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Tuberculosis Among Pregnant Women -- New York City, 1985-1992

From 1985 through 1992, the number of reported tuberculosis (TB) cases increased 20% in the United States (1). During 1985- 1990, TB cases increased 44% among persons aged 25-44 years and 27% among children (aged less than 15 years) (2), indicating that TB may be an increasing problem among reproductive-aged women (3,4). To determine the prevalence of active TB during pregnancy, the medical records from 1985 through 1992 of two public hospitals in New York City were reviewed. This report summarizes the results of the survey.

The populations served by these two hospitals are largely inner-city, indigent, and minority populations with a high prevalence of both TB and human immunodeficiency virus (HIV) infection. Active TB was defined as a positive culture for tubercle bacilli (sputum, urine, or spinal fluid specimens), regardless of smear findings for acid-fast bacilli. Sixteen pregnant women with active TB (12 from one hospital) were identified; TB was diagnosed in five among 40,388 births (12.4 per 100,000 births) at these hospitals during 1985-1990, and in 11 among 11,595 births (94.8) during 1991-1992.

Five of the 16 women had received prenatal care before TB diagnosis: two, after a positive skin test and further evaluation, and three, after admission to the emergency department with TB-related symptoms. The 11 remaining women had received no prenatal care before TB diagnosis; these women's pregnancies were confirmed when they were admitted to the emergency department with symptoms associated with TB.

Of the 16 women, TB was diagnosed in one during the first trimester of her pregnancy; in seven, during the second trimester; and in eight, during the third trimester. A Mantoux tuberculin intradermal test was positive for six of the 15 women who were tested. Ten of the 16 women had pulmonary TB; six had extrapulmonary TB (two had tuberculous meningitis; one, mediastinal; one, renal; one, gastrointestinal; and one, pleural).

Seven of 11 women tested for HIV were HIV positive. Seven of the 16 women were drug users (defined as current use of cocaine or heroin). Six of the seven women who were HIV positive were drug users or were described by their physicians as injecting-drug users (IDUs): two women were cocaine users, three were IDUs, and one was both a cocaine user and IDU. Six of the seven women who were HIV positive and five of the six women who were drug users had received no prenatal care at the time their TB was diagnosed.

Thirteen of the 16 patients were successfully treated with isoniazid (INH), ethambutol (EMB), and rifampin (RIF). Two women with TB of the central nervous system received pyrazinamide (PZA). One woman with pulmonary TB (cavitary) received additional PZA because of persistent positive sputum cultures after 5 months of therapy with INH, EMB, and RIF. The remaining 10 women became asymptomatic on initial therapeutic regimens: eight had negative repeat cultures, and two required invasive biopsies and were not recultured.

Reported by: F Margono, MD, A Garely, MD, Saint Vincent's Hospital, New York. J Mroueh, MD, H Minkoff, MD, Health and Science Center at Brooklyn, State Univ of New York. HIV Section, Women's Health and Fertility Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report document an increase in active TB among pregnant inner-city women in two hospitals in New York City. Many of these women had TB diagnosed after presentation with TB-related symptoms. These findings underscore the need for TB screening in high-risk communities. Because of their high rate of TB and their inadequate use of prenatal and general health care, special attention should be given to minority urban populations and some populations of recent immigrants from countries with high prevalences of TB (2,5).

HIV infection is an important risk factor for the development of clinical TB in an adult coinfected with Mycobacterium tuberculosis (6). Thus, screening for TB should focus on populations at high risk for HIV infection and acquired immunodeficiency syndrome, including IDUs and persons already infected with HIV.

TB-related symptoms can mimic the physiologic changes that occur during pregnancy (i.e., increased respiratory rate and fatigue). Consequently, pregnant women in high-risk groups and women from areas with a high prevalence of both HIV infection and TB should be routinely asked about contact with infectious TB patients, and tuberculin skin testing should always be considered for these women. Because prenatal or peripartum care is often the only contact many high-risk women have with the health-care system, screening for TB and HIV counseling and testing should be offered at this time.

The most appropriate method of screening for TB infection is the tuberculin skin test (Mantoux technique). Pregnancy does not measurably alter the response to a tuberculin test; subsequent investigation of tuberculin reactors, and persons with symptoms of TB, should facilitate the diagnosis and treatment of TB in pregnant women.

Because approximately 10% of immunocompetent and 40% of HIV-infected persons with active TB are negative by the tuberculin skin test, a negative result should never rule out the possibility of active disease (3,6-8). Factors such as age, poor nutrition, immunosuppression by disease or drugs, viral infections, and overwhelming TB can decrease tuberculin reactivity (3). Anergy to tuberculin has been reported among adults with HIV infection; therefore, a thorough investigation to detect active TB should be undertaken for all persons with clinical features compatible with TB, regardless of the results of the tuberculin skin test (7), and for all pregnant women at risk for or with known HIV infection.

To rule out active TB, routine chest roentgenogram with proper shielding of the abdomen should be performed after the 12th week of gestation for women with a positive tuberculin skin test (3,7). A chest roentgenogram should be performed sooner if the woman has symptoms suggestive of pulmonary TB, even if the tuberculin skin test is negative (3,4). Moreover, a comprehensive and systematic diagnostic approach, including appropriate examination of specimens for mycobacteria, should be followed for all patients with HIV infection and pulmonary disease (7). A complete review of systems and physical examination should be conducted to exclude extra- pulmonary TB.

The Advisory Council for the Elimination of Tuberculosis recommends initial treatment for nonpregnant patients with four drugs: INH, RIF, PZA, and EMB or streptomycin (SM) (1). For pregnant women, this regimen is modified to exclude SM because it may cause congenital ototoxicity, and PZA, because the risk for teratogenicity has not been determined (1,3,9). Pregnant women with drug-susceptible organisms can be treated safely with INH, RIF, and EMB (1,3), but treatment must be continued for 9 months (1,3). If resistance to other drugs is probable and susceptibility to PZA is likely, the risks and benefits of PZA should be weighed carefully, and its use should be considered.

References

  1. CDC. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1993:42(no. RR-7).

  2. CDC. Prevention and control of tuberculosis in U.S. communities with at-risk minority populations and prevention and control of tuberculosis among homeless persons. MMWR 1992;41(no. RR-5).

  3. Vallejo J, Starke J. Tuberculosis and pregnancy. Clin Chest Med 1992;13:693-707.

  4. Hamadeh MA, Glassroth J. Tuberculosis and pregnancy. Chest 1992;4:1114-20.

  5. CDC. Tuberculosis among foreign-born persons entering the United States: recommendations of the Advisory Committee for Elimination of Tuberculosis. MMWR 1990;39(no. RR-18).

  6. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989;320:545-50.

  7. Barnes PF, Bloch AB, Davidson PT, Snider DE Jr. Tuberculosis in patients with human immunodeficiency virus infection. N Engl J Med 1991;324:1644-50.

  8. CDC. Purified protein derivative (PPD)-tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR 1991;40(no. RR-5):27-33.

  9. Snider DE Jr, Layde PM, Johnson MW, Lyle MA. Treatment of tuberculosis during pregnancy. Am Rev Respir Dis 1980;122:65-79.



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