Tuberculosis during pregnancy. The Rhode Island experience, 1987 to 1991

The cascade of care for pregnant women with latent tuberculosis infection in a high-income country

BACKGROUND

Pregnant women have an increased risk of developing active tuberculosis (TB). The Public Health Agency of Sweden recommends screening of active TB and latent tuberculosis infection (LTBI) among pregnant women from countries with high TB incidence at Maternal Health Care (MHC) clinics. In Östergötland County, Sweden, a screening program has been active since 2013. The aim of this study was to evaluate this screening program and the cascade of care for LTBI among pregnant women in Östergötland county.

METHODS

Data were obtained from pregnant women screened for TB at MHC clinics and subsequently referred to the pulmonary medicine clinic or the clinic of infectious diseases in Östergötland County between 2013 and 2018. The Public Health Agency of Sweden's national database for active TB was used to analyse if any women developed active TB up to two years after the screening process.

RESULTS

A total of 439 women were included. Nine cases of active TB were discovered during the screening process and two developed active TB afterward. 177 women were recommended LTBI treatment and variables significantly associated with a decreased likelihood of being recommended treatment were increasing age, time in Sweden, and parity. 137 women received and 112 (82%) completed treatment. 14 women discontinued treatment due to adverse effects.

CONCLUSION

Screening of pregnant women from countries with high TB incidence at MHC clinics led to the discovery of several cases of active TB. The completion rate of LTBI treatment was high and few discontinued due to adverse effects.

Contribution of Xpert® MTB/RIF to tuberculosis case finding among pregnant women in Botswana

Setting

Seven health facilities with antenatal care (ANC) clinics in two districts near Gaborone, Botswana.

Objectives

To determine 1) the prevalence of tuberculosis (TB) and HIV-TB co-infection in pregnancy, and 2) the sensitivities of symptomatic TB screening and Xpert testing against gold standard culture.

Design

This was a cross-sectional study. Pregnant women were randomly enrolled and screened using TB symptoms. HIV status was determined from ANC clinics' client records. Two sputum specimens were collected from all clients and each was tested using Xpert^® and culture for Mycobacterium tuberculosis.

Results

Of 407 cases, eight had one or more TB symptoms, and all tested negative with Xpert^® and culture. Another two (0.5%, 95%CI 0.08-1.96) asymptomatic clients tested positive with both tests. The adjusted TB prevalence was higher than that of the general population (0.6% vs. 0.24%; P < 0.001). The prevalence of TB among HIV-positive and HIV-negative clients was 1/69 (1.45%, 95%CI 0.29-2.61) and 1/336 (0.3%, 95%CI 0.23-0.83), respectively (Fisher's exact test P = 0.312). Xpert^® demonstrated a 100% sensitivity and 100% specificity, while symptom screening had 0.0% sensitivity and 98% specificity.

Conclusions

TB prevalence among pregnant women was high and TB symptom screening had limited ability to detect TB. An alternative TB screening algorithm for pregnant women is urgently needed irrespective of TB symptoms.

Tuberculosis in Pregnancy

Tuberculosis (TB) in pregnancy poses a substantial risk of morbidity to both the pregnant woman and the fetus if not diagnosed and treated in a timely manner. Assessing the risk of having Mycobacterium tuberculosis infection is essential to determining when further evaluation should occur. Obstetrician-gynecologists are in a unique position to identify individuals with infection and facilitate further evaluation and follow up as needed. A TB evaluation consists of a TB risk assessment, medical history, physical examination, and a symptom screen; a TB test should be performed if indicated by the TB evaluation. If a pregnant woman has signs or symptoms of TB or if the test result for TB infection is positive, active TB disease must be ruled out before delivery, with a chest radiograph and other diagnostics as indicated. If active TB disease is diagnosed, it should be treated; providers must decide when treatment of latent TB infection is most beneficial. Most women will not require latent TB infection treatment while pregnant, but all require close follow up and monitoring. Treatment should be coordinated with the TB control program within the respective jurisdiction and initiated based on the woman's risk factors including social history, comorbidities (particularly human immunodeficiency virus [HIV] infection), and concomitant medications.

Increased risk of active tuberculosis during pregnancy and postpartum: a register-based cohort study in Sweden

Rationale

Studies investigating the risk of active tuberculosis (TB) in association with pregnancy have not been conclusive. We aimed to investigate this risk in a large retrospective register-based cohort study in Sweden.

