PULMONARY TUBERCULOSIS IN PREGNANCY

Pulmonary tuberculosis complicates 1-2 percent of pregnancies in the country. The tubercular lesions in the lung may be active or quiescent.

Effects of pregnancy on Tuberculosis: It was considered in the past that pregnancy is harmful to the tubercular lesion. It is now established that pregnancy, if properly managed, generally do no harmful effect on the course of pulmonary tuberculosis.

Effect of Pulmonary Tuberculosis on Pregnancy: In active but acute febrile cases, there are chances of premature labor and intra-uterine foetal death. In less acute and quiescent cases, no effect on pregnancy is observed. The foetus practically escapes the infection in utero.

Management of Pulmonary Tuberculosis in Pregnancy:

1. Early diagnosis of the pulmonary lesion is very important. A suspected case must have skiagram of the chest, although mass radiography of the chest of all pregnant women by a full size film and lead apron on the abdomen should be the ideal. Skiagram is taken during 12-24 weeks of pregnancy.

2. Active treatment of all forms can be generally performed during the pregnancy. Antitubercular drugs are employed without much fear of their effects on the foetus. Initial treatment for the first three months – Inj. streptomycin 1gm. i.m. daily for 30 days and then thrice weekly; isoniazid 100mg. thrice daily and PAS 5mg. or Ethambutol 400mg. twice daily are orally given.

MANAGEMENT OF HEART DISEASE DURING PREGNANCY

1. The patient has to come under antenatal care in the early months of pregnancy; closer antenatal supervision is needed. A cardiologist is required to be consulted for the cardiac condition.

2. She should be advised to live within the limits of her cardiac reserve; she should work to an extent that will not make her short-of-breath. More rest should be advised as pregnancy advances with the provision of home-help and transport to and from the hospital.

3. The health of the patient has to be improved by correcting anaemia.

4. Bowel should be regularly opened by mild laxative, if necessary.

5. Exposure to cold and infection should be avoided as respiratory tract infection can precipitate cardiac failure. Oral tab. Fenocin forte (phenoxymethyl penicillin) 130mg (Pfizer Limited) one tab. twice daily or Inj. Penidure LA 12 (benzathine penicillin), Wyeth, every fortnightly as directed by the cardiologist needs to be continued throughout the pregnancy; and also puerperium for prophylaxis against recurrence of rheumatic fever.

She should be admitted in a hospital; for that, admission should be made about a fortnight before term in Grade 1 cases. For Grade 11 cases, she is advised to have antenatal rest by hospital admission at about the 28^th week of pregnancy when the strain on heart seems to be the highest in pregnancy. Grade 111 cases are admitted without delay to improve cardiac deterioration. In Grade 1V cases, if pregnancy is allowed to continue, patient has to be kept in a hospital throughout the pregnancy. In general, she is expected to improve during last weeks of the pregnancy.

CAUSES OF DEATH IN PREGNANCY WITH HEART DISEASE

Cardiac failure – This is the commonest cause of death. Two types of cardiac failures can occur viz. (i) pulmonary oedema due to left atrial failure, and (ii) congestive failure due to failure of right ventricle. Pulmonary oedema appears with sudden dyspnoesa, cough, expectoration of frothy suptum and even haemoptysis. This is caused by obstruction of tight mitral ring in mitral stenosis; on skiagram, heart often shows normal or slightly enlarged. No severe right ventricular hypertrophy is shown on E.C.G. Acute pulmonary oedema is likely to develop when there are tachycardia as in emotion, exertion and also sudden increase of venous return to the heart following labor. In congestive failure, there appears dyspnoea more insidiously, with evidences of right ventricular failure. The cardiac lesions are those of enlarged heart (more due to right ventricular enlargement), mitral valvular lesions (stenosis with incompetence) and often by atrial fibrillation. This type of failure develops during pregnancy or in labor or after the delivery. The incidence of pulmonary oedema is less frequent than congestive failure but the former is more fatal. Cardiac failures account for about three quarter of all deaths commonly occurring after the delivery; undelivered women commonly die of cardiac failure during 28-32 weeks of pregnancy.

TYPES OF CARDIAC RESPONSES TO PHYSICAL ACTIVITIES - IN A PREGNANCY WITH HEART-DISEASE

Grade l - Patient suffering from organic heart disease is able to carry out normal active life without discomfort.

Grade ll - Patient with organic heart disease experiences discomfort (breathlessness, exhaustion) on ordinary physical activitities.

Grade lll – Patient with organic heart disease experiences discomfort even after minimal activities.

Grade lV - Patient with organic heart disease is unable to carry out any physical activity without breathlessness. She may be breathless even at rest.

The classification is based on subjective symptoms and does not relate to the degree of cardiac lesion. Grading is made at the time of examination of the patient. There is a possibility of change over of a patient from one grade to another during pregnancy. This functional assessment of the patient is made on her history of daily routine work, and therefrom her ability to go through the strains of pregnancy and labor can be assessed in anticipation. However in assessment, objective signs are also carefully elicited.

EFFECTS OF PREGNANCY ON HEART (CARDIO-VASCULAR PHYSIOLOGY)

During pregnancy, due to the increased blood volume and increased cardiac output, weight carrying for the foetus, compression of the bases of lungs and the axial rotation of the heart to the left (during late pregnancy), the “reserve force” of the heart is called on but heart lives well within the limits of the myocardial reserve. The increased work of heart in the third month of pregnancy, remains so throughout the pregnancy. The maximum work may be as high as 30 to 40 percent above the non-pregnant level as cardiac output increases in the same proportion. Heart’s increased work continues upto 36 weeks. Thereafter load on heart lessens as term approaches. A few suggestions are given for the rise and fall in cardiac output during pregnancy. The placenta behaves as modified arteriovenous fistula with decreased total peripheral resistance during second trimester with a progressive normal return towards the term; hence there is a variation in the cardiac output. Another explanation is that, increased blood volume during early last trimester of pregnancy causes increased cardiac output. During last month of the pregnancy, there happens pooling of blood in the lower limbs and vena caval compression by the gravid uterus in supine posture of the woman; hence there is fall in the cardiac output due to decreased venous return to the heart.

During labor contractions, heart has to work more as cardiac output increases by about 40 percent. Strain of second stage of labor becomes highest. Immediately after the delivery, cardiac output increases abruptly by about 30 per cent as some additional amount of blood is thrown into circulation from the contracted uterus and also the pressure of gravid uterus on great veins has been released. Cardiac output returns to pre-pregnancy level towards the end of the first week after delivery.

Cardiac changes in a normal pregnancy can simulate the manifestations of a cardiac disease. In a normal pregnancy, dyspnoea on exertion appears in about 60 percent; palpitation of apex of the heart is a common occurrence; splitting of loud first sound, appearance of a third sound at the base of the heart mimic manifestations for a cardiac disease. Moreover on skiagram, cardiac shadow appears enlarged.