5.Tuberculosis in Pregnancy

7/25/2019 5.Tuberculosis in Pregnancy

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TUBERCULOSIS IN PREGNANCY


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TUBERCULOSIS IN PREGNANCY

LEARNING OBJECTIVES:

Describe epidemiology oftuberculosis

Describe effects on mother andchild

Principle of Management

Preventive strategy


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EPIDEMIOLOGY

one-third of world pop. TB infected

8 M new cases each year

4.5 in Asia:

India, China, Bangladesh,

Pakistan, Indonesia, Philippines


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Indonesia :22 High Burden Countries 1. India

2. China

3. Indonesia4. Bangladesh

5. Nigeria6. Pakistan7. South Africa8. Philippines9. Russia10. Ethiopia11. Kenya12. DR Congo

13. Viet Nam14. UR Tanzania15. Brazil16. Thailand

17. Zimbabwe18. Cambodia19. Myanmar20. Uganda21. Afghanistan

22. Mozambique

Indonesia 10%

Bangladesh 4%

China

15%

India30%

Other

28%

Philippines 3%

Pakistan 4%

Nigeria 3%

South Africa 2%

Russia 1%

Penyebab kematian terbanyak penyakit infeksi(SKRT 1995)

583.000 kasus baru/tahun, 140.000 kematian/tahun (WHO)


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5% IN 2 YEARS

5% Reactivation TB

PEOPLE

Infection

Disease

Death

Exposure

Natural History of Tuberculosis

10-30%

10%

HIV

40-50%

Infectious

50% of smear positive

70% NON INFECTED

90% NO DISEASE


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PENYEBAB UTAMA PENINGKATAN BEBANMASALAH TBC (1)

Kemiskinan negara sedang berkembang

Kegagalan program TBC selama ini akibat :

Tidak memadainya komitmen & pendanaan

Tidak memadainya organisasi pelayanan TBC Tidak memadainya tatalaksana kasus

Salah persepsi terhadap hasil vaksinasi BCG

Infrastruktur kesehatan yang buruk

negara mengalami krisis ekonomi / pergolakanmasyarakat


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PENYEBAB UTAMA PENINGKATAN BEBAN

MASALAH TBC ( 2 )

Perubahan Demografik peningkatan pendudukdunia

Dampak Pandemi HIV/AIDS koinfeksi denganHIV akan meningkatkan secara signifikanrisiko menderita TBC


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Prevalence rate turun 4%per thn 1980-2004

42%

28%

54%

35%

0

100

200

300400

500

600

Smear+prevalen

ce/100K

1980 survey

1990

2004 survey

1980 survey 422 255 433 321

1990 311 146 342 217

2004 survey 203 67 246 125

Sumatra Java-Bali KTI (East) National

%fall cf 1990

Hasil Prevalensi Survey 2004Angka Prevalensi BTA Pos Baru per 100.000 pddk


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International Situasi TB di Indonesia 2004 & 2005

DOTS strategy

2004 2005*

Country population (in thousands) 216.415 219,142

No. of TB cases notified (all cases) 214,658 253,269

No. of TB cases notified (new ss+) 128,981 154,330

Cure rate (new ss+, one year earlier) 80.7% n.a

Treatment success rate (new ss+, one year earlier) 88.8% n.a

Case detection rate (all new ss+) 51.8% 65.8%

DOTS case detection rate (new ss+ under DOTS) 51.8% 65.8%

* annualized


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Tripathy SN, Int J Gynaecol Obstet. 2003 Mar;80(3):247-53

There were no statistical differences in

duration of gestation, preterm labor, and other

complications of pregnancy, labor, and

puerperium between the pregnancy groups.

There were no congenital anomalies in the

babies born to the groups.

Pregnancy had no effect on the course of TB

as regards sputum conversion, stabilization of

the disease, and non-relapse even after 2-5

years of follow-up and a further delivery in a

few cases.


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The small concentrations of TB drugs in breast milk dnot have a toxic effect on nursing newborns, and

breastfeeding should not be discouraged for womenundergoing anti-TB therapy.Similarly, drugs in breast milk should not be considereeffective treatment for disease or infection in a nursinginfant.

Breast-feeding is not contraindicated when a mother isbeing treated. Likewise, the amount of isoniazid providby breast milk is inadequate for the treatment of aninfant. Infants whose breast-feeding mothers are taking

isoniazid should receive supplemental pyridoxine.

CDC Fact Sheet : Tuberculosis and Pregnancy

Feb 5 , 2005


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TB in NEWBORN / INFANT

Prevention : BCG Vaccin

Quite serious

Prophylactic: INH


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Diagnosis PPD skin test (Mantoux)

Chest X-Ray

Sputum


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Preventive Strategy

Early diagnosis and

effective treatment Focus antenatal care

Vaccination: BCG


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The risk to a pregnant woman

and her fetus is far greater from

untreated TB than it is from the

drugs used in its treatment The use of INH, RMP & EMB has

been well studied during

pregnancy, and they are safe inthis setting

Canadian TB Standard, 5th ed, 2000


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Pregnant women with TB do notpose particular problem for

treatment

INH, RMP , EMB, PZA & THZ aresafe in pregnancy, and are not

reported to have teratogenic or

other adverse effects on the fetus

Intervention for TB Control Elimination.

