Tuberculosis and pregnancy: symptoms, consequences for the fetus, treatment

General information about tuberculosis during pregnancy

Throughout almost the entire last century, pregnancy due to tuberculosis was unacceptable, and it was recommended to terminate it at any time due to the high risk of adverse outcomes. But with the development of medicine, the availability of modern methods for detecting infection and the possibility of treating it, today women infected with tuberculosis are quite able to conceive, fully bear and give birth to a completely healthy baby. But for this you need to know certain features of the infectious process, approaches to diagnosis and treatment.

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Tuberculosis is classified as a chronic, slowly progressing infection of a bacterial nature. Today, up to a third of the population is infected with mycobacteria that cause tuberculosis. But infection does not mean a disease, it is a state of carriage of microbes, which at any moment can develop into an infection.

This is also possible for women of reproductive age who are preparing to become mothers. Activation of an infection that has been dormant for a long time in the body occurs with significant suppression of the immune system, against a background of constant stress and a decrease in the overall social standard of living.

This disease is very widespread, the peak of its spread occurs in Asian countries, where the largest percentage of patients are affected. The lifetime risk of contracting tuberculosis is about 10%. Women during pregnancy, along with other persons, due to the characteristics of their immunity, belong to a high-risk group .
Often the infection is combined with various dangerous infections - hepatitis, syphilis, especially among antisocial elements.

Women should be especially wary

have already had the disease;
with a detected variation in the tuberculin test;
those in direct contact with persons suffering from tuberculosis;
those suffering from diabetes mellitus, kidney pathologies, gastric and duodenal ulcers;
having bad habits.

Causes and conditions for the development of tuberculosis in pregnant women

The main causative agent of the infection is a special type of mycobacterium Mycobacterium tuberculosis; they are widely represented in the external environment, live in water and soil, and actively circulate among animals and people. The pathology is transmitted like any respiratory infection by airborne droplets, and there may also be a contact-household transmission route.

Infection through contaminated food is possible. Risk factors for the development of infection are identified, which include the presence of congenital or acquired immunodeficiency, including due to certain viral infections, as well as low material income and unfavorable living conditions, irrational poor nutrition, the presence of bad habits, age up to 12-14 years .

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Pregnancy in a weakened and sick woman can also become an impetus for the activation of tuberculosis infection in the lungs, which can lead to trouble. Therefore, it is important to plan pregnancy with a full preliminary examination, including for this infection. This is due to the fact that treating tuberculosis outside of pregnancy is much safer and easier than while pregnant.

There is a group of women at high risk for contracting this dangerous infection. These include:

women who have previously had tuberculosis, if less than 2 years have passed
women with chronic diseases that suppress the immune system
those in contact with patients with open tuberculosis at work or at home
living in areas where there are many sick people and low levels of medical care.

Important

After a previous infection, it is important to postpone planning for 2-3 years in order to completely avoid a relapse and restore the functioning of the immune system.

Lung damage due to tuberculosis

There are pulmonary and extrapulmonary forms of infection, and each type of infection has its own distinctive features. The most common location is pulmonary, which we will discuss in more detail.

Forms of pulmonary tuberculosis are divided into two types - primary and secondary.

Primary infection occurs when mycobacteria first enter the respiratory tract, which usually occurs in childhood or adolescence. From the lung area, microbes can penetrate the lymphatic tract and blood, spreading to many internal organs. A strong body and strong immunity cope with the influence of infection on its own, and then the disease does not develop, and the person develops specific immunity against tuberculous mycobacteria.
a secondary infection is formed when the pathogen penetrates from various internal organs, mainly through the lymphatic vessels, and this type of pathology is most typical for adults, including pregnant women.

There are also various forms of tuberculosis infection of the lungs. These include:

Disseminated, in which multiple lesions of the lung tissue are formed,
acute miliary, in which from foci in the lungs the infection spreads through the bloodstream to many other organs,
focal form, in which foci are formed that affect one or more pulmonary segments,
infiltrative, when inflammatory foci form in the lung area, within which tissue necrosis and active decay develop.

Also typical is the formation of pulmonary tuberculoma with a focal formation surrounded by a capsule inside the lung tissue, as well as cavernous pneumonia, acute tuberculous inflammation of the tissue with active decay.
A cavernous form of tuberculosis is possible, forming numerous cavities, cavities where the lung tissue disintegrates, as well as foci of cirrhosis, with the growth of connective tissue instead of lung tissue, which loses functionality.

