Diagnosis and treatment

of Tuberculosis in
pregnancy
Prof. Dr. (Mrs.) V. Agrawal
Professor & Head
Department of Obst. & Gynae
G.R. Medical College Gwalior, India
Dr Roli Gautam
Jr Consultant MAX Hospital
New Delhi
 Historical perspective

Hippocratic view

young woman with tuberculosis

should become pregnant to improve
her outcome!!
 Historical perspective…
1850 - 1920s
Tuberculosis was harmful
during pregnancy, and
termination of pregnancy -
recommended
 Global burden of TB
 2 billion infected, i.e. 1 in 3 of global population
 9.4 million (139/lakh) new cases in 2008, 80% in 22
high-burden countries
 4 m new sm+ve PTB (61/lakh) cases in 2008
 Global incidence of TB has peaked in 2004 and is
declining.
 1.77m deaths in 2007, 98% in low-income countries
 MDR-TB -prevalence in new cases around 3.6%

NTF Presentations for RNTCP Ref: WHO Global Report, 2006

Sensitization First edition 10th Nov 06
 WHO
10 facts about
tuberculosis
23 March 2009
 Fact 1
 Tuberculosis (TB) is
contagious and spreads
through the air.
 If not treated, each
person with active TB
can infect on average 10
to 15 people a year. WHO/ P.Hugo
 Fact 2

 > 2billion people, equal

to 1/3 of the world’s total
population, are infected.
 1 out of 10 of those
people will become sick
with active TB in his or WHO/R. Vora
her lifetime.
 People living with HIV
are at a much greater risk
 Fact 3
 1.77 million died from TB in
2007 (including 456 000
people with HIV), equal to
about 4800 deaths a day.
 disease of poverty, affecting
mostly young adults in their
most productive years.
 vast majority of TB deaths are
in the developing world, with WHO/J. Mollison

more than half occurring in

Asia.
 Fact 4
 TB is a leading killer
among people living
with HIV, who have
weakened immune
systems.
WHO/M. Shoul
 Fact 5
 There were 9.27 million
new TB cases in 2007,
of which 80% were in
just 22 countries. Per
capita, the global TB
incidence rate is falling,
but the rate of decline is WHO/TBP/Gary Hampton

very slow - less than

1%.
 Fact 6
 TB is a worldwide
pandemic. Among the 15
countries with the highest
estimated TB incidence
rates, 13 are in Africa,
while half of all new cases
are in six Asian countries
(Bangladesh, China, India,
WHO/J. Mollison
Indonesia, Pakistan and the
Philippines).
 Fact 7
 Multidrug-resistant TB
(MDR-TB) is a form of
TB that does not
respond to the standard
treatments using first-
line drugs.
 MDR-TB is present in
virtually all countries WHO/J. Langvad
surveyed by WHO and
its partners.
 Fact 8 Tony Moll
 estimated 511 000 new MDR-TB
cases in 2007 with three countries
accounting for 56% of all cases
globally: China, India and the
Russian Federation.
 Extensively drug-resistant TB
(XDR-TB) occurs when resistance
to 2nd -line drugs develops.
Tony Moll
 It is extremely difficult to treat and
cases have been confirmed in more
than 50 countries.
 Fact 9
 WHO’s Stop TB Strategy
aims to reach all pts
 MDG: target - reduce by 2015
the prevalence of & deaths
due to TB by 50% relative to
1990 and reverse the trend in
incidence.
 The strategy emphasizes the
need for proper health
systems and the importance of WHO/TBP/Gary Hampton
effective primary health care
to address the TB epidemic.
 Fact 10
 The Global Plan to Stop
TB 2006-2015, launched
January 2006, aims to
achieve the MDG target
with an investment of US$
67 billion. This represents
more than a ¾ increase in
investment from 2005. The
estimated funding gap is
US$ 40 billion.
INDIA
 Problem of TB in India
 Estimated incidence
 1.96 million new cases annually
 0.8 million new smear positive cases annually
 75 new smear positive PTB cases/1lakh population per year
 Estimated prevalence of TB disease
 3.8 million bacillary cases in 2000
 1.7 million new smear positive cases in 2000
 Estimated mortality
 330,000 deaths due to TB each year
 Over 1000 deaths a day
 2 deaths every 3 minutes
Gopi P et al (TRC), IJMR, Sep 2005
 Problem of TB in India (contd)
 Prevalence of TB infection
 40% (~400m) infected with M. tuberculosis (with a 10% lifetime risk
of TB disease in the absence of HIV)
 Estimated Multi-drug resistant TB
 < 3% in new cases
 12% in re-treatment cases
 TB-HIV
 ~2.31 million people living with HIV (PLWHA)
 10-15% annual risk (60% lifetime risk) of developing
active TB disease in PLWHA
 Estimated ~ 5% of TB patients are HIV infected
 India is the highest TB burden country accounting for more
than one-fifth of the global incidence
Global annual incidence = 9.4 million
India annual incidence = 1.96 million India
21%

