Tuberculosis and Pregnancy—Maternal, Fetal, and Neonatal Considerations

The epidemiology of tuberculosis in pregnancy reflects that of tuberculosis at large. Worldwide, the number of cases of tuberculosis appears to have peaked in 2004, with declining rates in Western and Central Europe, Latin America, the Eastern Mediterranean, Southeast Asia, and the Western Pacific. High prevalence rates have yet to decline substantially in Africa and Eastern Europe ( 1 ). According to the WHO, in 2013 tuberculosis caused half a million deaths among women worldwide, most of whom were human immunodeficiency virus (HIV) negative ( 2 ). For the United States, the rising incidence of tuberculosis seen during the late 1980s and early 1990s appears to have ended. The U.S. case rate (per 100,000 persons) of 10.4 in 1992 declined to 2.96 in 2014, with 66% of reported TB cases occurring among foreign-born persons. Different ethnic groups have widely different rates, however, with Asians having the highest case rate of 17.8 per 100,000 persons, followed by Native Hawaiians and other Pacific Islanders, with a case rate of 16.9 per 100,000 persons ( 3 ). The 2014 tuberculosis case rates for women of childbearing age from various ethnic groups ( 3 ) are shown in Table 1 . A recent systematic review of latent tuberculosis in pregnancy revealed a prevalence of 14 to 48% in the United States, with skin test positivity varying with ethnicity, representing a significant opportunity to potentially impact upon the development of tuberculosis disease in both the mother and the infant ( 4 ). For women of childbearing age, infection with HIV represents a significant risk factor for tuberculosis infection. Of 16 pregnant women with tuberculosis in New York City reported by Margono and coworkers, 7 of 11 (64%) tested were HIV positive ( 5 ). Another study of a cohort of HIV-infected women in the United States found that 5 out of 46 (11%) of the pregnant women were coinfected with the tuberculosis agent ( 6 ). In sub-Saharan Africa, where the burden of HIV and tuberculosis is among the largest worldwide, HIV infection has been correlated with a 10-fold-higher incidence of tuberculosis infection ( 7 ).