Manifestations of pulmonary tuberculosis during pregnancy

In general, the symptoms do not differ from those of ordinary people, and for pregnant women it is typical to have general symptoms against the background of local lesions of the lung tissue. General intoxication occurs caused by the metabolic products of mycobacteria - this is lethargy with weakness and apathy, general malaise. Also typical is an increase in temperature to subfebrile levels against the background of gradual loss of body weight, decreased appetite and the appearance of cough. It is initially dry, but then becomes moist, with the appearance of greenish or yellowish sputum. As the process progresses, hemoptysis, the presence of bloody streaks in the sputum, as well as chest pain against the background of deep breaths, shortness of breath, and sweating at night occur.

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In many ways, the severity of symptoms depends on the general condition of the pregnant woman; in some women, tuberculosis can occur without any special symptoms, often appearing even in the presence of serious complications.

Extrapulmonary localizations of tuberculosis during pregnancy

Genital lesions deserve special attention regarding female variants of extrapulmonary tuberculosis . This form is of secondary origin, occurring when bacteria spread to the genital area from the primary zone of infection. The infection usually spreads due to reduced immunity, existing chronic pathologies, stress, poor nutrition or additional factors. Manifestations of tuberculosis affecting the genitals do not have any special symptoms, often only infertility or problems with pregnancy, menstrual irregularities and ovulation problems, amenorrhea, cycle irregularity, bleeding and pain. Against the background of adhesions formed due to prolonged inflammation, ectopic pregnancies can occur, leading to bleeding and loss of the tube.

Living conditions

If such a disease is detected, a comprehensive check of the patient’s living conditions is carried out. In many cases, the disease can develop not due to contact with an infected person, but from working and living conditions.

There is a possibility that the disease appeared against the background of silicosis, which is an occupational disease. A search for the carrier of the infection among the closest people is also being carried out.

The conditions in which a pregnant woman finds herself make it possible to draw up a more detailed treatment plan and eliminate the source of infection.

How does tuberculosis progress in pregnant women: features of the disease

Although in general the manifestations are the same, there are certain features during tuberculosis in pregnant women that are worth knowing about. These include damage to only one lung in the vast majority of women, as well as the predominance of the infiltrative variant of the course over all other variants. But, unfortunately, about 20% of women complain about health problems already at the stage of decay of part of the lung tissue. About 50% of pregnant women become active excretors of mycobacteria, which makes them a potential source of infection for others. But extrapulmonary variants of tuberculosis during gestation are extremely rare; the presence of tuberculosis is often combined with syphilis, HIV infection or STIs, and hepatitis.

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It is also important to know that massive damage to lung tissue occurs in expectant mothers, and at the same time signs of acute respiratory failure are formed, which leads to disruption of the functioning of many internal organs. In such a situation, further pregnancy will be extremely difficult for both.

When lung tissue disintegrates, such a situation poses a danger not only to the life of the child, but also to the mother herself.

Diagnostic methods

The prohibition of x-rays complicates diagnostic measures. Untimely measures associated with an erased clinic lead to complications and the risk of incomplete recovery.

To examine the expectant mother, the following procedures are prescribed:

X-rays of light;
analysis of sputum, urine and blood;
electrocardiography;
tuberculin test.

Complaints and medical history data are also collected. This is how pregnant women are tested for tuberculosis.

Why is tuberculosis dangerous during pregnancy?

If tuberculosis does not have an aggressive and life-threatening course, in which immediate delivery or termination of pregnancy for health reasons is important, it can still significantly harm pregnancy. Against the background of an active tuberculosis process, complications such as:

Early toxicosis with severe nausea and malaise, weight loss
Severe anemia with poor treatment prognosis
Getoses in the second half of pregnancy
Acute and chronic placental insufficiency
State of chronic fetal hypoxia
Intrauterine growth retardation based on height and weight gain
Problems with the volume and composition of amniotic fluid.

Such complications of gestation do not have specificity in relation to tuberculosis, and therefore cannot indicate its presence. For many women, pregnancy for the time being proceeds without any abnormalities at all.

The presence of tuberculosis before childbirth does not affect the time of its onset; no more than 5% of children of women with infection are born prematurely, and most often this is associated with a general severe condition, as well as the presence of serious complications accompanying tuberculosis. The period after childbirth is no different.

