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Sir,

Tuberculosis, a global public health threat, poses enormous challenges to pregnant women. The UK nationwide survey by Knight et al1 serves as a timely wake-up call for both obstetricians and public health authorities. As approximately one-fourth of all cases of tuberculosis in the UK (Health Protection Agency 2008) are seen in non-immigrant population, it is surprising that only one case of tuberculosis has been identified in this group during pregnancy. The article also showed an equal distribution of tuberculosis at pulmonary and extrapulmonary sites, which does not conform to the usual predominance of pulmonary tuberculosis in the developing countries, from where the recently immigrant women came. Furthermore, difficulties in confirming extrapulmonary tuberculosis during pregnancy2 together with a lack of evidence to suggest that pregnant women are more prone to develop tuberculosis at the sites other than the lungs, support the possibility that many cases of tuberculosis, especially the less severe forms of pulmonary tuberculosis, were missed in this study. In addition, the tuberculin test, a standard screening method was performed only in 12.5% (4 of 32) women; this raises concerns about the adequacy of current screening. All these factors have major implications for the screening/diagnosis of tuberculosis in pregnancy. Therefore, the authors’ statement that ‘the patterns of disease observed in the women we have identified are likely to be representative of the population as whole’—is debatable.

Knight et al.1 concluded that ‘non-specific symptoms’ and ‘atypical presentation’ should prompt the diagnosis of tuberculosis in women, ‘especially recently arrived immigrants. But as clinicians, we would like to know the spectrum of symptoms and signs that prompted the obstetricians to consider tuberculosis in the first place, and how they proceeded with further diagnostic tests (microbiological tests, imaging studies and fine-needle biopsy etc.), especially in extrapulmonary cases. As universal screening for tuberculosis in pregnancy is not performed in most countries, a clear understanding of the clinical presentation would help the obstetricians make an early diagnosis, a vital factor in reducing the maternal and perinatal complications of tuberculosis.2–4 Furthermore, information regarding exact distribution of extrapulmonary tuberculosis in the current study would be of interest.

Although tuberculosis often affects women of reproductive age, very little is known regarding its effect on obstetrical outcomes. Only a few comparative studies with adequate controls are available,2–4 and these clearly suggest that tuberculosis at both pulmonary and extrapulmonary sites (except tuberculous lymphadenitis) are associated with a substantial increase in maternal and perinatal morbidity and mortality. The current study also showed suboptimal perinatal outcomes—a high rate of preterm delivery (33%), severe neonatal morbidity (6.2%) and perinatal death (3.1%).1 Furthermore, the overall risk of severe maternal morbidity (9.3%) and case fatality (3.1%)—all with extrapulmonary disease—was alarming. Contrary to these findings, the authors summarised, ‘the prognosis for both women and infants is good.’1 In our opinion, some descriptive studies—including the current one—underestimate the perinatal implications of tuberculosis particularly issues such as the high rate of fetal growth restriction, prematurity and perinatal deaths.2–4 Although this cohort is small,1 the composite outcome of the study reiterates earlier findings that tuberculosis in pregnancy remains a potential danger for both the mothers and their infants,2–4 and for this timely warning, we thank the authors.

References

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  2. References
  • 1
    Knight M, Kurinczuk JJ, Nelson-Piercy C, Spark P, Brocklehurst P, On Behalf of UKOSS. Tuberculosis in pregnancy in the UK. BJOG 2009;116:3848.
  • 2
    Jana N, Vasishta K, Saha SC, Ghosh K. Obstetrical outcome among women with extrapulmonary tuberculosis. N Eng J Med 1999;341:6459.
  • 3
    Jana N, Vasishta K, Jindal SK, Khunnu B, Ghosh K. Perinatal outcome in pregnancies complicated by pulmonary tuberculosis. Int J Gynecol Obstet 1994;44:11924.
  • 4
    Figueroa-Damián R, Arredondo-García JL. Neonatal outcome of children born to women with tuberculosis. Arch Med Res 2001;32:669.