Leprosy & Pregnancy: Presented By:-Bhawna Joshi MSC. 1 Yeae

LEPROSY &
PREGNANCY
PRESENTED BY:-
Definition of leprosy

• A chronic infectious disease caused by a
mycobacterium (Mycobacterium leprae)
affecting especially the skin and peripheral
nerves and characterized by the formation of
nodules or macules that enlarge and spread
accompanied by loss of sensation with eventual
paralysis, wasting of muscle, and production of
deformities.
Course of leprosy in pregnancy
• It depends upon the changes occurring in a pregnant lady
1. Metabolic changes:
Due to several metabolical changes occurring during pregnancy , there
occurs a state of relative & absolute malnutrition ( deficiency of proteins,
vitamins, iron & other minerals)
Cell mediated immunity gets depressed
Worsening of leprosy
2. Altered secretion of steroids:
levels of free cortisol & 17- hydroxycorticosteroid increases during pregnancy
Reduced cell mediated immunity
Exacerbation of leprosy, TB
3. Altered immunological response:
Humoral immunity Cell mediated

immunity
Pregnancy increased depressed
Post Partum depressed Increased

IMPACT OF LEPROSY
1. Fetus:
• Only few obstetric complications have been consistently reported in women
with leprosy
• Babies born to mothers with LL hansen’s weigh significantly less at birth than
babies born to mothers with tuberculoid leprosy & normal healthy controls
• This may be due to fetoplacental inadequacy in women with LL hansen’s
2. placenta:
• Though the morphology & immunohistology of placenta is normal, the
placental weight & placental coefficient ( ratio of baby weight to placental
weight) is lower in women with leprosy ( more marked in LL hansen’s )
3. Infants, childhood, adolescence:
• 80% of babies born to LL mothers have been found to be severely
underweighted
• Infants born to LL mothers have a higher incidence of respiratory
problems
• Newborns of mothers on MDT may present with intercurrent disease such as
exfoliative dermatitis in first hours of life (due to dapsone) & brownish
discoloration (due to clofazimine)
Drug Therapy of leprosy
during pregnancy
• Drugs are best avoided in pregnancy, but the benefits of treating leprosy
during pregnancy far outweighs the risks of the drugs.
• WHO recommends that pregnant women with leprosy should continue to
take the standard MDT
• Drugs which can be administered are dapsone, rifampicin, clofazimine,
corticosteroids, NSAID’S for reactions
• Drugs which are avoided are quinolones, minocycline, thalidomide
Side effects of drugs on fetus
1. Dapsone - hemolytic anemia, hyperbilirubinemia
2. Rifampicin - hemorrhagic disease of new born ( parenteral vit K)
3. Clofazimine – fetal discoloration, sometimes death ( perinatal center)
4. Quinolones – arthropathies , osteochondrosis
5. Corticosteroids – risk of oral clefts ( avoid in 1st trimester)
6. NSAID’S – premature closure of ductus arteriosus , renal adverse effects,
premature birth ( avoid in 3rd trimester )
7. Thalidomide – phocomelia
MANAGEMENT
• The patient should be counseled to complete the course of ALT during
pregnancy & emphasize on the safety of these drugs
• She should be counseled about the possibility of reactions during
pregnancy
& lactation and advise them to take medical help immediately
• If possible, the patients on ALT during pregnancy should be managed at a
perinatal center with adequate neonatal care facilities
MDT DRUGS
• The drugs used in MDT are a combination of Rifampicin, clofazimine, and
dapsone for MB patients.
• A combination of rifampicin and dapsone is used for PB patients.
MB-MDT regimen
Monthly treatment : day 1
• Rifampicin 600mg
• Clofazimine 300mg
• Dapsone 100mg
Daily treatment : day 2 to 28
• Clofazimine 50mg
• Dapsone 100mg
Duration of treatment :12 blister packs to be taken monthly within a maximum period
of 18 months
Introduction
 Pulmonary tuberculosis is an infectious disease of the lungs

caused by acid fast bacilli (AFB) known as
mycobacterium tuberculosis characterized by low grade
fever, loss of weight, chronic cough, etc.
 The bacteria gets into the lungs through inhaled air
contaminated by the sputum of positive cases.
 About 45% of total population is infected by TB of which
60% is adult.
Definition
• An infectious disease caused by bacteria that mainly
attack the lungs. The disease is characterized by the
formation of patches, called tubercles, that appear in
the lungs and, in later stages, the bones, joints, and
other parts of the body.
Incidence
 The incidence ranges between 1-2% amongst the hospital
deliveries.
 Infact in 1993, WHO pronounced tuberculosis “a global health
emergency”.
 In 2000, WHO showed the emergence of multidrug resistant
tuberculosis (MDR-TB) all over the world.
Causative agents:
Mycobacterium Tuberculosis(Human type)

Mycobacterium Tuberculosis(Bovine type)
Predisposing factors
Positive family history or past history.