Folk remedies and prevention

Among the traditional methods of treating infection with Koch's bacillus, there are no sufficiently effective drugs that can suppress the infection. TVS is treated exclusively using traditional medicine methods - conservative drug therapy based on antibiotics and antiseptic drugs.

Taking all kinds of breast mixtures and herbal decoctions should also be prescribed by a doctor. Not all herbal remedies are safe for pregnant women.

Prevention of the disease consists of strengthening the immune system and enhancing the body's protective function.

Important! All newborns whose mothers are diagnosed with any form of TVS are vaccinated with BCG immediately after birth, a drug made from a strain of live, weakened tuberculin bacilli that has lost its virulence.

If a woman has a history of TVS disease or a weakened immune system, then at the stage of pregnancy planning she is recommended to take preventive measures aimed at strengthening the immune system. These include mineral and vitamin complexes and supplements, spa treatment, and physiotherapy. All activities should be performed only after consultation with your doctor.

In this video, the famous specialist Komarovsky shares his professional experience:

Consequences of tuberculosis during pregnancy for the fetus and child

Although, with the modern level of medicine and timely provision of assistance, up to 80% of children are born completely healthy, even if their mother suffered tuberculosis during pregnancy, various types of complications associated with the development of the baby are also likely. So, it is likely that the baby’s growth rate will slow down, body weight deficiency and a high risk of birth injuries . If a child is born healthy, such complications quickly disappear in the first months of life, and children do not differ from their peers.

But it’s a completely different matter if congenital tuberculosis . Such a pathology occurs in extremely rare cases and is detected from the first months after birth. Typically, infection occurs transplacentally, during fetal development. Infection is also possible during childbirth if there is a genital form of tuberculosis. Such cases are typical for existing disseminated forms of infection in the mother, if mycobacteria are spread through the bloodstream throughout the woman’s body.

Important

Typically, the fetus becomes infected in women who did not receive vaccination against tuberculosis in childhood or adolescence.

Childbirth and postpartum period

Doctors try to carry out childbirth naturally. Caesarean section or other birth operations are performed in extreme cases due to obstetric indications or pathologies. The greatest danger of exacerbation of the disease is the postpartum period. After childbirth, the mother undergoes an active restructuring of all systems and functions of the body, and the period of breastfeeding leads to an increase in the consumption of nutrients.

Frequent subsequent pregnancies significantly weaken the body and lead to the progression and exacerbation of tuberculosis with the appearance of new foci of localization. Repeated pregnancy after tuberculosis is not recommended for women within 3 years after recovery. Pulmonary tuberculosis is not dangerous for the fetus in the womb; infection can occur during or after childbirth.

Breastfeeding is allowed for women with inactive types of the disease. If active tuberculosis is detected in the last stages or in the postpartum period, breastfeeding is prohibited. Such mothers are given complete antibacterial therapy. If the disease has not lost its activity, but bacterial excretion has stopped, the decision about breastfeeding is made by a phthisiatrician and an obstetrician-gynecologist. After birth, the child is vaccinated with BCG in the same way as other children.

If intrauterine infection of the fetus occurs, the clinical picture is extremely unfavorable. Most often, children are born prematurely, the disease manifests itself at 3-6 weeks. The child becomes restless, stops gaining weight, there is diarrhea and vomiting, the temperature rises, and an enlargement of the liver and spleen is observed. Over time, the child develops shortness of breath and cough, which indicates the development of pneumonia. The disease often ends in death.

Treat yourself correctly!

Symptoms of congenital tuberculosis

Manifestations of the congenital form of tuberculosis are varied; in the early stages of gestation, miscarriages are usually provoked; in the later stages, damage to the internal organs of the fetus is possible, which threatens death in utero or at birth. If pregnancy continues, children are born premature, with severe intrauterine hypoxia. A constantly elevated body temperature and breast refusal, sharply suppressed appetite, weight loss or weight gain below normal, drowsiness with lethargy of the baby, weak reflexes and pale skin with a yellowish tint are typical. Shortness of breath with cyanosis of the face and extremities, enlarged spleen and liver and almost all groups of lymph nodes may also be expressed.

Mycobacteria form numerous large foci of inflammation of different sizes in the lung tissue, often prone to fusion. Lung tissue is also affected on both sides, damage to the brain and nervous system may occur, and neurological symptoms develop.