Other countries
India is 17th among 22 20%
High Burden Countries
(in terms of TB incidence
rate)
Other 13 HBCs
16% China
14%

Phillipines
3% Indonesia
Pakistan 6%
3%
Nigeria
Ethiopia
Bangladesh South Africa 5%
3%
4% 5%
Source: WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing

NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06

 Estimated Incidence of TB in India*
(No. of NSP Cases per 100,000 population, per year)
* Estimated from recent ARTI survey

North
West East
National 75
North Zone 95
East Zone 75**
West Zone 80
South South Zone 75**
** For programme monitoring
purpose estimated cases in East &
South zones have been kept at the
national level of 75 and this is
within the upper limit of CI or
NTF Presentations for RNTCP ARTI in these zones
Source: Module 9, Managing the RNTCP in your area Sensitization First edition 10th Nov 06
 Tuberculosis
 Chronic granulomatous infection caused by
mycobacterium tuberculosis.
 Well recognized health hazard in India and developing
countries.
 Kills more adults in India as compared to any other
infectious disease.
 India constitutes 1/5th of the global burden (2/3rd cases in
SEAR). Every year approx. 1.8 million people develop
TB, 0.8 million new smear +ve highly infectious, 0.37
million die every year.

(SPM 20th Edition)

 Tuberculosis
 Annual risk of becoming infected 1.5% and once
infected 10% life time risk of developing TB.
 India’s DOTS programme (March 1997) against TB
has covered the whole country by 2006. > 7.3 million
are on DOTS and 1.4 million additional live have
been saved. Death rate under RNTCP have been cut
7-folds from 29% to 4% in smear +ve patients.

(SPM 20th Edition)

 Effects
Effect of disease on pregnancy
 ↑ risk of reactivation but the disease does not

affect the outcome of therapy.

 No evidence that tuberculosis complicates

pregnancy or mode of delivery.

 Advance disease – premature labour

 Spontaneous abortion – No substantial

evidence.
 Maternal outcome
Depends on site & timing of diagnosis

Late diagnosis – morbidity increase 4 fold

Early diagnosis – outcome similar to non

pregnant women
 ? Therapeutic abortion
 Tuberculosis during pregnancy -rarely
an indication for a therapeutic abortion
But
 pregnant woman with MDRTB, should be
offered abortion counseling medications
used are known to cause fetal abnormalities
 Effects
Of pregnancy on TB
 No development or progression of disease.

