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In pregnant women diagnosed with multi-drug resistant (MDR)/rifampicin-resistant TB (RR-TB), if the duration of pregnancy is <20 weeks*, the patient should be advised to opt for medical termination of pregnancy (MTP) in view of the potential severe risk to both the mother and the fetus. Figure 1 shows the management algorithm for pregnant patients based on their gestational age.

 

Figure 1: Management of M/XDR-TB patients during pregnancy based on gestation age; Source: Guidelines for PMDT, India 2021, p.71
* 24 weeks will apply wherever the bill is passed.
# 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 post-partum period only. Am will not be started in the final 12 months of treatment.

 

  • If the pregnancy is ≤ ​20 weeks* and the patient is willing to opt for MTP, she should be referred to a gynecologist or obstetrician for MTP after which shorter oral Bedaquiline-containing MDR/RR-TB regimen can be initiated (if the patient has not started treatment) or continued (if the patient is already on treatment) by the DR-TB Centre committee.

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  • If she does not opt for MTP or has a pregnancy >20 weeks* duration, she will be shifted to a longer oral M/XDR-TB regimen. 

 

  • For patients who are unwilling for MTP or have a pregnancy of >20 weeks* (making them ineligible for MTP), the risk to the mother and the fetus should be explained clearly and the pregnant DR-TB patients need to be monitored carefully, both in relation to the treatment and progress of the pregnancy.

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

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  • Beyond 32 weeks, the choice of regimen (shorter/longer) needs to be a consultative decision between the obstetrician and physician at the nodal (N)/district DR-TB Centre (DDR-TBC).​ More compelling evidence on toxicity causes attributed to the use of specific anti-TB drugs during pregnancy and lactation is needed.​

 

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