Tuberculosis in Obstetrics and Gynecology

NAME ALEFIYAH SALEEM ID - 07090124

I had Genital TB too

Incidence
1% of the OPD patients in the developing world

Patients with infertility 5-10%

Prevalence of HIV rise in TB

Pathogenesis
Causative organism mycobacterium TB mostly

human type Genital TB is always secondary to primary infection ( lungs 50%, lymph nodes, urinary tract, bones and joints) The fallopian tubes are invariably the primary sites of pelvic TB from where secondary spread occurs to other genital organs.

Mode of spread
Blood stream 90%

Lymphatic or direct from infected organs such as

peritoneum, bowel or mesenteric nodes Ascending male with urogenital TB

Pathology of pelvic organs

Fallopian tubes
Commonest site ( nearly 100%) Bilateral affection Initial site submucosal layer of the ampullary part Infection spread medially destruction of the muscles fibrous tissue thickened calcified Infection spread inward swollen mucosa and destroyed fimbria are everted and abdominal ostium usually remains patent Elongated and distended distal tube give appearance of tobacco pouch Adhesions tubercles burst out (inward pyosalphinx and outward perisalphingitis)

Salpingitis isthimica nodosa

Nodular thickening of the tube d.t proliferation of

the tubal epithelium within the hypertrophied myosalphinx. Etiology unknown Radiology small diverticulum Non specific for TB DD pelvic endometriosis

Uterus
60%

Spread from tubes lymphatic or direct

Site corunal ends commonly Tubercle is situated in the basal layer and only comes

to the surface premenstrual After menstruation reinfection lesion in basal layer or from tubes. Endometrial ulcerations may lead to adhesion or synechia ashermans syndrome infertility, secondary amenorrhea or recurrent abortion

Cervix
5-15%

By sexual intercourse is rare

Ulcerative or bright nodular type Bleed on touch thus confused with carcinoma

Histology marked epithelial hyperplasia and some

atypia ( misdiagnosis of carcinoma)

Vulva and vagina

Very rare 1%

Ulcerative with undermined edges

Or hypertrophied edges Diagnosis by histology

Ovary
30%

Surface tubercles, adhesions, thickening of the

capsule or even caseating abscess

Pelvic peritoneum
Peritonitis 40-50%

2 types Wet type or exudative ascites with straw colored fluid in the peritoneal cavity, parietal and visceral peritoneum covered with numerous small tubercles Dry type or adhesive dense adhesions with the bowel loops, adhesions are due to the fibrosis when wet heals

Microscopic appearance
Typical for TB

Granuloma with infiltration of multinucleated giant

cells ( langerhans), chronic inflammatory cells and epitheloid cells, surrounding a central area of caseation necrosis

Clinical features
History

Childbearing period
PMH- pulmonary TB in adolescence (10-20%) FH- positive

Asymptomatic
Incident findings while investigating for infertility or

DUB

 Infertility Primary or secondary 70-80% Tubal blockage, synechia or ovulatory dysfunction Menstrual abnormalities Menorrhagia or irregular bleeding Amenorrhea or oligomenorrhae

 Chronic pelvic pain tubo-ovarian mass

Vaginal discharge cervical or vaginal TB

Constitutional symptoms weight loss, fever,

anorexia, etc

Signs
PA normal Irregular tender mass Feel doughy due to matted intestines Ascites PV ulcers Thickened tubes in the lateral fornices

Differntial diagnosis
Pyogenic tubo-ovarian mass

Pelvic endometriosis
Adherent ovarian cyst

Investigation
Aim is to Identify the primary lesion Confirm the genital lesion

 CBC

Mantoux test
CRX Diagnostic uterine curettage premenstruation

PCR biopsy or first day menstrual discharge

HSG CT/MRI abdominal and pelvic

Laparoscopy

Treatment
General

Chemotherapy
Surgical

General
Acute pulmonary infection requires hospital

admission Pelvic infection doesnt require hospital admission Good healthy diet Use condom during intercourse to avoid the spread of infection

Chemotherapy
Initial phase isoniazid, rifampicin, pyranzinamide

and ethambutol are used for 2 months Continuation phase isoniazid and rifampicin for 4 months One year after treatment diagnostic endometrial curettage and bacteriology examination is done.

Drug

Daily dosing

Thrice-weekly dosing*

Adverse reactions

Isoniazid (INH)

5 mg/kg max. 300 mg Adults: 15 mg per kg Elevation of hepatic orally or IM enzyme levels, hepatitis, neuropathy, central nervous system effects

Rifampin (Rifadin)

10 mg/kg max. 600 mg

Pyrazinamide

20 -25 mg/kg max. 3gm

Adults: 10 mg per kg Orange discoloration orally or IV of secretions and urine, gastrointestinal tract upset, hepatitis, bleeding problems, flu-like symptoms, drug interactions, rash Adults: 50 to 70 mg Gastrointestinal tract per kg orally upset, hepatitis, hyperuricemia, arthralgias

Ethambutol (Myambutol)

15-20 mg/kg max. 2.5 adults: 25 to 30 mg perOptic neuritis gm kg orally

Surgery
Indication 1. Unresponsiveness of active disease in spite of adequate anti- TB chemotherapy 2. TB pyosalpinx, ovarian abscess or pyometra 3. Persistent Menorrhagia or chronic pelvic pain causing functional impairment

Contraindications
1. 2. 3.

Presence of active TB in extra genital sites Favorable response to chemotherapy Accidently discovery of tubo-ovarian mass on laparotomy

 Precautions Anti TB drug therapy should be

given at full doses for at least 6 weeks prior to the surgery and even continued after the surgery. Type of surgery Total hysterectomy with bilateral salpingooophprectomy Young women preserve atleast one ovary and resection of the mass, drain the pyometra or repair of the fistula.

TB in pregnancy
Incidence - 1-2%, increase incidence in patients with

HIV Risk factors

1. 2. 3. 4. 5.

6.
7.

PMH or FH positive Low socio-economic status Area with high prevalence of TB HIV infection Alcohol addiction IV drug abuse DM, jejunoileal bypass, Underweight by >=15%

Diagnosis
Tuberculin skin test

CXR after 12 weeks

Early morning sputum Gastric washing

Diagnostic bronchoscopy
PCR

Congenital TB
Rare

Associated with HIV 1. Lesion noted in first week of life 2. Infected maternal genital tract or placenta 3. Cavitating hepatic Granuloma dx by percutanous liver biopsy 4. No evidence of post natal transmission

Prognosis
Pregnancy has got no deleterious side effect on the

course of the disease nor has the disease got any adverse effect on the course of pregnancy. In active disease fetus maybe affected via transplacental or aspiration of the amniotic fluid Untreated patients

Preterm labor IUGR Perinatal mortality

Management
Medical

Prevention women with positive PPD and

asymptomatic INH 300mg/day + pyridoxine 50 mg/day start in first trimester and continue for 6-9 months Treatment same as for gynecology Surgery surgery should be avoided usually in pregnancy

Obstetric management
TB is not an indication for termination of pregnancy Obstetric management is same for any other pregnant

women Breast feeding No CI when women is on chemotherapy But avoided if infant is also on chemotherapy because of overdose Active lesions, it is CI as well as baby is isolated from the mother. Infant is given prophylactic INH 10-20 mg/day for 3 months along with BCG vaccination. Contraception for at least 2years after test results are negative.

Thank you for listening. She is fine now (hopefully!!!).