Acute miliary tuberculosis in pregnancy after in vitro fertilization and embryo transfer: a report of seven cases

Tuberculosis and its clinical consequences on Women's health

Mycobacterium tuberculosis causes tuberculosis, a fatal infection resulting in widespread illness and death. In 2020, approximately 10 million people were diagnosed with tuberculosis. The top 30 tuberculosis-endemic countries accounted for 86% of all estimated occurrence cases worldwide. In this context, eight of these accounted for two-thirds of the global total, with India having a prevalence of 26%. Aside from lung inflammation, the risk factors for tuberculosis in women include extra-pulmonary infection, particularly genital tuberculosis, tuberculous mastitis, and tuberculous in the peritoneum, intestine, and spine. Depending on the epidemiologic context and screening methods, different tuberculosis symptoms and disease diagnoses are more or less common among expectant mothers. The disease is almost certainly going to have a global impact. The social stigma and anxiety associated with tuberculosis may have a much more significant negative impact on women's health behaviors than men. Notably, the abdominal sites of miliary tuberculosis could mimic tumor likely, carcinoma and lymphoma. Also, the results of the diagnostic accuracy tests for the condition demonstrate that extra-pulmonary tuberculosis can be quickly and accurately diagnosed in various sites using both the T-SPOT assay and the GeneXpert/PCR test. Therefore, this review exemplified the prevalence of extra-pulmonary tuberculosis at various points in women's lives. On the contrary, it also illustrated the symptoms and dangers of TB as they relate to women's health.

Case-controlled study of tuberculosis in in-vitro fertilisation-embryo transfer and natural pregnancy

OBJECTIVE

To improve the understanding of the clinical features and imaging characteristics of pregnant women with and without in-vitro fertilisation-embryo transfer combined with pulmonary tuberculosis (TB).

METHODS

A retrospective analysis was conducted involving 50 patients with pregnancy who had pulmonary TB and were admitted to the Third People's Hospital of Kunming (China) between 1 January 2017 and 31 December 2021. These patients were divided into an in-vitro fertilisation and embryo transfer (IVF-ET) conception group and a natural conception group according to the conception method. The clinical and imaging data were then collected and compared.

RESULTS

The mean age of the IVF-ET group (n = 13, 31.85 ± 5.84 years) was higher than in the natural conception group (n = 37, 27.05 ± 5.5 years). The proportions of fever, haematogenous TB and extrapulmonary TB in the IVF-ET group (92.31%, 84.62% and 76.92%, respectively) were higher than those in the natural conception group (40.54%,16.22%,27.03%,respectively). The percentage of patients with pregnancy who had intracranial TB (76.9%) in the IVF-ET group was higher than in the natural conception group (10.8%). The percentage of pregnancy terminations in the IVF-ET conception group (84.62%) was higher than in the natural conception group (48.65%). All the above results had statistically significant differences (p < 0.05).

CONCLUSION

Overall, IVF-ET conception combined with extensive pulmonary TB lesions lead to heavy systemic toxic symptoms, severe disease and poor pregnancy outcomes. Therefore, screening for TB prior to performing IVF-ET is recommended.

The Effect of Latent Tuberculosis Infection on Ovarian Reserve and Pregnancy Outcomes among Infertile Women Undergoing Intrauterine Insemination: A Retrospective Cohort Study with Propensity Score Matching

Latent tuberculosis infection (LTBI) widely exists in patients with unexplained infertility, and whether LTBI would affect the ovarian reserve and pregnancy outcome of infertile women undergoing intrauterine insemination (IUI) is still unknown. A single-center, retrospective, cohort study was designed that included infertile women undergoing IUI at the Department of Reproductive Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, from January 2018 to December 2020. The primary outcomes of this study were ovarian reserve and live birth rate. Secondary outcomes included pregnancy outcomes and maternal and neonatal complications. As a result, 3066 IUI cycles were eventually enrolled in this study. Of these women, 9.6% (295/3066) had LTBI evidence. After propensity score matching (PSM), there was no significant difference in the baseline between the LTBI and non-LTBI groups. The data showed that women who had LTBI had trends toward lower biochemical pregnancy rates (12.9% vs. 17.7%, p-value 0.068), lower clinical pregnancy rates (10.8% vs. 15.1%, p-value 0.082) and lower live birth rates (8.1% vs. 12.1%, p-value 0.076), with no significant differences. There were also no significant differences in ovarian reserve and other secondary outcomes between the two groups. In conclusion, there were no significant differences in ovarian reserve, perinatal or neonatal complications between women with and without LTBI. Women with LTBI tended to have worse pregnancy outcomes after receiving IUI, but the difference was not significant.

