THE MATERNAL AND FETAL EFFECTS OF TUBERCULOSIS THERAPY

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Although tuberculosis is an uncommon condition in pregnant women in the United States, endemic areas can have rates as high as 0.1%.2 The clinical presentation of tuberculosis does not differ in pregnant and nonpregnant women except for increased rates of malaise and fatigue in noninfected pregnant women. The use of tine tuberculin (TB) testing is not contraindicated during pregnancy and may be considered a routine prenatal diagnostic test in endemic areas or in women at high risk for tuberculosis. Recent tine test converters and symptomatic women with more than 5 mm of induration should undergo shielded chest radiography (results in minimal radiation exposure to the fetus [<3 mrads]). Sputum samples should be obtained from all women with active tuberculosis to evaluate for the presence of possible drug resistance. The presence of active disease mandates treatment at the time of diagnosis to protect the pregnant woman, fetus, family members, and members of the community.

Numerous reports documented a steady decline in the rate of tuberculosis after effective therapies were found in the early 1950s. This decreasing trend in the United States was reversed in the mid-1980s, with a steady rise in the number of cases reported until the early 1990s. Many of these cases occurred in reproductive aged women (25- to 44-years-old) and were attributed to increasing rates of tuberculosis among intravenous drug abusers and HIV-infected patients during this period.13 Although the overall number of tuberculosis cases reported to the Centers for Disease Control (CDC) decreased from 1992 to 1995 (26,673 to 22,813), the number of cases reported in foreign-born persons increased by 63.3% since 1986.13 These numbers underscore the need for increased tuberculosis surveillance in high-risk populations.

This article reviews the use of therapeutic agents for tuberculosis with a particular focus on their use during pregnancy. The maternal and fetal effects of first- and second-line agents are discussed in detail to aid the health care provider in providing the most safe and effective therapy.

Section snippets

Isoniazid

Isoniazid is the drug of choice for tuberculosis prophylaxis and treatment of active disease during pregnancy. It is an inexpensive medication that is easily administered and highly active against many strains of mycobacterium. The side effect profile includes cutaneous hypersensitivity, hepatitis, and peripheral neuropathy. Isoniazid also seems to potentiate the action of anticonvulsants, including phenytoin, ethosuximide, and carbamazepine.

Peak blood concentrations of 5 μg/mL occur within 1

CONSIDERATIONS FOR THERAPY DURING PREGNANCY

Once a diagnosis of tuberculosis is made, it is important to begin aggressive therapy and to observe the pregnant woman during both the antepartum and postpartum period to ensure compliance with medical therapy. Although the CDC has proposed a variety of regimens for the initial treatment of children and adults11 (including daily or two to three times per week therapy options), these regimens cannot be used during pregnancy because of potential (streptomycin) and unknown (pyrazinamide) fetal

THERAPY IN THE IMMUNOCOMPROMISED WOMAN

The overall prevalence of tuberculosis coinfection in HIV-infected individuals ranges from 5% to 35%.76 The risk for active disease increases 8% annually in HIV-infected individuals with a positive tine test in comparison with a 10% lifetime risk in immunocompetent individuals.18, 61 The progression to active and sometimes fulminate disease can occur within months of exposure in HIV-positive individuals. A limited number of reports describe coinfection with tuberculosis in HIV-positive pregnant

SUMMARY

Tuberculosis can cause significant morbidity in the pregnant woman, fetus, and members of the community. The first-line agents suggested by the CDC for use during pregnancy (isoniazid, rifampin, and ethambutol) seem to have minimal risk of induced congenital anomalies. Maternal morbidity associated with therapy does not seem increased above rates observed in the nonpregnant population. Education of the patient concerning the potential adverse side effects may decrease maternal morbidity.

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    Address reprint requests to Brian C. Brost, MD, Department of Obstetrics and Gynecology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425–2233

    *

    Department of Obstetrics and Gynecology, Keefler Air Force Base, Biloxi, Mississippi (BCB); and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina (RBN)

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