 Thought to improve the outcome of disease –

enlarging uterus  Pressure on lungs, collapse

open cavities.
 However, untreated active TB – Significant

risk to mother.
 Effects
Effect on fetus
Late diagnosis incidence of prematurity and LBW

Early diagnosis outcome similar to non pregnant

woman

  perinatal mortality.
  incidence of babies with SGA, LBW.
 Congenital tuberculosis – rare complication.
 Mode of spread of tuberculosis from
mother to fetus

Maternal focus Mode of spread

Placentitis Hematogenous
Amniotic fluid Aspiration
Cervicitis Direct spread
Pneumonitis Airborne (postnatal)
 Antenatal management
 ANC same as routine
 Screening test of Recommended individual
 Diagnosis of TB
 H/O
 Examination
 Tests to confirm
 Treatment of TB
 Screening test
Screening Criteria
 Recent exposure

 HIV positive

 Other immunocompromised state

Recommended screening test include

 tuberculin skin testing,

 chest radiography if MT +ve,

 interferon  blood test.

 TB Screening During
Pregnancy?
 Studies indicate that routine skin test screening
of all pregnant women is appropriate.
 The goal is to discover dormant infection and
asymptomatic disease and
 to lower the incidence of congenital or
infantile TB
 Test Tuberculin skin test Interferon  blood CBC
tests
(a) All tuberculins have Antigens used not
Advantage been standardised in +nt in non tuberculus
“Tuberculin units” myco. or BCG. Can
against the Int. stds. to distinguish latent TB
maintain uniformity, infection.
comparability of global
test results.
Prognostic significance
(b) only means of Quantities total NEVER
Disadvanta estimating prevalence amount of interferon- DIAGNOSTIC
ge of infection. γ/counts no. of
BCG or exposure to activated T-
non-tuberculus bacteria. lymphocytes, poor
MT specific antigens result in
absent (BCG), non- immunocompromize
tuberculus myco. have d
been identified.
 Test Tuberculin skin test Interferon  blood CBC
tests
(c) 73% 32-100%, active TB -
Sensitivity latent TB 80%
(d) - - -
Specificity

(e) 92% new cases occur It includes ESR

Others in pts. with +ve TST. QuantiERON-TB Normocytic
+ve reaction - and T-SPOT anameia,
past/present infection. antigens used early lyumphopenia,
secretory antigen Ca++, Na+,
target 6 (ESAT-6) hyperglobulinemia,
and culture filtrate hyperproteinemia,
protein 10 (CFP- hypoalbunemia in
10) to stimulate advance disease.
host production of
interferon- γ.
 Tuberculin skin test (TST):Mantoux
tuberculin test (MT)
 most commonly used.
 Delayed hypersensitivity test.
 Test antigen used PPD-RT-23 and PPD-S.
 WHO recommended 1 TU for standard MT in
India because of great prevalence,as well as
typical mycobacteria infections. This leads to
high sensitivity but low specificity.
 Not detrimental to the fetus or mother
 no evidence that the immunosuppression found in
preg leads to false-negative results.
 Prior vaccination with BCG can complicate the
interpretation of the Mantoux test.
 most recent guidelines from the CDC – MT not
influenced by the effect of the BCG vaccine as it
wears off at a variable rate. despite being immunized,
these persons are still at risk for active TB.
 Chest X-Ray Film

 when PPD test is positive

 asymptomatic pt, the chest radiograph done
after 12th week of gestation.
 Routine screening with radiography is not
indicated
(a) AFB smear report per RNTCP guidelines:
Negative: no AFB/100 oil immersion fields.
Positive scanty: 1-9 AFB/100 oil immersion fields.
1+ : 10-99 AFB/100 oil immersion fields.
2+ : 1-10 AFB/oil immersion field.
3+ : > 10 AFB/oil immersion field.

To detect 1-3 organism in 300 oil immersion fields,

the conc. Of organism 5000-10000/ml.
 Diagnosing tuberculosis in
pregnancy…

 Contrary to popular belief, the Heaf and

Mantoux skin tests are probably as reliable as
in non-pregnant women.
CDC classification of tuberculin reaction
 > 5 mm considered +ve in
 HIV +ve person
 Recent contacts of TB case
 Persons with nodular or fibrotic changes on CxR
consistent with old healed TB
 Pts with organ transplants & other
immunosuppressed pts.
> 10 mm +ve in
 Recent arrivals (from high prevent countries).