Paris : IUAT-LD , 2002


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International Treatment of TB, Guidelines for National

Programme. Geneve : WHO , 1997

Most anti TB drugs are safe for use inpregnant woman

The exception is streptomycin which is

ototoxic to the fetus, should not be usedin pregnancy and can be replaced by

ethambutol

All the anti TB drugs are compatible withbreastfeeding


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Pregnant women with TB must be given adequate

therapy as soon as TB is suspected. The preferred

initial treatment regimen is isoniazid, rifampin,

and ethambutol

- Because the 6-month treatment regimen cannot b

used, a minimum of 9 months of therapy should be

given

CDC Fact Sheet : Tuberculosis and Pregnancy

Feb 5 , 2005


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Risk

Rate per 100. 000 pregancies

normal pregnancy withTB

Low birth weight (


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Risiko ESO dalam 100.000

Isoniazid-induced hepatitis 1.600

Rifampicin-induced hepatitis 1.100

Hepatitis with standard TB

treatment2.700

Fatal hepatitis 9,4-14


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Di seluruh dunia menggunakan

STRATEGI DOTS (Directly Observe

Treatment Shortcourse)

PENANGGULANGAN TBC


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5 komponen DOTS:1. Komitmen

2. Penegakan diagnosa mikroskop

basil tahan asam positif

3. Pengobatan dengan RHZE+S

dengan Pengawasan menelan obaoleh PMO (Pengawas Menelan

Obat)

4. Kepastian persediaan OAT pada

saat penderita membutuhkan

5. Pencatatan pelaporan terintegra

menggunakan format baku


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Short-course Chemotherapy Treatment for


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py

New Tuberculosis Cases, Adult >50kg


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International JENIS TABLET FDCUntuk sementara ada 2 macam FDC:

4FDC, Setiap tablet mengandung:- 75 mg Isoniasid (INH)

- 150 mg Rifampisin

- 400 mg Pirazinamid

- 275 mg Etambutol.Utk pengobatan HARIAN tahap Intensif dan Sisipan.

2FDC, Setiap tablet mengandung:

- 150 mg Isoniasid (INH).- 150 mg RifampisinUntuk pengobatan 3 KALI SEMINGGU tahap lanjutan.


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KEMASAN OBAT FDC

- Tablet 4FDC dikemas dalam blister @ 28 tablet.

- Tablet 2FDC dikemas dalam blister @ 28 tablet.

- Tablet Etambutol 400 mg dikemas dlm blister @

28 tablet.

- Streptomisin vial @ 750 mg

- Aquabidest vial @ 5 ml dan

- Disposable syringe .


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Disamping itu,

Tersedia obat lain untuk melengkapi paduan obat

kategori 2, yaitu:

Tablet Etambutol @ 400 mg,

Streptomisin injeksi, vial @ 750 mg.

Aquabidest.

KATEGORI PENGOBATAN


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InternationalKATEGORI PENGOBATAN

Kategori 1 (2HRZE/4H3R3):

- penderita baru TBC Paru BTA positif- penderita baru TBC Paru BTA negatif/Rontge

positif (ringan atau berat)

- penderita TBC Ekstra Paru (ringan atau berat

Kategori 2 (2HRZES/HRZE/5H3R3E3):

- penderita TBC BTA positif Kambuh

- penderita TBC BTA positif Gagal- penderita TBC bekas defaulter yang kembali

dengan BTA positif.


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BERAT TAHAP INTENSIF TAHAP LANJUTAN

BADAN TIAP HARI 3 KALI SEMINGGUSELAMA 2 BLN SELAMA 4 BLN

30 - 37 Kg 2 Tab 4FDC 2 Tab 2FDC



> 70 Kg 5 Tab 4FDC 5 Tab 2FDC

DOSIS KATEGORI 1 (2HRZE/4H3R3):

KETERANGAN: 1 BULAN = 28 HARI.


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TAHAP

BERAT LANJUTAN

BADAN TIAP HARI TIAP HARI 3 X SEMINGGU2 BULAN 1 BULAN SELAMA 5 BULAN

30 - 37 Kg 2 Tab 4FDC 2 Tab 4FDC 2 Tab 2FDC

+ 2 ml Strepto + 2 Tab Etamb


+ 3 ml Strepto +3 Tab Etamb



> 70 Kg 5 Tab 4FDC 5 Tab 4FDC 5 Tab 2FDC


TAHAP INTENSIF

SELAMA 3 BULAN

DOSIS KAT 2 (2HRZES/HRZE/5H3R3E3)

KETERANGAN: 1 BULAN = 28 HARI


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MODIFIED DOTS - REGIMEN

In Indonesia:

INH 300 mg daily

Rifampicin 600 mg daily

6 months


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Resistant to INH & Rifampicin MDR

DOTS Plus

Need other drugs Cost

MDR TB i h d


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0

20

40

60

80

100

Russia Dominican Rep. Korea Peru Hong Kong

Treatmentsuc

cess(%)

all TB MDR-TB

Espinal MA et al. JAMA 2000; 283:2537-2545

MDR-TB is harder to cure


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5.Tuberculosis in Pregnancy

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