TB in pregnant women

Isaac Eranga, CNS Correspondent, Nigeria
There were an estimated 3.3 million new cases of TB and an estimated 510 000 TB deaths among women in 2013, says the WHO Global TB Report 2014. While TB as a women’s health issue has been largely overlooked, it presents one of the major reasons that TB in women should be taken seriously. Gender inequality around the world makes women with TB particularly vulnerable to stigma. In addition, TB poses a variety of deep threats to women’s lives medically, economically, and socially.

In the words of Paula I Fujiwara, Scientific Director and Riitta Dlodlo, Director, Department of Tuberculosis and HIV of the International Union Against Tuberculosis and Lung Disease, “Women and girls with TB suffer unique and often oppressive challenges. Women diagnosed with TB are often abandoned by their families, ostracized by their communities, fired from their jobs, deemed unworthy of marriage and motherhood. In some countries where TB is common, traditional gender dynamics prevent women from going to the clinic on their own to seek treatment and care, leaving the disease to advance into critical stages”.

When it comes to TB in pregnancy, one has to take diagnosis keenly as TB symptoms in pregnancy may be attributed to the pregnancy itself. According to experts Olabisi M. Loto and Ibraheem Awowole of the Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria, “The exact incidence of TB in pregnancy, though not readily available, is expected to be as high as in the general population. Diagnosis of TB in pregnancy may be challenging, as the symptoms may initially be ascribed to the pregnancy, and the normal weight gain in pregnancy may temporarily mask the associated weight loss due to TB.”

TB in pregnant women simply reflects the public health significance of the condition. It is best described as a doubled-edged sword, one blade being the effect of TB on pregnancy and the pattern of growth of the newborn, while the other is the effect of pregnancy on the progression of TB. TB not only accounts for a significant proportion of the global burden of disease, it is also a significant contributor to maternal mortality, with the disease being among the three leading causes of death among women aged 15–45 years.

The exact incidence of TB in pregnancy is not readily available in many countries due to a lot of confounding factors. It is, however, expected that the incidence of TB among pregnant women could be as high as in the general population, with possibly higher incidence in developing countries, including Nigeria.

Speaking to CNS Correspondent in Benin City, Nigeria, Dr. Joy Amusa, a consultant at the Stella Obasanjo Hospital for Women and Children, Benin City, said: “Researchers from the days of Hippocrates have expressed their worries about the untoward effects that pregnancy may have on preexisting TB. Pulmonary cavities resulting from TB were believed to collapse as a result of the increased intra-abdominal pressure associated with pregnancy. This belief was widely held till the beginning of the 14th century. Indeed, a German physician went so far as to suggest that young women with TB should get married and become pregnant to slow the progression of the disease. This was practiced in many areas till the 19th century while in the early 20th century, induced abortion was recommended for these women. Researchers like Hedvall and Schaefer however, demonstrated no net benefit or adverse effect of pregnancy on the progression of TB. Frequent, consecutive pregnancies may, however, have a negative effect, as they may promote reactivation of latent TB”.

“It is, however, important to note that the diagnosis of TB in pregnancy may be more challenging, as the symptoms may initially be ascribed to the pregnancy. The weight loss associated with the disease may also be temporarily masked by the normal weight gain in pregnancy”, she added.

P. Ormerod’s published study on ‘Tuberculosis in pregnancy and the puerperium’ shows that “The effects of TB on pregnancy may be influenced by many factors, including the severity of the disease, how advanced the pregnancy has gone at the time of diagnosis, the presence of extrapulmonary spread, and HIV co-infection and the treatment instituted. The worst prognosis is recorded in women in whom a diagnosis of advanced disease is made in the puerperium as well as those with HIV co-infection. Failure to comply with treatment also worsens the prognosis”.

Other studies done on this vital issue indicate that-- “Other obstetric complications that have been reported in these women (with TB) include a higher rate of spontaneous abortion and suboptimal weight gain in pregnancy. Others include preterm labour, low birth weight and increased neonatal mortality. Late diagnosis is an independent factor, which may increase obstetric morbidity about fourfold, while the risk of preterm labour may be increased nine folds”.

According to Centre for Disease Control, untreated TB represents a far greater hazard to a pregnant woman and her fetus than does treatment of the disease. The management of TB in pregnancy is a multidisciplinary approach, with the team comprising the obstetrician, communicable disease specialty personnel, neonatologists, counselling unit, and public health officials.

The prevention, however, goes beyond administering anti TB drugs, as this is essentially a disease of poverty. Improved living conditions are, therefore, encouraged with good ventilation, while overcrowding should be avoided. Improvement in nutritional status is another important aspect of the prevention.

Pregnant women living with HIV are at higher risk for TB, which can adversely influence maternal and perinatal outcomes. Primary prevention of HIV/AIDS is, therefore, another major step in the prevention of TB in pregnancy. Screening of all pregnant women living with HIV for active TB is recommended even in the absence of overt clinical signs of the disease.

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, rational clinical judgment is required for decisions such as the best time to provide IPT to pregnant women.

Most importantly, governments commitments to take adequate measures are highly encouraged so that the World Health Organisation and all other international bodies involved in fighting TB may succeed in chasing this monster out of all communities.

Isaac Eranga, Citizen News Service - CNS
27 March 2015