Methods

Data from women of 15–49 years of age who had given birth in Sweden between 2005 and 2013 were extracted from the national childbirth register and linked to the national TB register. Cohort time was divided into three exposure periods: during pregnancy, six months (180 days) postpartum and time neither pregnant nor postpartum. We calculated incidence rates (IRs) per 100 000 person-years for each period and incidence rate ratios (IRRs) with IRs neither pregnant nor postpartum as the reference.

Results

The cohort included 649 342 women, of whom 553 were registered as cases of active TB, 389 when neither pregnant nor postpartum, 85 during pregnancy and 79 when postpartum. Overall IRs were 9, 12 and 17 cases per 100 000 person-years, respectively, giving IRR 1.4, 95% CI 1.1–1.7 (during pregnancy) and IRR 1.9, 95% CI 1.5–2.5 (when postpartum). Stratification by TB incidence in country of origin showed that the increased risk was concentrated amongst women from countries with a TB incidence of 100 or higher, where IRs per 100 000 person-years were 137 (when neither pregnant nor postpartum), 182 (during pregnancy) and 233 (when postpartum).

Conclusion

We show a significant increase in risk of active TB during both pregnancy and postpartum in women from high incidence countries and recommend TB screening in pregnant women belonging to this risk group.

There is an increased risk of active TB in women during pregnancy and postpartum. We recommend screening for latent TB in pregnant women from TB risk groups and for clinicians to use a low threshold for suspecting active TB in pregnancy and postpartumhttp://bit.ly/34pqXT8

Low Prevalence of Active Tuberculosis among High-Risk Pregnant and Postpartum Women in Sweden: A Retrospective Epidemiological Cohort Study Using and Evaluating TST as Screening Method

Objective

Studies on the prevalence of active tuberculosis (TB) and latent tuberculosis infection (LTBI) among high-risk pregnant and postpartum women are few and prevalence is not well known. The methods used for diagnosing and treating TB and LTBI also differ both within and between countries. The aim of the study was to investigate the prevalence of TB and LTBI among high-risk pregnant and postpartum women in a Western Region of Sweden using tuberculin skin test (TST) as screening method. Secondary aims were to evaluate the effectiveness of the screening method and possible negative labour and neonatal outcomes among TST-positive women.

Methods

Pregnant women attending an antenatal care unit (ACU) allocated for TST screening were investigated and followed up for two years postpartum.

Results

Only one woman out of 902 screened women in the study group was diagnosed with active TB because of TB symptoms and not because of positive TST. 36% of the skin-tested women fulfilled criteria for LTBI. No difference in perinatal outcome was found between women with and without positive TST.

Conclusions

Our findings suggest that TST screening of high-risk women may not be an effective strategy, since the prevalence of active TB is low. Investigating pregnant and postpartum women with TB symptoms instead of TST for screening could be an option in low TB prevalence areas. The criteria for diagnosing and treating LTBI should be clearly stated.

Tuberculosis and Pregnancy-Maternal, Fetal, and Neonatal Considerations

The issue of tuberculosis during pregnancy is not simply a historical inquiry but rather an increasingly familiar clinical problem facing industrial nations as well as the developing countries of the world. This review focuses on the maternal aspects of tuberculous infection, as well as transmission to the fetus and newborn.

Risk of Adverse Infant Outcomes Associated with Maternal Tuberculosis in a Low Burden Setting: A Population-Based Retrospective Cohort Study

Background. Maternal tuberculosis (TB) may be associated with increased risk of adverse infant outcomes. Study Design. We examined the risk of low birth weight (LBW), small for gestational age (SGA), and preterm birth (<37 weeks) associated with maternal TB in a retrospective population-based Washington State cohort using linked infant birth certificate and maternal delivery hospitalization discharge records. We identified 134 women with births between 1987 and 2012 with TB-associated ICD-9 diagnosis codes at hospital delivery discharge and 536 randomly selected women without TB, frequency matched 4 : 1 on delivery year. Multinomial logistic regression analyses were performed to compare the risk of LBW, SGA, and preterm birth between infants born to mothers with and without TB. Results. Infants born to women with TB were 3.74 (aRR 95% CI 1.40–10.00) times as likely to be LBW and 1.96 (aRR 95% CI 0.91–4.22) as likely to be SGA compared to infants born to mothers without TB. Risk of prematurity was similar (aRR 1.01 95% CI 0.39–2.58). Conclusion. Maternal TB is associated with poor infant outcomes even in a low burden setting. A better understanding of the adverse infant outcomes associated with maternal TB, reflecting recent trends in US TB epidemiology, may inform potential targeted interventions in other low prevalence settings.

