Extrapulmonary tuberculosis and pregnancy

Abstract

Extrapulmonary tuberculosis is an infrequent complication of pregnancy (0.1 per cent at the New York Lying-In Hospital). Usually the original site of inoculation has healed and only the extrapulmonary focus remains so that pulmonary tuberculosis is seldom a factor in the prognosis. The osseous and renal systems were most frequently involved in our patients, 21 and 18 times, respectively. The lymph nodes were the site of tuberculosis in 9 patients, the intestines in 3, and miliary, peritoneal, and pericardial tuberculosis each occurred once.No operative procedures were performed during pregnancy in the patients with osseous tuberculosis. Conception occurred on an average of 17 years after the onset of the skeletal tuberculosis so that these patients had no active lesions. In the patients with renal tuberculosis, nephrectomy was performed on an average of 5 years before conception in 9 patients, during the seventh month of gestation in 2 patients, and 3 weeks post partum in 2 patients. Case reports in the literature substantiate the opinion that pregnancy is not a contraindication to nephrectomy for tuberculosis. Streptomycin and para-aminosalicylic acid should be used pre- and postoperatively. At present these drugs are not considered a substitute for surgical treatment.The cervical lymph nodes are the most commonly involved in tuberculosis and were the site of the disease in all 9 of our patients. In 2 patients excision was performed during gestation. Lymph node tuberculosis occurring during pregnancy should be treated as in the nonpregnant patient with application of the same principles as apply to surgical eradication of tuberculosis elsewhere in the body. Streptomycin and PAS are valuable additions to surgical therapy in tuberculous lymphadenitis.Intestinal tuberculosis occurred in 3 patients, each of whom had two pregnancies. Streptomycin and PAS were available for use in only one patient, who also had anal and perineal tuberculous sinuses, and this patient's condition improved following delivery. It is suggested that streptomycin and PAS be used in the pregnant patient with intestinal tuberculosis.One patient developed miliary tuberculosis while being treated with pneumothorax for pulmonary tuberculosis during pregnancy. A normal infant was delivered and the patient responded to streptomycin and PAS post partum. One patient had tuberculosis of the pericardium and delivered a premature infant. She subsequently had a partial pericardectomy and improved.Analgesia and anesthesia in pregnant patients with nonpulmonary tuberculosis is not as much of a factor as in pulmonary tuberculosis. No apparent ill effects resulted from the use of morphine in our patients in 32 instances. Ether was used at 28 deliveries without ill effect. Normal spontaneous delivery occurred 33 times, low forceps were used 11 times, midforceps on 4 occasions, and there were 2 breech deliveries. Cesarean section was performed on 9 occasions but nonpulmonary tuberculosis was the indication in only 6 instances. Although 3 sections were done for renal tuberculosis, we would not do sections for this condition at present and believe that nonpulmonary tuberculosis per se is not an indication for cesarean section.The results in the 45 patients who had full-term or premature deliveries, 93 per cent of whom were followed for 3 months to 20 years, were uniformly good. Thirty-nine showed no change in their condition and 6 patients were improved. Two of the latter group had nephrectomies performed during pregnancy and 4 received streptomycin and para-aminosalicylic acid either during pregnancy or immediately post partum.