 Injectable drug users.

 Residents & employees of high-risk congregate settings

 Mycobacteriology lab personnel

 Children < 4 yrs of age, or children and adolescents

exposed to adults in high-risk categories.

 > 15 mm +ve in

 Persons with no known risk factors for TB.

Chemo prophylaxis for Latent TB

Criteria -
 Recent convertors (+ tuberculin test).

 Close contacts.

 Immunocompromised (HIV)

 Neonates of tubercular mother.

 Recent convertors (+ tuberculin test) – INH for 6
mon postpartum.
 recent exposure - INH 6 mon after Ist trimester
 MDR-TB no current chemoprophylaxis regimen.
 CDC –EMB+ PZA or fluoroquinolone 6 to 12

months
 PZA? Controversial!

 Rifampicin + pyrazinamide (2 months) for HIV

infected individuals.
 Diagnosis OF Active TB
History
 Predisposing factors

 Signs and symptoms

 Complications
 Pregnancy and TB Symptoms
 with active TB often have few typical TB
symptoms.
 20% - 67% pts with pul TB are unaware of
their disease and have no significant symptoms
 Even mothers of children born with congenital
TB often have unremarkable symptoms
Diagnosis of TB not easy. :
 CULTURE - Gold standard -
 Serological test do not offer accurate
sensitivity and should not be pursued.
 Molecular test hold promise in diagnosis,
but lack sensitivity in paucibacillary states.
 Diagnosis of active TB
 Identifying the organism gold standard.
 24 hrs sputum collection justified.
 Sputum (sputum or laryngeal swab or
bronchial lavage or gastric aspirate) -
microscopic examination and culture
 Tests Microscopy Culture Chest X-ray
GOLD STANDARD
(a) Easy and quick Radiometric and Rules out PTB in
Advantage to perform fluoroscence based TST +ve reactors &
culture system allow asymptomatic
rapid isolation, persons
antibiotic sensitivity
testing, differentiate M
tb from MOTT.
(b) Cannot Time consuming (3 Films can be taken
Disadvanta distinguish M. tb wks) preferably in IInd
ge from other Appropriate trimester by
AFBs. infrastructure, Shielding the
Fluorochrome fluorescence based abdomen.
stain -high cost, methods needs
skill personnels. monitoring, high cost
Specialized disposal
protocol for radioactive
isotopes.
 Tests Microscopy Culture Chest X-ray
GOLD STANDARD
(c) 40-65.4% 80-85% -----
Sensitivity
(d) 90.5% 98% -----
Specificity
(e) Others -ve smear does New automatic systems Abnormalities s/o of
not exclude TB but never
(1) BACTEC (detects diagnostic ,
radioactive CO2 used to rule out PTB
generated by bacteria in persons with +ve
grown on radio-labelled TST and no
carbon source). (2) symptoms
MGIT (microbacterial
growth indicator tube)
960 TB test : employs
new fluorescent
indicator.
Other tests
 Test Serological tests
(a) Rapid test, great value in screening
Advantage indirect ELISA is more sensitive
-no cross reactivity in BCG
vaccinated individuals, detect PTB
+ ETB.
1st generation i.e. lateral flow ICT,
flow through ICT, and SPIA or
Dot Blot Assays. SPIA gives less
false +ve results due to past &
latent infections and BCG
vaccinations.
2nd generation SPIA and 2nd
generation ELISA.
Rapid test detecting IgG antibodies
against 38 kDa and LAM antigen.
Nucleic acid tests
Amplification based Nucleic acid
test (NAT) and non
amplification-based nucleic acid
tests using specific probes
(DNA/RNA probes).
Rapid & widely available.
PCR widely used amplification of
genetic target rapidly detect <1-
10 organisms.
+ve NAT + +ve AFB smear,
highly productive of TB but
myco. culture needed
-confirmation, susceptibility
testing.
-ve NAT + +ve AFB AFB is
probably another species of
myco./MOTT. Smear -ve TB
considered, excluded after –ve
cultures.
 Test Serological tests
(b) Major challenge -distinguish b/w
Disadvantage MTB and MOTT, active & latent
TB. Time consuming, complex,
expensive, difficulty in setting
cut off point. Immune response
associated with HLA class II
allotypes and different patient
recognized different antigens,
probability of recognizing single
antigen is low.
(c) Sensitivity 61.9-81.4%
(d) Specificity 90%
Nucleic acid tests
Efficient sample processing
very essential.
Experience referral laboratories
with appropriate expertise,
personnel, laboratory
infrastructure and
contamination control measures
needed.
88.5-90.5%
98.6%
 Test Serological tests
(e) Others Antigen used A-60, 38 kDA,
45/47 kDA lipoarabinomannan
(LAM), Antigen p90, antigen
19 kDA, antigen p32 and
antigen 16 kDA, cord factor
(trehalose dimycolate) recent
novel antigens include
RV2041c Ag, MPT64 and
Rv3425.
Nucleic acid tests
PCR based assays target
DNA or rRNA (sequences
IS6110 and 16S rRNA).
RNA targeted applications
more sensitive. Several
commercial and in-house
multiplex assays available i.e.
INNO-LiPA tests
(Innogenetics) and Genotype-
MTBC assays.
 Plan of management
Cough for 3 Weeks or More