Respiratory disease in pregnancy

Many physiological and anatomical changes of pregnancy affect the respiratory system. These changes often affect the presentation and management of the various respiratory illnesses in pregnancy. This article focuses on several important respiratory issues in pregnancy. The management of asthma, one of the most common chronic illnesses in pregnancy, remains largely unchanged compared to the nonpregnant state. Infectious respiratory illness, including pneumonia and tuberculosis, are similarly managed in pregnancy with antibiotics, although special attention may be needed for antibiotic choices with more pregnancy safety data. When mechanical ventilation is necessary, consideration should be given to the maternal hemodynamics of pregnancy and fetal oxygenation. Maintaining maternal oxygen saturation above 95% is recommended to sustain optimal fetal oxygenation. Cigarette smoking has known risks in pregnancy, and current practice guidelines recommend offering cognitive and pharmacologic interventions to pregnant women to assist in smoking cessation.

Tuberculosis care for pregnant women: a systematic review

Background

Tuberculosis (TB) during pregnancy may lead to severe consequences affecting both mother and child. Prenatal care could be a very good opportunity for TB care, especially for women who have limited access to health services. The aim of this review was to gather and evaluate studies on TB care for pregnant women.

Methods

We used a combination of the terms “tuberculosis” and “pregnancy”, limited to human, to search for published articles. Studies reflecting original data and focusing on TB care for pregnant women were included. All references retrieved were collected using the Reference Manager software (Version 11).

Results

Thirty five studies were selected for review and their data showed that diagnosis was often delayed because TB symptoms during pregnancy were not typical. TB prophylaxis and anti-TB therapy appeared to be safe and effective for pregnant women and their babies when suitable follow up and early initiation were present, but the compliance rate to TB prophylaxis is still low due to lack of follow up and referral services. TB care practices in the reviewed studies were in line in principle with the WHO International Standards for Tuberculosis Care (ISTC).

Conclusions

Integration of TB care within prenatal care would improve TB diagnosis and treatment for pregnant women. To improve the quality of TB care, it is necessary to develop national level guidelines based on the ISTC with detailed guidelines for pregnant women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0617-x) contains supplementary material, which is available to authorized users.

Tuberculosis in pregnancy: the challenges for South Asian countries

AIM

Despite tuberculosis (TB) being a global problem, maternal TB remains an unrecognized and underestimated tragedy, especially in South Asian countries. Therefore, we performed a non-systematic review regarding implications of maternal TB on obstetric and perinatal outcomes in the South Asian context.

MATERIAL AND METHODS

We reviewed original studies, both descriptive and analytical, that originated from South Asian countries following an electronic search supplemented by a manual search. Although relevant studies from developed countries were reviewed, they were not included in the tabulation process because those studies had different socioeconomic/epidemiological background.

RESULTS

Diagnosis of TB is often delayed during pregnancy, because of its non-specific symptoms, and overlapping presentation with other infectious diseases. Poverty, undernutrition, lack of social support and poor health infrastructure along with complications of TB and need for prolonged medications lead to increased maternal morbidity and mortality. Maternal TB in general (except lymphadenitis), is associated with an increased risk of small-for-gestational age, preterm and low-birthweight neonates, and high perinatal mortality. These adverse perinatal outcomes are even more pronounced in women with advanced disease, late diagnosis, and incomplete or irregular drug treatment. There could be a synergy of TB, socioeconomic and nutritional factors, which might have contributed to adverse perinatal effects, especially in low-income countries.

CONCLUSIONS

As active TB poses grave maternal and perinatal risks, early, appropriate and adequate anti-TB treatment is a mainstay for successful pregnancy outcome. The current knowledge gaps in perinatal implications of maternal TB can be addressed by a multicenter comparative cohort study.

Infantile pulmonary tuberculosis: the great mimic

PURPOSE

Infantile tuberculosis is common in developing countries and rarely presents as space occupying thoracic lesions mimicking congenital malformations. This case series reviews four such infants with varied presentations and their outcome.

METHODS

Four cases of infantile pulmonary/mediastinal tuberculosis that presented like congenital thoracic lesions are described. Details of demography, symptomatology, contact history, immunization status, provisional diagnosis, tuberculin testing, imaging, histopathology, final diagnosis, management and outcome were retrospectively collated and analyzed.

