Tuberculosis Clinical Care and Treatment During Pregnancy

Effect on pregnancy outcomes

Untreated TB disease poses a greater risk to the pregnant woman and fetus than does its treatment. Although the TB drugs used in recommended treatment plans for TB disease cross the placenta, these drugs are not known to have harmful effects on the unborn fetus.

If the pregnant woman is not treated for TB disease, the infant may be born with a low birth weight. In rare circumstances, the infant may be born with TB disease. TB disease in babies is often severe and may be deadly.

Helping patients stay well during pregnancy

Testing for TB infection during pregnancy

Health care providers should test pregnant women at higher risk of developing TB disease. Generally, pregnant women at higher risk for TB disease (once infected) fall into two categories:

• Those who are taking certain medications or have health conditions such as diabetes, cancer, or HIV that may weaken their immune system; and
• Those who have been recently infected with TB bacteria.

Types of TB tests

TB blood tests and the TB skin test are safe to use during pregnancy. TB experts are available to help interpret the TB blood test or TB skin test results.

If a TB blood test or TB skin test result is positive, other tests such as chest radiography may be needed to evaluate for TB disease.

Treatment options

Latent TB infection

Most pregnant women can delay treatment for latent TB infection until two-three months post-partum. It may be reasonable to delay treatment until after delivery to avoid the risk of liver toxicity as an adverse effect of treatment for latent TB infection, which is higher during pregnancy.

However, pregnant women who are at higher risk for developing TB disease should not delay treatment, even during the first trimester. This includes pregnant women:

• Who have weakened immune systems, such as a person with HIV and a low CD4 count
• Who recently spent time with someone with infectious TB disease

Treatment regimens for latent TB infection

There are several treatment regimens recommended to treat latent TB infection during pregnancy. Health care providers can consult TB experts for additional information.

• Four-month daily regimen of rifampin (also called 4R)
• Three-month daily regimen of isoniazid and rifampin (also called 3HR)
• Six- or nine-month daily regimen of isoniazid (also called 6H or 9H), with pyridoxine (vitamin B6) supplementation

Pregnant women taking isoniazid should take 25–50 mg/day of pyridoxine (vitamin B6) to reduce possible adverse effects of isoniazid. Women taking isoniazid in the post-partum period (within three months of delivery) should have blood tests checked for liver function before starting treatment.

Pregnant women or women expecting to become pregnant during treatment should not take the three-month weekly isoniazid and rifapentine (3HP) regimen. Its safety during pregnancy has not been studied.

Treatment guidelines for latent TB infection

TB disease

Women who are diagnosed with TB disease during pregnancy should start treatment right away. Health care providers should:

• Choose TB drugs that are recommended for use during pregnancy,
• Monitor the pregnant women and fetus during treatment, and
• Ask the patient if they are having any problems taking the medicine.

Treatment regimens for TB disease

Health care providers should evaluate the risks and benefits of prescribing pyrazinamide as part of a treatment regimen on a case-by-case basis and allow patients to make an informed and educated decision.

For pregnant women with TB disease and HIV, extrapulmonary, or severe TB disease, it may be more beneficial to include pyrazinamide in the treatment regimen. Pyrazinamide is used routinely as part of TB treatment in pregnancy in many other countries.

If pyrazinamide is excluded from the treatment regimen, a minimum of nine months of isonaizid, rifampin, and ethambutol is used for most pregnant women with drug-susceptible TB disease. It includes:

• Isoniazid, rifampin, and ethambutol daily for two months, followed by
• Isoniazid and rifampin daily, or twice weekly for seven months.

Health care providers can contact their state or local TB program or the TB Centers of Excellence for expert consultation.

Treatment guidelines for TB disease

Pregnant women with HIV and TB disease

Treatment of TB disease for pregnant women with HIV should be the same as for other people with HIV but with particular attention to .

Health care providers can contact their state or local TB program or the TB Centers of Excellence for expert consultation.

Health care providers may also consult .

Contraindications

Antituberculosis drugs contraindicated during pregnancy include:

• Streptomycin
• Amikacin
• Capreomycin

Fluoroquinolones

Fluoroquinolones (including moxifloxacin and levofloxacin) are not routinely used for standard treatment of TB disease in pregnancy but may be used for treatment of drug-resistant TB, severe TB disease, or treatment-intolerant TB disease, with discussion about benefits and risks.

Drug-resistant TB disease

There are known and unknown risks of medications for drug-resistant TB disease. Pregnant women diagnosed with drug-resistant TB disease should receive counseling about both the benefits of TB treatment and the possible risk to the pregnancy.

Treatment guidelines for drug-resistant TB disease

Potential impacts for breastfeeding

Women taking first-line antituberculosis drugs may continue to breastfeed their newborn. The concentrations of these drugs in breast milk are too small to produce toxicity in the nursing newborn. For the same reason, TB drugs in breast milk are not an effective treatment for TB disease or latent TB infection in a nursing newborn.

Rifampin can cause orange discoloration of body fluids, including breast milk This discoloration is normal, harmless, and goes away after stopping rifampin.

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