3 Sputum smears

3 or 2 Positives 1 Positive 3 Negative

X-ray

Positive Negative for TB

Smear-positive TB Non-TB

Anti-TB Treatment
 3 Negatives

Antibiotics 1-2 weeks

Symptoms persist

Repeat smear examination

Negative

X-ray

Negative for TB Positive

Smear-negative TB

Anti-TB Treatment
Tuberculosis treatment
 Various pharmaceutical
treatments and their actions
 Effect Anti-tuberculous therapy
on fetus
 no ↑ in congenital malformations or fetal
damage when rifampicin, isoniazid and
ethambutol are used in combination

 pyrazinamide is also safe

Category of
Type of patient Regimen
treatment
New sputum smear+ve
CATEGORY I Seriously ill smear-ve 2(HRZE) 4(HR)
Seriously ill extrapul
Sputum
smear+ve  relapse
Sputum smear +ve 2(HRZES)/1(HRZE)/
Category II
failure 5(HRE)
Sputum smear +ve tx
after default
Sputumsmear -ve not
Category III 2(HRZ)/4(HR)
seriously ill
24(at least 3 new
Category IV Chronic cases drugs) not received
in past
 Categorywise sputum examination
results and actions to be taken
Test
Category IF
Pretx at
of result THEN
sputum mont
treatment is:
h
Start CP,
-
+ 2 test at 4 and 6 months
+ Contd IP for one more month
Category Start continuation phase,
I -
test sputum again at 6 months
- 2 Continue IP for 1 more
+ month,test sputum 3,4, and 7
months
 Test
Category IF
Pretx at
of result THEN
sputum mont
treatment is:
h
Start continuation phase,
-
Category test sputum at 5 & 6 months
+ 3
II Contd IP for one more month,
+
test sputum at 4,6 & 9 months
Start continuation phase,
-
Category test sputum at 5 and 6 months
+ 3
II Continue IP for 1 more month,
+
test sputum at 4,6 & 9 months
Phases and duration of treatment

Duration(Number of doses)
Category Intensive Continuation Total
phase phase
8 wks 18 wks 26 wks
CAT I
(24 doses) (54 doses) (78 doses)
12 wks 22 wks 34 wks
CAT II
(36 doses) (66 doses) (102 doses)
8 wks 18 wks 26 wks
CAT III
(24 doses) (54 doses) (78 doses)
Drug Recommended dose

Daily 3 times per week

Dose & range Max Dose & range Max

(mg/kg ) (mg) (mg/kg) (mg)