The clinical presentation and detection of tuberculosis during pregnancy and in the postpartum period in low- and middle-income countries: A systematic review and meta-analysis

For women infected with Mycobacterium tuberculosis, pregnancy is associated with an increased risk of developing or worsening TB disease. TB in pregnancy increases the risk of adverse maternal and neonatal outcomes, however the detection of TB in pregnancy is challenging. We aimed to identify and summarise the findings of studies regarding the clinical presentation and diagnosis of TB during pregnancy and the postpartum period (within 6 months of birth) in low-and middle-income countries (LMICs). A systematic review was conducted searching Ovid MEDLINE, Embase, CINAHL and Global Index Medicus databases. We included any primary research study of women diagnosed with TB during pregnancy or the postpartum period in LMICs that described the clinical presentation or method of diagnosis. Meta-analysis was used to determine pooled prevalence of TB clinical features and health outcomes, as well as detection method yield. Eighty-seven studies of 2,965 women from 27 countries were included. 70.4% of women were from South Africa or India and 44.7% were known to be HIV positive. For 1,833 women where TB type was reported, pulmonary TB was most common (79.6%). Most studies did not report the prevalence of presenting clinical features. Where reported, the most common were sputum production (73%) and cough (68%). Having a recent TB contact was found in 45% of women. Only six studies screened for TB using diagnostic testing for asymptomatic antenatal women and included mainly HIV-positive women ‒ 58% of women with bacteriologically confirmed TB did not report symptoms and only two were in HIV-negative women. Chest X-ray had the highest screening yield; 60% abnormal results of 3036 women tested. Screening pregnant women for TB-related symptoms and risk factors is important but detection yields are limited. Chest radiography and bacteriological detection methods can improve this, but procedures for optimal utilisation remain uncertain in this at-risk population. Trial registration: Prospero registration number: CRD42020202493.

Genital tuberculosis, infertility and assisted reproduction

PURPOSE OF REVIEW

The goal of this review is to familiarize a global readership on the subtilities of clinical presentation and the mayhem that a missed diagnosis of genital tuberculosis (GTB) is capable of inflicting on the health and wellbeing of infertile women with untreated GTB attempting to conceive with assisted reproductive technology (ART).

RECENT FINDINGS

Emerging and recent literature relating to the epidemiology and clinical presentation of GTB and reporting of unique risks of ART for maternal and fetal morbidity in untreated cases of GTB are reviewed. Evidence relating to a broadening spectrum of screening methodologies for GTB detection of GTB is additionally considered.

SUMMARY

Genital TB must be considered as a mechanism for couple's infertility in at-risk populations. Attempting to treat female GTB-related infertility with in-vitro fertilization poses unique and potentially life-threatening risks, both to the mother and to the conceptus; these risks can be avoided through vigilance, appropriate screening and timely treatment prior to proceeding with IVF.

Reactivated disseminated tuberculosis in pregnancy: Case report and review of the literature

This case report describes the evaluation and management of a 32-year-old woman who presented shortly after a fetal demise at 23 weeks of gestation with multiple symptoms, including bloody vaginal discharge. Although the initial diagnostic concern was for metastatic malignancy, the patient was ultimately determined to have disseminated tuberculosis. Genital tuberculosis is common worldwide, yet guidelines for evaluation are limited. This report highlights the relationship between pregnancy-reactivated tuberculosis, and guides clinicians on diagnostic and management considerations in the peripartum period.