Diagnosis of tuberculosis in pregnant women: norm and interpretation

For all women who register in the early stages of pregnancy, the results of previously performed lung fluorography . During pregnancy, this procedure is not performed, since X-rays negatively affect the development of the fetus in the womb, especially in the early stages. The latest fluorography results can detect or remove suspicion of lesions in the lungs. Such a mass screening study allows us to identify people who require additional targeted control.

If there is a wet cough or there is a suspicion of infection, sputum ; the resulting sputum is inoculated onto nutrient media, identifying bacteria in the samples and determining their sensitivity to certain antibiotics. Tuberculosis bacteria can also be detected in oral swabs. Moreover, they are detected by a PCR reaction that detects mycobacterial DNA. Such a study is carried out in the absence of obvious signs of damage. The result must be negative, then the woman is healthy. If a positive answer is received, further research is carried out.

Confirmation of tuberculosis in the presence of suspicion, questionable culture data and data on possible infection is carried out through a number of studies:

tuberculin tests, which include the traditional Mantoux test and its modern analogue - Diaskintest, which has a more highly accurate result. One of the serious disadvantages of these methods is the high allergization of the body, which can subsequently negatively affect the health of the fetus.
Quantiferon test, which is carried out in venous blood and is 100% accurate. It detects a special gamma interferon, which is typical only for tuberculosis bacilli. If it is positive, there is tuberculosis; if it is negative, the diagnosis is removed.
conducting an immunogram that reflects not only tuberculosis infection, but also the state of the immune system, its possible problems, due to which the infection has intensified. This is important during pregnancy, when immune defenses are generally reduced.

Important

Fluorography and radiography of the lungs are not performed during pregnancy due to their danger to the fetus; an MRI may be prescribed, which does not expose the fetus to radiation and can detect dangerous foci in the lung tissue. X-rays or fluorography are performed on all family members of a pregnant woman if tuberculosis is suspected.

Treatment options

TVS is treated by a TB doctor, who registers the pregnant woman with pulmonology and prescribes conservative therapy. The most effective drugs are special-spectrum antibiotics. The main anti-tuberculosis drug prescribed by phthisiatricians is para-aminosalicylic acid (PAS) in the form of sodium salt.

Other medications that should be taken only on the recommendation of a doctor:

Isoniazid;
Ethambutol;
Prothionamide.

Many antibiotics prescribed for the treatment of bronchopulmonary infections in the normal state are contraindicated in pregnant and lactating women. To avoid side effects and harmful effects on the fetus, the doctor must carefully calculate the dose.

Self-medication for infections of the bronchopulmonary system during pregnancy is unacceptable!

Treatment of tuberculosis during pregnancy

This infection is treated by a phthisiatrician and a gynecologist in tandem, using antimicrobial that act on mycobacteria.

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Some of the drugs used to treat the infection are safe for the fetus and mother, although streptomycin, ethambutol and kanamycin can cause problems in the development of the fetus in utero. Any medications should be used in the treatment of tuberculosis only after consultation with a doctor.

Tuberculosis therapy is long-term and is carried out in two stages. Drugs against tuberculosis microbes are prescribed after the 14th week of pregnancy. In the early stages of pregnancy, the decision to treat or terminate depends on many factors. It is indicated to terminate pregnancy in the presence of a fibrous-cavernous form of the disease, damage to bones and joints , and bilateral damage to the kidneys by tuberculosis . All other forms allow for continuation of gestation and the birth of a child on time. The main decision about the fate of the fetus is made by the woman together with the doctor.

Important

Surgical methods for treating tuberculosis during gestation are not indicated; they are carried out only if there are vital indications; organ-preserving interventions are indicated, as well as taking measures to carry the pregnancy to term.

Each specific case of treatment for pregnant women from 14 weeks and the choice of drugs for them is considered individually.

Some anti-tuberculosis drugs can be taken during gestation, but you need to be aware of certain consequences for the fetus:

Taking isoniazid is most beneficial for the mother and baby. But the fetus may experience delayed psychomotor development, problems with the spinal cord, lesions of the spinal column, defects in the development of the genitourinary organs, hemorrhages of varying severity, and a decrease in the supply of vitamins. Use the drug only under the strict supervision of a doctor.
Prothionamide, pyrazinamide and ethambutol are less effective; there is no evidence of an increased risk of congenital anomalies and negative effects on the fetus when taken during gestation. During pregnancy, their intake is strictly controlled due to individual influences.
taking ethionamide, thiocetazone, rifabutin, capreomycin and cycloserine leads to teratogenic effects on the fetus; they are strictly prohibited during pregnancy.