Isoniazid 5 (4–6) 300 10 (8–12) 900

Rifampicin 10(8- 12) 600 10(8- 12) 600

Pyrazinamide 25(20 – 30) 35(30 – 40) 2500

Ethambutol 15 (15 – 20) 30 (25 – 35) 2500

Streptomycin 15 (12–18) 15 (12–18) 1000

 Side effect
 Thrombocytopenia: RMP
 Neuropathy: INH
 Vertigo: STM
 Hepatitis: PZA, RMP, INH
 Rash: PZA, RMP, EMB
 International guidelines
 BTS, IUATLD, WHO - use first-line drug regimens
 CDC endorse pyrazinamide probably be used safely.
First line drug
 Isoniazid (preg category A) recommended for use.
- Hepatotoxicity (LFTs)
- QTCC recommends Pyridoxine supplementation
 Rifampicin (pregcategory C) recommended along
with vit K to both mother & infant postpartum if use
in last few days (Bothamely, 2001), bleeding
(hypoprothrombinemia).
 Ethambutol (pregnancy category A)
 Pyrazinamide (pregnancy category n/a)
- CDC guidelines do not endorses.
- supported by IUATLD and BTS due to
lack sufficient data.
Second line drug
 Streptomycin (pregnancy category n/a) not recommended.
 Fluoroquinolones (pregnancy category B3)
 Amoxycilin/Clavulanic Acid (Pregnancy category B1).
- Used in late pregnancy in PROM.
- Minor role in M/N MDR-TB (Bothamley 2001).
 Para-Aminosalicylic Acid (PAS) (pregnancy category n/a)
(Bothamley, 2001)
- Limb and ear abnormality.
Second line drug
 Amikacin (Preg category D) (WHO 2003)

- nephrotoxic and ototoxic.

 Capreomycin (Pregcategory C)

 Ethionamide and Prothionamide (Preg Category n/a)

(Ormerod 2009)
 Cycloserine (Pregnancy category n/a) (MIMS 2003)
 Summary of Multidrug therapy
in pregnancy
 with active TB –
 INH & RMP with EMB in resistant cases.
 PZA is not routinely recommended
 Therapy continue for 9 mon.
 complicated by highly resistant organisms
and/or AIDS
 combinations of 4 or 5 drugs may be necessary,
including drugs such as SM
Intrapartum – routine as
high risk
 Congenital tuberculosis
Cantewell Criteria
1. Lesion in the first week
2. Primary hepatic complex or caseating
granuloma
3. Documented TB of placenta or endometrium
4. Exclusion of TB infection by carrrier
 TB in Neonates
 potentially serious, with morbidity and mortality 50%
 Signs and symptoms
 nonspecific - respiratory distress, fever,

hepatosplenomegaly, lethargy, lymphadenopathy, and

irritability.
 Other signs include abdominal distention, ear discharge,

and skin lesions

 An abnormal chest radiograph is not a consistent finding, and
a positive PPD test result is even less common.
 Isolation
 Child should not be isolated
 Isolation - born to a PPD+ve mother, mother
infected with multidrug- resistant organisms or
a contagious family member known to be
noncompliant with treatment.
 BCG vaccination of the infant if no isolatiobn
Breast feeding
 safe when the mother is taking standard anti-
tuberculous medication
 If mother is taking isoniazid, pyridoxine
supplementation to child as a small amount of
isoniazid is present in breast milk
 Toxicity not reported.
 Conc. of ATT drugs ineffective for TB T/t in nursing
infants.
 Breast feeding…
It is usually unnecessary for the child to receive
treatment unless the mother is diagnosed with
open (infectious) at the time of delivery
OR
contact tracing (which should be performed
promptly) reveals that the child has had contact
with another infectious member of the family.
 Breast feeding…

Mother with open Tuberculosis

Breast feeding can be done with

INAH prophylaxis
mother can use a mask
 Neonate….
 INAH prophylaxis is given for 3 months

