Abstract
Aims and Objectives : To study the incidence, demography, parity, focus of TB, maternal morbidity and mortality, perinatal outcome and the association of HIV with TB.

Material and Methods : 85 cases of tuberculosis in pregnancy were evaluated for presenting complaints, onset, duration and progress of the disease, period of gestation, type of anti-Koch’s therapy received. Maternal and foetal morbidity and mortality was studied.

Results : 85 cases of pregnancy with TB out of 32,795 deliveries over 5 years. Out of 53 cases of pulmonary TB, 10 were sputum positive and 45 patients had X-ray chest suggestive of pulmonary Koch’s. Out of 85, 17 were HIV seropositive. Of the 13 deaths, 6 patients were defaulters and 5 patients had received chemotherapy at an advanced stage of the disease.

Conclusion : DOTS has emerged as one of the most reassuring tool to improve the challenging situation of pregnancy with TB.

Introduction
Tuberculosis (TB) is a major health hazard in developing countries like India. It accounts for almost 3/4th of the 15-20 million affected individuals worldwide. The overall prevalence of TB infection is 30% (Males - 35% and female 25%).1 TB in pregnancy poses a unique challenge to the obstetrician in terms of foeto-maternal morbidity and mortality, association and the influence of HIV, drug resistant TB and patient compliance. The incidence of TB is around 1-2% amongst hospital deliveries, especially in the under privileged sections of the society.

Aims and Objectives

1. To study the incidence, demography, parity, focus of TB, maternal morbidity and mortality, perinatal outcome and the association of HIV with TB.
2. To evaluate the impact of Directly Observed Therapy - Short course (DOTS) on patient compliance during treatment of TB in pregnancy.

Material and Methods
85 cases of tuberculosis in pregnancy were evaluated from six obstetric units over a period of 5 years at the Lokmanya Municipal Medical College and Hospital, Sion, Mumbai. Each case was assessed for presenting complaints, onset, duration and progress of the disease, period of gestation, type of anti-Koch’s therapy received - conventional or DOTS. The pregnancy outcome in terms of maternal and foetal morbidity and mortality was studied.

Observations
There were 85 cases of pregnancy with TB out of 32,795 deliveries over 5 years. (Incidence = 2.6/1000). 65 patients were between the age group of 20-30 years, 12 cases among 30-40 years and 8 were less than 20 years of age. 25 patients were primigravidae, 54 were multigravidae and 6 were grand multigravidae. 14 patients (16.4%) had TB before conception. 12 (14.1%) were diagnosed to be suffering from TB in the first trimester and 21 (24.7%) were diagnosed postpartum. Out of 53 cases of pulmonary TB, 10 were sputum positive and 45 patients had X-ray chest suggestive of pulmonary Koch’s. One patient had concomitant pericardial effusion diagnosed on 2D echocardiography. Out of 85, 17 were HIV seropositive.

Analysis of obstetric outcomes showed that 30 patients (35.3%) had full term normal deliveries, 28 (32.9%) had a preterm vaginal delivery. 11.8% patients had IUGR and 4.71% had spontaneous abortions. 3 patients underwent caesarean section for obstetric indications. 6 died undelivered in the antenatal period due to systemic complications of TB. 31 babaies weighed between 1.5 - 2.5 kg and only 20 were more than 2.5 kg. 11 babies were less than 1.5 kg in weight.

Of the 13 deaths, 6 patients were defaulters and 5 patients had received chemotherapy at an advanced stage of the disease. Four patients had Multi Drug Resistant TB (MDR-TB). Out of the 85 patients, 53 received conventional chemotherapy and 32 received Directly Observed Treatment, Short-course (DOTS). All the 6 defaulters belonged to the group receiving conventional anti-Koch’s therapy.

Discussion
TB is the leading cause of death amongst women of reproductive age group, surpassing all other causes of maternal mortality. Incidence of new cases is 1/1000.² In our study, we had 85 cases out of 32,795 deliveries in 5 years (Incidence - 2.6/1000). Ray A Kurseung sub-divisional hospital, reported incidence of pulmonary TB of 3.7/1000 (1996).³

Majority of our patients (65-76.4%) were in 20-30 years age group. National Institute of TB has reported a peak prevalence of TB below 35 years of age.4 16.4% of our patients had TB existent before conception. 14.1% (12 cases) were diagnosed in the 1st trimester of pregnancy and 24.7% (21 cases) in the postpartum period. Immunosuppression, poor nutritional status and rapid descent of diaphragm during pregnancy and lactation can alter the course of the disease during the postpartum period. Cohen had no increase in TB in the postpartum women as compared to the general population in a study at Boston.5 All the 5 cases of TB lymphadenitis reported by him were confirmed by FNAC examination. A review of literature shows that re-activation of Tuberculous lymphadenitis occurring in pregnancy was also noted by Warner TT, Middlesex, UK, 1992.⁶

In the present series, 17 out of 85 patients were tested positive for HIV by ELISA (7.05%). HIV is the most important identified risk factor that allows progression to clinically active TB. A study from Norway revealed a higher incidence of toxaemia, PPH and difficult labour in mothers suffering from TB.⁷ The incidence of miscarriage was 10 times higher in-patients with TB. Jana et al in 1994 found a 2-fold increase in prematurity (22.8%) and 6-fold increase in perinatal deaths.⁸ The perinatal mortality in our series was 10.5% and the main causes were prematurity or chronic intrauterine hypoxia leading to foetal distress. 23% neonates were HIV seropositive and 29% were seronegative. In a study by Margono et al, 16 pregnant women diagnosed with TB were seropositive.⁹

53 patients in the present series had received conventional anti-Koch’s therapy and another 32 (37.6%) had received DOTS. It was significant to note that all the 6 (7.05%) defaulters were receiving conventional chemotherapy whereas none receiving DOTS had defaulted. It is needless to emphasize that DOTS ensures high cure rates in successful management of TB by prompt diagnosis, appropriate medical treatment with quality drugs for free of charge. There is supervision and motivation by a health or non health worker during intensive phase and regular monitoring of disease status. Under DOTS programme, a health worker or a trained person who is not a family member watches the patient swallow anti-TB drugs in their presence.10 Thus, DOTS prevents drug resistance and achieves higher cure rates.

Conclusion
Early diagnosis and prompt treatment of Tuberculosis during pregnancy would give better results. Drug therapy in appropriate dosage has no major adverse effects on the offspring. Breast-feeding should be actively encouraged. Early ANC registration, intensive intrapartum monitoring and post partum surveillance, adequate rest and nutrition are crucial. Patient compliance has to be good to ensure the success of the DOTS strategy. DOTS has emerged as one of the most reassuring tool to improve the challenging situation of pregnancy with TB.

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