95093246 Tuberculosis in Obstetrics and Gynecology

7/30/2019 95093246 Tuberculosis in Obstetrics and Gynecology

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N A M E A L E F I Y A H S A L E E M

I D - 0 7 0 9 0 1 2 4

Tuberculosis in Obstetrics and

Gynecology


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I hadGenital

TBtoo


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Incidence

1% of the OPD patients in the developing world

Patients with infertility 5-10%

Prevalence of HIV rise in TB


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Pathogenesis

Causative organism mycobacterium TB mostlyhuman type

Genital TB is always secondary to primary infection (

lungs 50%, lymph nodes, urinary tract, bones andjoints)

The fallopian tubes are invariably the primary sitesof pelvic TB from where secondary spread occurs to

other genital organs.


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Mode of spread

Blood stream 90%

Lymphatic or direct from infected organs such asperitoneum, bowel or mesenteric nodes

Ascending male with urogenital TB


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Pathology of pelvic organs


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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 ostiumusually remains patent

Elongated and distended distal tube give appearance of

tobacco pouch Adhesions tubercles burst out (inward pyosalphinx

and outward perisalphingitis)


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Salpingitis isthimica nodosa

Nodular thickening of the tube d.t proliferation ofthe tubal epithelium within the hypertrophiedmyosalphinx.

Etiology unknown Radiology small diverticulum

Non specific for TB

DD pelvic endometriosis


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Uterus

60%

Spread from tubes lymphatic or direct

Site corunal ends commonly

Tubercle is situated in the basal layer and only comesto the surface premenstrual

After menstruation reinfection lesion in basallayer or from tubes.

Endometrial ulcerations may lead to adhesion orsynechiaashermans syndrome infertility,secondary amenorrhea or recurrent abortion


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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)


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Ovary

30%

Surface tubercles, adhesions, thickening of thecapsule or even caseating abscess


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Pelvic peritoneum

Peritonitis 40-50%

2 types Wet type or exudative ascites with straw colored fluid in the

peritoneal cavity, parietal and visceral peritoneum coveredwith numerous small tubercles

Dry type or adhesive dense adhesions with the bowel loops,adhesions are due to the fibrosis when wet heals


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Microscopic appearance

Typical for TB

Granuloma with infiltration of multinucleated giantcells ( langerhans), chronic inflammatory cells and

epitheloid cells, surrounding a central area ofcaseation necrosis


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Clinical features

History

Childbearing period

PMH- pulmonary TB in adolescence (10-20%)

FH- positive Asymptomatic

Incident findings while investigating for infertility or

DUB


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Infertility

Primary or secondary

70-80%

Tubal blockage, synechia or ovulatory dysfunction

Menstrual abnormalities

Menorrhagia or irregular bleeding

Amenorrhea or oligomenorrhae


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Chronic pelvic pain tubo-ovarian mass

Vaginal discharge cervical or vaginal TB

Constitutional symptoms weight loss, fever,

anorexia, etc


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Signs

PA normal

Irregular tender mass

Feel doughy due to matted intestines

Ascites

PV- ulcers

Thickened tubes in the lateral fornices


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Differntial diagnosis

Pyogenic tubo-ovarian mass

Pelvic endometriosis

Adherent ovarian cyst


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Investigation

Aim is to Identify the primary lesion

Confirm the genital lesion


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CBC

Mantoux test

CRX

Diagnostic uterine curettage premenstruation PCR biopsy or first day menstrual discharge

HSG

CT/MRI abdominal and pelvic Laparoscopy


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Treatment

General

Chemotherapy

Surgical


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General

Acute pulmonary infection requires hospitaladmission

Pelvic infection doesnt require hospital admission

Good healthy diet Use condom during intercourse to avoid the spread

of infection


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Chemotherapy

Initial phase isoniazid, rifampicin, pyranzinamideand 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.


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Drug Daily dosing Thrice-weekly dosing* Adverse reactions

Isoniazid (INH) 5 mg/kg max. 300 mg Adults: 15 mg per kg

orally or IM

Elevation of hepatic

enzyme levels,

hepatitis, neuropathy,

central nervous system

effects

Rifampin (Rifadin) 10 mg/kg max. 600

mg

Adults: 10 mg per kg

orally or IV

Orange discoloration

of secretions and

urine, gastrointestinal

tract upset, hepatitis,

bleeding problems,

flu-like symptoms,

drug interactions, rash

Pyrazinamide 20 -25 mg/kg max.

3gm

Adults: 50 to 70 mg

per kg orally

Gastrointestinal tract

upset, hepatitis,

hyperuricemia,

arthralgias

Ethambutol(Myambutol)

15-20 mg/kg max. 2.5gm

adults: 25 to 30 mg perkg orally

Optic neuritis


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Surgery

Indication1. 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 causingfunctional impairment

Contraindications1. Presence of active TB in extra genital sites

2. Favorable response to chemotherapy

3. Accidently discovery of tubo-ovarian mass on laparotomy


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Precautions Anti TB drug therapy should begiven at full doses for at least 6 weeks prior to thesurgery and even continued after the surgery.

Type of surgery Total hysterectomy with bilateral salpingo-

oophprectomy

Young women preserve atleast one ovary and

resection of the mass, drain the pyometra or repair ofthe fistula.


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TB in pregnancy

Incidence - 1-2%, increase incidence in patients withHIV

Risk factors 1.

PMH or FH positive2. Low socio-economic status

3. Area with high prevalence of TB

4. HIV infection

5.

Alcohol addiction6. IV drug abuse

7. DM, jejunoileal bypass, Underweight by >=15%


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Diagnosis

Tuberculin skin test

CXR after 12 weeks

Early morning sputum

Gastric washing Diagnostic bronchoscopy

PCR


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Congenital TB

Rare

Associated with HIV1. 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


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Prognosis

Pregnancy has got no deleterious side effect on thecourse of the disease nor has the disease got anyadverse effect on the course of pregnancy.

In active disease fetus maybe affected viatransplacental or aspiration of the amniotic fluid

Untreated patients Preterm labor

IUGR Perinatal mortality


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Management

Medical

Prevention women with positive PPD andasymptomatic

INH 300mg/day + pyridoxine 50 mg/day start infirst trimester and continue for 6-9 months

Treatment same as for gynecology

Surgery surgery should be avoided usually in

pregnancy


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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.

Th k f


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Thank you forlistening. She is fine

now (hopefully!!!).

Documents

95093246 Tuberculosis in Obstetrics and Gynecology