Low socio-economic status.
Area of high prevalence of tuberculosis.
HIV infection.
Alcohol addiction.
Intravenous drug abuse.
Clinical features:
Evening pyrexia(low grade fever)

Loss of weight
Night sweating/Sleep sweats
Chronic fatigue
Loss of appetite, pale and ill looking
Chronic cough
Malaise
Haemoptysis
Breathlessness
Diagnostic evaluation:
 Positive family history

 Clinical features
 X-ray examinations(after 12 weeks)
 Early morning Sputum for AFB examination
 Diagnostic bronchoscopy
 Gastric washing
Cont..
Tuberculin skin test with purified protein

derivates(PPD) montox test when ≥10 mm is
considered positive esp. in presence of risk factors.
Extra-pulmonary sites; lymph nodes, bones (rare
in pregnancy)
Direct amplification test to detect Mycobacterium
tuberculosis.
Effect on pregnancy
MOTHER:
 Pregnant women with untreated TB are more likely to have pre- eclampsia,
spontaneous abortion, preterm labour, difficult labour and PPH.
 Intrauterine fetal death.
 Anemia
FETUS:
 Under weight infant
 Low apgar score
 Perinatal death
 IUGR
 Preterm labour.
• New born baby is at risk of postnatally acquired TB if mother has still TB at the time
of birth.
Effect of pregnancy on TB:
• Higher risk of relapse in the puerperium. This may be due

to the disturbed nights, increased work and anxiety for
care of a new born .

Prevention
 The BCG vaccine has been incorporated into the National
immunization policy of many countries, especially the high
burden countries, thereby conferring active immunity from
childhood.
 Non-immune women travelling to tuberculosis endemic
countries should also be vaccinated. It must, however, be noted
that the vaccine is contraindicated in pregnancy.
 The prevention, however, goes beyond this as it is essentially a
disease of poverty. Improved living condition is, therefore,
encouraged with good ventilation, while overcrowding should
be avoided. Improvement in nutritional status is another
important aspect of the prevention.
Cont…
 Primary prevention of HIV/AIDS is, therefore, another

major step in the prevention of tuberculosis in pregnancy.
Screening of all pregnant women living with HIV for
active tuberculosis is recommended even in the absence
of overt clinical signs of the disease.
Cont..
Isoniazid preventive therapy (IPT) is another

innovation of the World Health Organisation that is
aimed at reducing the infection in HIV positive
pregnant women based on evidence and experience
and it has been concluded that pregnancy should not
be a contraindication to receiving IPT. However,
patient's individualisation and rational clinical
judgement is required for decisions such as the best
time to provide IPT to pregnant women.
Therapeutic management
 The principles of treatment for the pregnant woman with TB are
same as in the non pregnant patient.
 The treatment of TB in pregnancy is important for two reason.
 For serious consequences of untreated TB and the risk of its spread to
newborns.
 Secondly the effect of the drugs used in its treatment on the fetus.
1. Women with positive purified protein derivates (PPD) and no
evidence of active disease (asymptomatic), Isoniazid prophylaxis
300mg/day is started after the first trimester and continued for 6-9
months. Pyridoxine (vit.B6) 50mg/day is added to prevent peripheral
neuropathy.
2.Women with active tuberculosis should
receive the following drugs orally daily for
a minimum period of 9 months.
Cont..
3. Surgical management should be withheld, if

possible, but if deemed necessary should be
restricted for first half of pregnancy beyond 12
weeks.
Obstetrical management
During pregnancy
 Supervision and joint care with obstetrician and chest
physician is necessary.
 In the first trimester anti-TB drug should be continued. The
choice of drug and the dosage may have to be modified.
Morning sickness may pose some difficulties.
 In 2nd and 3rd trimester, the status should be reviewed.
Women will need advice regarding workload, diet and rest.
 Treatment with iron, folic acid and vitamin is necessary to
improve general condition/health.
During labour
 Close monitoring of pulse and respiratory rate are

necessary especially in pulmonary TB.
 Normal vaginal delivery is routine for women with
tuberculosis and low forcep may be used to short the 2nd
stage of labour.
 Spinal or epidural anesthesia are preferred than inhalation
anesthesia for fear of contamination.
During postnatal period
• After delivery the women with active disease must stay in

