are frequently observed.

Effect of Pregnancy on Tuberculosis. Pregnancy causes exacerbation of the process, most frequently at hematogenous disseminated, infiltrative and fibrous-cavernous pulmonary tuberculosis. Exacerbation of the process is more often observed in the first months of pregnancy and immediately after labor.

At tuberculous process in the phase of pulmonary consolidation the exacerbation during pregnancy is commonly not observed.

At the end of pregnancy and in postpartum period the progressive pulmonary tuberculosis is possible in women, who worked much, were chronically overtired during pregnancy and badly fed. A combination of these factors with decrease of immunity causes exacerbation of tuberculous process.

Conducting Pregnancy at Tuberculous Process. Until recently tuberculosis was one of the most frequent indications for abortion. However a timely revealing and systematic treatment (in TB prophylactic centre and in a hospital) allows to maintain pregnancy in women, ill with tuberculosis.

The indications for abortion are the following:

· a general destructive process in the lungs, badly yielding to treatment;

· an active form of spinal and pelvic tuberculosis, especially with formation of abscess or fistula, at tuberculosis of coxofemoral, knee, talocrural articulation;

· bilateral renal tuberculosis;

· active forms of tuberculosis, when the treatment undertaken before pregnancy or during it has appeared ineffective and duration of gestation is less than 28 weeks;

· exacerbation of the process during the previous pregnancy;

· a two-year period after the suffered miliary tuberculosis or meningitis;

· concomitant kidney diseases, diabetes mellitus, cardiopulmonary failure.

The abortion should be made in early terms (till 12 weeks) as a single-stage operation (curettage of the uterine cavity or vacuum aspiration). The question of abortion is solved finally by tuberculosis specialist (phthisiatrician), therefore at establishing the diagnosis of pregnancy in woman with any form of tuberculosis it is necessary to hospitalize her at the in-patient phthisiology department.

In the late term pregnancy is terminated in the life-threatening cases.

The examination during pregnancy to reveal tuberculosis is necessary in groups of risk. To these refer pregnant women with tuberculosis in the family or life history, having such clinical signs as weakness, sweating, subfebrile temperature, cough. These women undergo a Mantoux test with estimation of dermal reaction in 48 and 72 h. A positive result does not mean availability of active pathological process; it indicates the necessity of further examination (culture of sputum for Mycobacterium tuberculosis and radiography of the chest). An x-ray examination of the chest in pregnant women is carried out with careful shielding of the abdomen area (fetus thus is exposed to the minimal irradiation). The diagnosis is established on the basis of revealing Mycobacterium tuberculosis in sputum.

Management of Pregnancy. At continuation of pregnancy the complex in-patient treatment during the first three months of pregnancy should be carried out, the next months the treatment should be given in tubercular dispensary. Preference is given to isoniazid and ethambutol. At very serious forms or in the presence of resistance to the specified preparations the application of rifampicinum is allowable, however in the first trimester of pregnancy the treatment with this preparation is undesirable. All persons contacting the woman carrying mycobacterium of tuberculosis are subjected to obligatory inspection and observation in antituberculous dispensary. In term of 36-38 weeks of pregnancy the repeated course of in-patient treatment to prepare for labor is indicated.

Management of Labor. Methods of delivery in women with tuberculosis are chosen by obstetric indication and criteria; labor is conducted in specialized departments or separate wards. Expectant management is applied at labor with the use of respiratory gymnastics; physiological and psychological preparation should be made. Prevention and treatment of occurring obstetrical complications is carried out. For acceleration of delivery and exclusion of expulsive efforts forceps delivery can be used.

If the woman received antituberculous therapy at the end of pregnancy or by the moment of labor, the histological research of placenta is necessary.

Breast feeding can be permitted to women in whom Mycobacterium tuberculosis is not revealed; otherwise newborns are isolated and fed artificially.

Contamination of the fetus is possible at inhalation of the infected amniotic fluid or contents of maternal passages during labor. The infection of children is encountered extremely rarely, and newborns, as a rule, are practically healthy. They should be inoculated against Calmette-Guerin bacillus (BCG) during first 6 weeks of life.