RESULTS

They were 4-6-month males, term-born and immunized. They presented with pneumonia/hyperactive airway disease since 2-12 weeks. One had a suspect and another a close tuberculous contact. The provisional diagnosis after imaging were infected congenital lung cyst, posterior mediastinal cyst and bronchopulmonary malformation. Two were tuberculin positive; none had gastric acid-fast bacilli. One underwent a pulmonary lobectomy for necrotic lung cyst; the second had a biopsy and drainage of a posterior mediastinal cyst that contained caseating material and was densely adherent to the esophagus. Surgical biopsy showed necrotizing granulomatous inflammation in both; one with acid-fast bacilli. Both succumbed to postoperative complications. The other two with tuberculous contacts who were managed with early antituberculous therapy, responded well and recovered uneventfully.

CONCLUSIONS

Infantile pulmonary/mediastinal tuberculosis may mimic congenital thoracic malformations. A review of contact history, investigations and imaging help to establish the tuberculous etiology, avoids surgical misadventures and prompts early antituberculous therapy to achieve a favorable outcome.

Tuberculosis in pregnancy: a review

Tuberculosis (TB) was declared a public health emergency by WHO in 2005. The disease is a significant contributor to maternal mortality and is among the three leading causes of death among women aged 15-45 years in high burden areas. The exact incidence of tuberculosis in pregnancy, though not readily available, is expected to be as high as in the general population. Diagnosis of tuberculosis in pregnancy may be challenging, as the symptoms may initially be ascribed to the pregnancy, and the normal weight gain in pregnancy may temporarily mask the associated weight loss. Obstetric complications of TB include spontaneous abortion, small for date uterus, preterm labour, low birth weight, and increased neonatal mortality. Congenital TB though rare, is associated with high perinatal mortality. Rifampicin, INH and Ethambutol are the first line drugs while Pyrazinamide use in pregnancy is gaining popularity. Isoniazid preventive therapy is a WHO innovation aimed at reducing the infection in HIV positive pregnant women. Babies born to this mother should be commenced on INH prophylaxis for six months, after which they are vaccinated with BCG if they test negative. Successful control of TB demands improved living conditions, public enlightenment, primary prevention of HIV/AIDS and BCG vaccination.

The use of anti-tuberculosis therapy for latent TB infection

Tuberculosis infection is of global public health significance, with millions of incident cases each year. Many cases, particularly in low-prevalence settings, result from the reactivation of latent tuberculosis infection (LTBI); potentially acquired years prior to active disease. Up to one-third of the world’s population has been infected with LTBI, and so may be at risk for future active TB disease. A variety of antituberculosis medications and treatment regimens have now been evaluated in the management of LTBI, with the aim of eradicating tuberculosis bacilli and reducing the likelihood of subsequent reactivation disease. This article reviews LTBI therapies and their use in clinical contexts, and considers future directions for individual and population-based strategies in LTBI management.

Saudi guidelines for testing and treatment of latent tuberculosis infection

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection (LTBI) who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI.

Perinatal tuberculosis: new challenges in the diagnosis and treatment of tuberculosis in infants and the newborn

With increasing rates of tuberculosis (TB) infection and disease worldwide, the rate of perinatal TB is also affected. A high index of suspicion by health professionals, in both the developed and developing world, is required to detect and manage tuberculosis in pregnancy and the early newborn period. Differences in immune responses in the fetus and neonate add to the diagnostic difficulties already recognised in young children. Although specific guidelines for the treatment of this potentially devastating disease are lacking due to paucity of experience, outcome is favourable, if the condition is recognised and treated according to existing TB protocols. HIV co-infection, multi- and extensively-drug resistant (MDR/XDR) TB contribute to the challenges. New diagnostic and vaccine developments hold future promise, but much work is needed to completely understand the complex immune responses to tuberculosis and control this disease.

Congenital infections associated with international travel during pregnancy

With the overall increase in international travel, there is likely to be an increase in travel during pregnancy as well. In developing countries, pregnant women face exposures that can add significant risk for neonatal morbidity and mortality. Infections that can occur in utero or in the early neonatal period include malaria, yellow fever, tuberculosis, hepatitis, human immunodeficiency virus, leishmaniasis, toxoplasmosis, filariasis, Japanese encephalitis, rubella, typhoid fever, leptospirosis, dengue fever, Helicobacter pylori, and trypanosomiasis. When travel and potential exposure cannot be avoided, preventive measures are usually effective. Pretravel consultation should include careful discussion of length of travel, antimalarial prophylaxis, insect avoidance, food and water hygiene, vaccination, and body fluid precautions.