hospital or transferred to a hospital for two or three weeks to
allow them a period of rest before they return to their house
hold duties.
Breast feeding is not contraindicated when a woman is taking
anti-tuberculosis drugs.
Breast feeding should be avoided if the infant is also taking the
drugs (to avoid excess drug level)
in active lesion, not only is breast feeding contraindicated but
the baby is to be isolated from the mother following delivery.
• Baby should be given prophylactic isoniazid 10-
20mg/kg/day for 3 month when the mother is suffering
from the active disease.
• If the mother is on effective chemotherapy for at least 2
weeks, there is no need to isolate the baby. BCG should
be given to the baby as early as possible.
Cont..
 Pregnancy is to be avoided until quescence is assured for

about two years.
 Oral contraceptives should be avoided when rifampicin is
used.
 Due to accelerated drug metabolism, contraceptive failure
is
high.
 Puerperal sterilization should be considered if the family is
completed.
Nursing management
 Review the woman's history for risk factors such as

immuno-compromized status, recent immigration status,
homeless, over crowded living conditions and injectable
drug use.
 At antepartum visits, be alert for clinical manifestation of
TB including fatigue, fever or night sweats, non productive
cough, slow weight loss, anemia, haemoptysis and anorexia.
Cont…
 If the TB is suspected or the woman is at risk for developing

TB, anticipate screening with purified protein derivative
(PPD) administered by intradermal injection.
 If the client has been exposed to TB, a reddened
induration will appear within 72 hours.
 If the test is positive anticipate a follow up chest x-ray
with lead shielding over the abdomen and sputum culture
to confirm the diagnosis.
Cont..
 Complaining with the multidrug therapy is critical to

protect the woman and her fetus from progression of TB.
 Provide education about the disease process, the mode
of transmission, prevention, potential complications, and
the importance of adhering to the treatment regimen.
Cont..
 Stressing the importance of health promotion activities

throughout the pregnancy is important. Some suggestion
might include;
 Avoiding crowded living conditions.
 Avoiding sick people.
 Maintaining adequate hydration.
 Eating a nutritious well balanced diet.
 Keeping all prenatal appointments to evaluate fetal
growth
and well being.
 Getting plenty of air by going outside frequently.
Determining the woman's understanding of her condition
and treatment plan is important for compliance.
Breast feeding is not contraindicated during the
medication regimen and should be encouraged
Management of the newborn of a mother with TB
involves preventing transmission by teaching the parent
not to sneeze, cough or talk directly into the newborns
face.
Points to be remember:
During pregnancy,
 Streptomycin can cause permanent deafness in the
baby, so ethambutol should be used instead of
streptomycin.
 Isoniazid, rifampicin, pyrazinamide and
ethambutol are safe to use.
 Second-line drugs such as fluroquinolones,
ethionamide and protionamide are teratogenic,
and should not be used.
• Oral contraceptives should be avoided when
rifampicin is used.
For Children:
 Ethambutol should not be given to children below 6
years of age.
References:
• K.Park, park’s textbook of preventive and
social medicine,21st edition,pageno:164-175.
S.Durga, G.Saraswoti, midwifery nursing
(part-1), 2nd edition, pageno:379- 382.
T.Roshani, manual of midwifery I, 8th edition,
pageno:313-314.
H.L.M.C. Midwifery manual, 1st edition,
pageno: 124-125.
D.C.Dutta, textbook of obstetrics,6th edition,
pageno:282-283.
Www.Mayoclinic.Com

Leprosy & Pregnancy: Presented By:-Bhawna Joshi MSC. 1 Yeae

Uploaded by

Copyright:

Available Formats

Leprosy & Pregnancy: Presented By:-Bhawna Joshi MSC. 1 Yeae

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Leprosy & Pregnancy: Presented By:-Bhawna Joshi MSC. 1 Yeae

Uploaded by

Copyright:

Available Formats

LEPROSY &

Cell mediated immunity gets depressed

Reduced cell mediated immunity

Humoral immunity Cell mediated

Pregnancy increased depressed

Post Partum depressed Increased

 Pulmonary tuberculosis is an infectious disease of the lungs

Mycobacterium Tuberculosis(Human type)

Positive family history or past history.

Evening pyrexia(low grade fever)

 Positive family history

Tuberculin skin test with purified protein

• Higher risk of relapse in the puerperium. This may be due

care of a new born .

 Primary prevention of HIV/AIDS is, therefore, another

Isoniazid preventive therapy (IPT) is another

3. Surgical management should be withheld, if

 Close monitoring of pulse and respiratory rate are

• After delivery the women with active disease must stay in

 Pregnancy is to be avoided until quescence is assured for

 Review the woman's history for risk factors such as

 If the TB is suspected or the woman is at risk for developing

 Complaining with the multidrug therapy is critical to

 Stressing the importance of health promotion activities

You might also like