 Check Mantoux

 Mantoux Negative need BCG vaccination

 Contraception

oral contracepives:effectiveness is
reduced
MDR-TB and XDR-TB
 MDR TB - resistance to INH and rifampicin
± resistance to other anti TB drugs.
 XDR TB - resistance to at least H and R plus
resistance to any of the fluoroquinolones and
any one of the second-line injectable drugs
(amikacin, kanamycin, or capreomycin).
 Drug resistant MTB

Drug Mutant gene Frequency

Rifampicin rpo B ~96%

INH kat G/inhA 75-85%

Streptomycin rpsL 65-75%

PZI pnc A ~70%

Ethambutol emb B 70%

Management
 National guidelines and plans for m/m of MDR-TB

have been under RNTCP. RNTCP DOTS services

are being expanded.
 Diagnosis based on history of prior t/t (t/t failure,

cat II failure), exposure confirmed drug-resistant

TB.
 Diagnosis further done by culture and drug

susceptibility testing.
 Other method of testing includes: DNA sequencing,

line probe assay, PCR based assay, single strand

conformation polymorphism, mocybacteriophage
assay.
 Treatment regimen : [6(9) Km Ofx Eto Cs
ZE/18 Ofx Eto Cs E] as per national DOTS
guidelines if resistant to 2nd line Anti-TB drug
+nt individualized regimen recommended.
 Duration of tx: 6 mon IP extended to 9 mon
(+ve culture result - 4 months), 18 mon CP
following IP:
 Smear examination monthly during IP and
quarterly during CP.
 Culture at 4, 6, 12, 18 and 24 months of treatment.
Prevention
 Implementation of a good quality DOTS.

 Improve quality and reach of DOTS

services.
 Proportion of TB patients treated outside

DOTS to be minimized.
 ISTC need to be used by RNTCP and

professional medical associations.

 Prevention
 BCG vaccination in childhood.
 Isolation of open cases and their prompt
treatment
 Screening of close contacts.
 Nutritious diet
 Use of face mask.
 References
 Bothamley G (2001) Drug Treatment for Tuberculosis during Pregnancy:
Safety Considerations Drug Safety 24(7):553-65.
 British Thoracic Society (1998) Chemotherapy and management of
tuberculosis in the United Kingdom: recommendations 1998 Thorax
53:536-48.
 Centers for Disease Control (2003) Treatment of Tuberculosis MMWR
52(RR-11):1-77.
 MIMS (2003) acessed electronically via http://ckn.health.gld.gov.au in
January 2006.
 World Health Organization (2003) “Treatment of Tuberculosis: Guideliens
for National Program” WHO, Geneva 3rd Ed.
 Miller KS, Miller JM. Tuberculosis in pregnancy: interactions, diagnosis,
and management. Clin Obstet Gynaecol, 1996;39:120-142.
 References
 Centers for Disease Control and Prevention. Tuberculosis morbidity –
United States, 1995, MMWR. 1996;45:365-370.
 American Thoracic Society. Treatment of tuberculosis and tuberculosis
infection in adults and children. Am J Respir Crit Care Med.
1994;149:1359-1374.
 Mehta B: Pregnancy and tuberculosis. Dis Chest 39:505-11, 1981.
 Centers for Disease Control and Prevention: Initial therapy for tuberculosis
in the era of multidrug resistance: Recommendations of the advisory
council for the elimination of tuberculosis. MMWR 42(RR-7):1-8, 1993.
 International Standards for Tuberculosis Care (ISTC). Tuberculosis
Coalition for Technicasl Assistance, The Hauge, Holland (2006).
 Hopewell PC, Pai M, Maher D, Uplekar M, Raviglione MC. International
standards for tuberculosis caser. Lancet Infect. Dis. 6(11), 710-725 (2006).
 Fidelma B. Rigb: Tuberculosis and Pregnancy: Update on an Old Nemesis:
Posted: 04/01/2000; © Medscape Ob/Gyn& Women health
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