High rates of clinical and subclinical tuberculosis among HIV-infected ambulatory subjects in Tanzania

BACKGROUND

We sought to determine the prevalence of active tuberculosis among ambulatory HIV-infected persons in Tanzania with CD4 cell counts of > or =200 cells/mm3 and a bacille Calmette-Guerin vaccination scar.

METHODS

Subjects who volunteered for a tuberculosis booster vaccine trial were screened for active tuberculosis by obtainment of a history, physical examination, chest radiography, sputum culture and acid fast bacillus (AFB) stain, and blood culture. All subjects underwent a tuberculin skin test (TST) and lymphocyte proliferation assays (LPAs) for detection of responses to mycobacterial antigens.

RESULTS

Active tuberculosis was identified at baseline in 14 (15%) of the first 93 subjects who were enrolled: 10 (71%) had clinical tuberculosis (symptoms or chest radiograph findings), and 4 (29%) had subclinical tuberculosis (positive sputum AFB stain or culture results but no symptoms or chest radiograph findings). An additional 6 subjects with subclinical tuberculosis were identified subsequently. The 10 subjects with subclinical tuberculosis included 3 with positive sputum AFB stains results and 7 who were only identified by a positive sputum culture result. Compared with subjects who did not have tuberculosis, the 10 subjects with subclinical tuberculosis were more likely to have peripheral lymphadenopathy, positive TST results, and elevated LPA responses to early secreted antigenic target-6 (ESAT). Eight of 10 patients had received isoniazid because of a positive TST result before active tuberculosis was recognized.

CONCLUSIONS

Clinical and subclinical tuberculosis are common among ambulatory HIV-infected persons, and some cases can only be identified by sputum culture. World Health Organization guidelines for screening for latent tuberculosis before treatment do not recommend sputum culture and, therefore, may fail to identify a substantial number of HIV-infected persons with subclinical, active tuberculosis.

Peripartum tuberculosis as a form of immunorestitution disease

The aim of this study was to assess the clinical spectrum of peripartum tuberculosis from the perspective of immunorestitution disease. Of 29 patients with peripartum tuberculosis, 27 (93.1%) had extrapulmonary tuberculosis, 20 (69%) of whom were affected in the central nervous system. Twenty-two (75.9%) patients had no clinical features suggestive of tuberculosis during pregnancy. The median time from delivery to the onset of immunorestitution was 4 days, but treatment with anti-tuberculous therapy was delayed for a median time of 27 days after the onset of symptoms. Despite therapy, 11 (38%) patients died and 4 (13.8%) had residual functional deficits. Peripartum tuberculosis is an important differential diagnosis of postpartum fever (of unknown origin) without localized signs.

Congenital tuberculosis: a rare manifestation of a common infection

The epidemiology of tuberculosis has changed dramatically over the past 5 years with significant shifts in at-risk populations, resulting in increased disease among young adults and children, especially among those from developing countries. Congenital tuberculosis is rare, and the clinical presentation of tuberculosis during pregnancy and infancy is often non-specific, making recognition difficult. Advances have been made with diagnostic tools, in public health practices, and with treatment recommendations. Controversy and debate continue regarding the safety and use of isoniazid for latent tuberculosis infection during pregnancy. New vaccine development may be promising for the future, but much work is needed to understand the complicated immune response to tuberculosis.

[Pregnancy, tuberculosis and inappropriate antidiuretic hormone secretion]

We report a pregnant woman presenting with seizure secondary to hyponatremia by inappropriate antidiuretic hormone secretion. Aetiology was unknown urinary and lung tuberculosis. This case report presents diagnosis strategy of inappropriate antidiuretic hormone secretion and the arguments for its aetiology.

Drugs in pregnancy. Respiratory disease

Respiratory illnesses are the commonest cause of patient visits to physicians. Although the common cold, sinusitis and bronchitis may be lacking in drama, they account for a substantial amount of morbidity among women of reproductive age and are frequently encountered by physicians caring for pregnant women. Present knowledge about the management of these common conditions and the safety of the medications often used to treat them are reviewed in this chapter. Asthma and community-acquired pneumonia are more serious respiratory illnesses that are also often encountered in pregnancy. Present evidence suggests that community-acquired pneumonia is best treated empirically, with additional investigation usually necessary only if there is a failure of initial treatment. The recognition of asthma as an inflammatory condition has led to a very specific approach to its management that can readily and safely be applied to the pregnant woman. Treatment of HIV and tuberculosis should not be withheld during pregnancy because of the life-threatening nature of these infections and the importance of preventing vertical transmission.