Three hospitalizations during gestation are routinely indicated; they are necessary to assess the dynamics of the infection and the condition of the fetus and mother.

Forecast

Early diagnosis and timely treatment ensure a favorable outcome of fetal development and subsequent births. Most often, children from a sick mother are born healthy, the exception being infection due to pathological problems with the placenta, as well as during the pushing itself. Often, infection occurs after the birth process from a mother who has tuberculosis during pregnancy. The consequences are not very favorable, but, according to experts, it is not worth separating the child from the mother. The exception is when a woman suffers the most severe and hopeless types of illness. If the woman in labor does not have bacilli excretion, the child is vaccinated with BCG and breastfeeding is allowed. After discharge from the maternity hospital, a mother with a newly-made member of society should be under constant supervision of a antenatal and children's clinic and a tuberculosis dispensary.

Is it necessary to terminate pregnancy if infected?

Infection with tuberculosis is dangerous at any stage, but it is especially unfavorable in the first trimester, during which time up to a third of exacerbations of the infection, which has a latent course, occur. Exacerbation of tuberculosis, which previously occurred latently, against the background of pregnancy and childbirth occurs due to various reasons:

Possible injuries during childbirth
Loss of large volume of blood with the development of anemia
Active neuro-hormonal restructuring of the body
Physical and mental stress, changes in the load on the body.

Against the background of constant medical supervision of a woman during gestation, it is quite possible to maintain and successfully carry a pregnancy to term in most cases. Doctors can only recommend early termination of pregnancy for certain categories of women whose gestation may threaten their own life and health:

fibrous and cavernous form of pulmonary tuberculosis
active form of infection in the spine and skeletal bones
combination of pulmonary tuberculosis with diabetes mellitus
in the presence of tuberculous lesions in the area of the knee, ankle or hip joints
with bilateral and advanced kidney damage
against the background of genital lesions by infection
for pathology that requires surgical correction.

Termination is indicated during the first trimester; at a later date, this threatens the activation or exacerbation of tuberculosis infection, but the decision to carry the fetus or terminate the pregnancy remains only with the woman and the medical commission.

If a woman has an active tuberculosis process, in which she decides to prolong pregnancy and subsequent childbirth, a set of measures is required. They include preliminary notification of the maternity hospital about the presence of a woman with an infection and providing her with a separate boxed delivery room. Immediately after birth, the child is isolated from the mother and weaned from breastfeeding in order to protect against infection. He is immediately vaccinated with BCG, separating him from his mother for at least 8-10 weeks. The house where the baby will live is thoroughly disinfected, and the mother is treated in an anti-tuberculosis dispensary.

The presence of tuberculosis does not lead to significant effects on the birth process, but certain restrictive measures are important due to the risk of infection of the fetus or personnel through contact with blood.

Causes

The direct cause of this pathology is Mycobacterium tuberculosis (Koch bacillus). A woman can become infected during or before pregnancy. In the latter case, women usually do not yet know about the presence of the pathogen in their body and do not attempt birth control in order to first cure the disease and then plan the birth of a child.

The causative agents of tuberculosis infect a large number of people. But this does not mean that the incidence should be 100%. This pattern also applies to pregnant women, but it should be remembered that due to the restructuring of the body, they are more vulnerable, and tuberculosis can occur in them even under those unfavorable conditions under which it does not yet occur in other groups.

Tuberculosis is a social disease - it affects asocial segments of the population. In this case, pregnant women who:

are in prison;
belong to the category of people without a fixed place of residence;
live in conditions that are unsuitable for human habitation - high humidity, low temperature, drafts, and so on;
significantly violate the principles of rational nutrition - they go hungry, experience a regular lack of proteins, fats, carbohydrates, and vitamins.

Basics of tuberculosis prevention

The most basic specific prevention of tuberculosis is vaccination against it in childhood, carried out in the neonatal period, and then at 7 years and 14 years. It is indicated in the presence of a negative Mantoux test, based on the results of which the issue of revaccination is decided.

The presence of an active form of tuberculosis in the mother is a reason for separating her from the baby; with inactive tuberculosis, the child is close to the mother. Breastfeeding is allowed in the inactive stage of infection; after discharge, both are observed by a doctor.

Alena Paretskaya, pediatrician, medical columnist

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