Management of M/XDR-TB Treatment During Pregnancy​

Management of M/XDR-TB Treatment During Pregnancy

In pregnant women diagnosed with Multi-Drug Resistant (MDR) or Rifampicin-Resistant TB (RR-TB), a critical decision regarding management depends on the gestational age.

Management Algorithm Based on Gestational Age

If the duration of pregnancy is less than 20 weeks, medical termination of pregnancy (MTP) should be advised due to the potential severe risk to both the mother and the fetus. Figure 1 (as referenced in source material) illustrates the management algorithm for pregnant women based on their gestational age. Note that 24 weeks will apply wherever the bill is passed.

Scenario 1: Pregnancy ≤ 20 Weeks and Willingness for MTP

If the pregnancy is less than or equal to 20 weeks and the individual is willing to opt for MTP, she should be referred to a gynecologist or obstetrician for MTP. Following MTP, a shorter oral Bedaquiline-containing MDR/RR-TB regimen can be initiated if treatment hasn't started, or continued if already on treatment, by the DR-TB Centre committee.

Scenario 2: Pregnancy > 20 Weeks or Unwillingness for MTP

If the individual does not opt for MTP or has a pregnancy greater than 20 weeks duration, she will be shifted to a longer oral M/XDR-TB regimen. For individuals unwilling for MTP or with a pregnancy of more than 20 weeks, making them ineligible for MTP, the risks to the mother and fetus must be clearly explained. Pregnant women with DR-TB in this category need careful monitoring of both their treatment and the progress of the pregnancy.

Regimen Considerations During Pregnancy

The shorter oral Bedaquiline-containing MDR/RR-TB regimen cannot be administered in pregnant women before 32 weeks. This is due to the potential teratogenicity of Ethionamide (Eto) in the first trimester and the risk of hypothyroidism in the infant during the second trimester.

Beyond 32 weeks, the choice between a shorter or longer regimen must be a consultative decision between the obstetrician and the physician at the nodal (N) or district DR-TB Centre (DDR-TBC). More compelling evidence on toxicity caused by specific anti-TB drugs during pregnancy and lactation is still needed.

Regimen Details (Referenced)

• Regimen: 4-6 Bdq (6m) Lfx, Cfz, Eto, Hh, Z, E / 5 Lfx, Cfz, Z, E. No modifications allowed.
• Regimen: 18-20 Lfx, Bdq(6m or longer) Lzd#, Cfz, Cs. Lzd dose to be tapered to half after 6-8 months based on bacteriological response. Modify regimen if one or more drug cannot be used due to reasons of resistance, tolerability, contraindication, availability etc.
• In the order of Z E PAS.
• Eto may be considered after 32 weeks’ gestation.
• Am may be considered in the post-partum period only. Am will not be started in the final 12 months of treatment.