Tuberculosis in pregnancy

Due to COVID-19 pandemic, the latest progress of the End Tuberculosis (TB) Strategy was far from optimal and services for TB needs to be quickly restored. Pregnancy is a unique opportunity to screen and manage TB, and it is an essential step in TB eradication. Early diagnosis and treatment for active disease can reduce maternal and neonatal morbidities and mortality. The more widespread utilization of newer rapid molecular assays with drug-susceptibility testing has significantly shortened the diagnostic process for active TB disease. First-line anti-TB drugs are proven to be safe in pregnancy. Management of latent TB infection (LTBI) during pregnancy is controversial, but puerperium is a period of increased susceptibility to progress to active disease. Extrapulmonary TB (EPTB), multidrug-resistant TB (MDR-TB) and HIV co-infection remain significant issues surrounding TB management during pregnancy and often require input from a multidisciplinary team including TB experts.

Impact of Positive Interferon-Gamma Release Assay on IVF-ET Pregnancy Outcomes in Infertile Patients With Untreated Prior Tuberculosis: A Prospective Cohort Study

Introduction: Tuberculosis (TB) is a major infectious disease that seriously endangers human health and female reproduction. In our previous study, 10.4% of infertile patients preparing for In vitro fertilization and embryo transfer (IVF-ET) had prior pulmonary TB (PTB) as detected on chest X-ray (CXR) screening. Among them, 81.8% did not receive anti-TB treatment. It remains unclear whether infertile women with untreated prior PTB have latent TB infection (LTBI) and whether LTBI affects IVF-ET outcomes. In this study, we aim to analyze the relationship between LTBI and pregnancy outcomes following IVF-ET in patients with untreated prior PTB.

Methods and Analysis: We designed a prospective cohort study of 1,200 infertile women with CXR findings suggestive of old-healed untreated TB, who are preparing for IVF-ET. Patients with a history of active TB and anti-TB treatment will be excluded. Interferon-gamma release assay (IGRA) will be used in patients with CXR findings suggestive of old-healed untreated TB to construct a cohort of IGRA-positive and IGRA-negative patients. Participants will undergo IVF-ET. General information, including age, body mass index, infertility causes, and controlled ovarian hyperstimulation protocol, will be recorded. Participants will be followed up during pregnancy. The primary outcome is live birth. Secondary outcomes include the numbers of retrieved oocytes, high-quality embryo rate, clinical pregnancy, number of active TB cases during pregnancy, and miscarriage.

Ethics and Dissemination: The study was approved by the Ethics Committee of Peking University Third Hospital [approval number (2020)218-01; approval date: June 19, 2020]. The research results will be disseminated through scientific/medical conferences and published in academic journals.

Trial Registration:ClinicalTrials.gov; identifier: NCT04443283.

Disseminated Hematogenous Tuberculosis Following in vitro Fertilization-Embryo Transfer: A Case Report

This study aimed to analyze the diagnosis and treatment process of patients with hematogenous disseminated pulmonary tuberculosis after treatment with in vitro fertilization-embryo transfer (IVF-ET). We retrospectively analyzed the clinical data, including imaging and etiological data, the use of antimicrobials, metagenomic next-generation sequencing (mNGS) results, and the treatment process, of a patient who underwent IVF-ET due to an obstruction in the fallopian tube; after the treatment, she developed a persistent fever with shortness of breath and suffered a spontaneous abortion. Due to the failure of other treatment modalities, fiber optic bronchoscopy was performed, and the alveolar lavage fluid was obtained for mNGS. Tests for Mycobacterium tuberculosis and rifampicin resistance (Xpert MTB/RIF) showed positive and negative results, respectively. Subsequently, anti-tuberculosis treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol was administered. After the patient's condition improved, she was transferred to a specialized tuberculosis hospital for further treatment, where she died one month later from multiple organ failure. From this case, we conclude that clinicians should remain highly vigilant for pulmonary infection with M. tuberculosis in pregnant women, particularly in patients treated with IVF-ET, and check for its presence as soon as possible.