Current issues in maternal and perinatal tuberculosis: impact of the HIV-1 epidemic

Human immunodeficiency virus type 1 (HIV-1) and tuberculosis (TB) are among the leading causes of disability and death in the developing world, the largest burden borne by sub-Saharan Africa and Asia. Both diseases are significant among women of childbearing age, and TB, although uncommon in pregnancy, is on the increase. While earlier reports were contradictory regarding the effect of TB on the course of pregnancy and vice versa, the negative impacts of each on the other have been documented, some in relation to HIV-1 co-infection. This review focuses on emerging data on maternal and perinatal TB within the context of HIV-1 infection.

Tuberculosis diagnosed during pregnancy: a prospective study from London

BACKGROUND

A study was undertaken to characterise the presentation of tuberculosis in pregnancy and the difficulties in diagnosis in an area of the UK with a high incidence of tuberculosis.

METHODS

A prospective case series was investigated at Northwick Park Hospital, a university affiliated district general hospital in Brent and Harrow health authority in north-west London which incorporates a regional infectious diseases unit. Patients diagnosed with tuberculosis over the study period were included if the onset of symptoms occurred during pregnancy.

RESULTS

Thirteen patients were diagnosed during a 30 month period from December 1995 to May 1998 during which 9069 mothers were delivered, a prevalence of 143.3/100 000 deliveries. Symptoms began at a median of 22 weeks gestation (range 9-40 weeks). All patients were recent immigrants of Indian subcontinent or Somali origin and their median duration of residence in the UK was 31 months (range 1-72). Prevalence broken down for racial origin of mothers was 466.3/100 000 for mothers of black African origin and 239.1/100 000 for mothers of Indian origin. Nine of the 13 patients had extrapulmonary tuberculosis. Four patients with widely disseminated disease had a negative Mantoux response and five with localised disease had a strongly positive Mantoux response. HIV co-infection was absent. The median delay between the onset of symptoms and diagnosis was seven weeks (range 2-30). The response to standard treatment was excellent and all patients were cured.

CONCLUSIONS

Tuberculosis occurring in pregnancy is common in recent immigrants. Diagnosis during pregnancy is delayed because the disease is frequently extrapulmonary with few symptoms.

Medical problems during pregnancy

Dramatic physiologic changes are part of normal human pregnancy. The physiologic alterations of pregnancy have the potential to affect chronic diseases, to unmask subclinical conditions, or to alter the presentation and course of newly acquired illnesses. An update in selected topics of obstetric medicine follows, focusing on clinical entities in which there have been significant advances in diagnosis or management. Additionally, reviews of selected medical disorders, such as HIV infection and asthma, that are rising in incidence in women of reproductive age are included.

Tuberculosis in pregnancy

Tuberculosis has re-emerged as a serious health problem throughout the world. In the United States, the human immunodeficiency virus epidemic, increased numbers of foreigners from areas where tuberculosis is endemic, and lack of an adequate infrastructure to deal with the large increase of new cases have led to tuberculosis being a serious problem. Because of the long treatment time required, there is a significant risk of developing drug resistance in partially treated patients. Directly observed therapy is a cornerstone of treatment in both pregnant and nonpregnant patients. We need to think about those at risk for tuberculosis in pregnancy and screen the high-risk population. With the advent of satisfactory drugs to treat tuberculosis, the effects on pregnancy are not as serious as before. However, particularly in low socioeconomic populations, tuberculosis probably increases the prematurity and abortion rate.

Preconception counseling for the primary care physician

All health care providers that interact with women of childbearing age should understand the potential benefits of preconception counseling and to approach the evaluation in a thorough manner during routine health maintenance visits. With the increased number of patients enrolled in managed care programs, health maintenance visits provide the unique opportunity to educate women contemplating pregnancy regarding the potential influences of their lifestyle and health status on the future pregnancy. It is becoming increasingly apparent that interventions made during the preconception period are just as crucial as the subsequent 9 months of prenatal care to achieve an optimal maternal-fetal outcome. Some guidelines for the preconception evaluation have been provided, and the implications of chronic medical illness on pregnancy have been discussed.