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South Australian Perinatal Practice Guideline 

Tuberculosis in pregnancy 
  Department for Health and Wellbeing, Government of South Australia. All rights reserved.  

Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate 
standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of 
published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not 
sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and 
professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the 
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are 
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful 
confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of 

professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal 
culture. The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts 
a pregnant women. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the 
document symbolises a footprint and demonstrates the need to move forward together in unison. 
 

     

 

 

 

 

 

Purpose and Scope of PPG 
This purpose of this guideline is to provide clinicians with information on Tuberculosis disease 
in pregnancy. It includes details of risk factors to guide clinicians with targeted antenatal 
screening, maternal diagnosis and management, infection control measures and neonatal 
management. 
  

  

Australian Aboriginal Culture is the oldest living culture in the world yet 
Aboriginal people continue to experience the poorest health outcomes when 
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are 
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to 
be of low birth weight.  The accumulative effects of stress, low socio economic 
status, exposure to violence, historical trauma, culturally unsafe and discriminatory 
health services and health systems are all major contributors to the disparities in 
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics 
the birth of an Aboriginal baby is a celebration of life and an important cultural 
event bringing family together in celebration, obligation and responsibility. The 
diversity between Aboriginal cultures, language and practices differ greatly and so 
it is imperative that perinatal services prepare to respectively manage Aboriginal 
protocol and provide a culturally positive health care experience for Aboriginal 
people to ensure the best maternal, neonatal and child health outcomes. 

 

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Tuberculosis in pregnancy 
 
 

Table of Contents 

Purpose and Scope of PPG 
Summary of Practice Recommendations 
Abbreviations 
Tuberculosis 
Tuberculosis infection 
Tuberculosis disease 
  Clinical features 
  Route of transmission 
  Infection control 
Antenatal screening 
  Risk factors for LTBI 
Maternal diagnosis 
Maternal management 
  TB infection 
  TB disease 
Neonatal management 
  Evidence of congenital TB 
  Investigations 
  Management 
  No evidence of TB 
Tuberculosis drugs and pregnancy 
  First line drugs 
  Breastfeeding 
Tuberculin skin test (TST) (mantoux skin test) 
  Background 
  Tuberculin skin tests (TST) 
  Interpretation of tuberculin skin test positivity 
References  
Acknowledgments 

Summary of Practice Recommendations  
Women who have recently arrived from an area with a high prevalence of TB or have had 
close contact with someone with infectious TB should be referred to the Chest Clinic 
Women who have symptoms and signs suspicious of active TB, are HIV positive or have had 
a recent positive TST should be referred to the Chest Clinic  
Identification of risk factors, early diagnosis, prompt treatment and isolation of a woman with 
suspected pulmonary TB are important infection control measures 
Transmission-based airborne precautions should be used for all suspected or confirmed 
cases of pulmonary TB  
The risk of congenital TB should be assessed by a Paediatrician at birth if the mother has 
disseminated TB, pelvic TB, pulmonary or extra-pulmonary disease  

 
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Abbreviations   
AFB Acid fast bacilli 
AIDS Acquired immunodeficiency syndrome  
BCG Bacille Calmette-Gu rin  
CDI Communicable Diseases Intelligence 
DoH Department of Health  
et al And others 
g Gram(s) 
? Greater than or equal to 
HIV Human immunodeficiency virus 
INH Isoniazid 
kg Kilogram(s) 
LTBI Latent Tuberculosis Infection 
&lt; Less than 
M,C&amp;S Microscopy, culture and sensitivity 
mg Milligram(s) 
NHMRC National Health and Medical Research Council  
% Percent 
PPD Purified Protein Derivative  
TST Tuberculin skin test  
TB Tuberculosis  

 

Tuberculosis 
&gt; Tuberculosis (TB) is caused by Mycobacterium tuberculosis complex (MTBC), a slow 

growing, and aerobic, acid-fast bacillus (AFB).  The MTBC consists of Mycobacterium 
tuberculosis, and rarely Mycobacterium bovis and Mycobacterium africanum 

&gt; Tuberculosis is a notifiable disease.  The South Australian Public Health Act 2011 requires 
that notification should be made within three days of suspicion or confirmation to the South 
Australian TB Services (Telephone: 8225483 or Fax 82225398) 

&gt; More detail on the notification process and access to the appropriate notification 
form are available from the SA Health website at:  URL:  
http://www.sahealth.sa.gov.au/NotifiableDiseaseReporting 

Tuberculosis infection 
&gt; Inhalation of tubercle bacilli results in a primary infection which usually resolves without 

clinical features. Small numbers of TB bacilli can remain in a latent form commonly known 
as Latent Tuberculosis Infection (LTBI) and in most persons never progresses to active TB 
This episode is detected by immunological testing:  

&gt; Tuberculin Skin test (Mantoux technique)- preferred test1 

&gt; Interferon Gamma Release Assay (IGRA) 
&gt; LTBI is not infectious, but is associated with a risk of reactivation and development of active 

disease 

&gt;   10-15 % lifetime risk in a healthy adult 

&gt; Up to 10 % annual risk in immunocompromised  
&gt;  There is no evidence that pregnancy increases the risk of TB reactivation 

  

 
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Tuberculosis disease 
Clinical features 
&gt; Most Tuberculosis in Australia is pulmonary (60 -70 %) 
&gt; Common symptoms of TB disease / reactivation include: 

&gt; Cough 

&gt; Fever 

&gt; Night sweats 

&gt; Weight loss 

&gt; Haemoptysis 
&gt; In pregnancy the presentation is usually similar to that of the non-pregnant woman but in 

some can be deceptive with non-specific pregnancy like symptoms  
&gt; TB lymphadenitis is the most common extra-pulmonary manifestation; however the disease 

can occur in any part of the body, including the pleura, bone, kidneys and the meninges.  
The range of symptoms will depend on the site of disease 

Route of transmission  
&gt; Air-borne 

&gt; Pulmonary and laryngeal cases that are smear positive for AFBs on sputum 
sampling are potentially the most infectious 

&gt; Extra-pulmonary cases are usually non-infectious but can be associated with 
pulmonary disease 

&gt; High risk procedures including sputum induction, nebuliser treatment and 
bronchoscopy, can result in transmission of infection   

&gt; Congenital (very rare in Australia) 

&gt; Maternal haematogenous spread via the umbilical vein from disseminated disease 

&gt; Antenatal aspiration or ingestion of infected amniotic fluid 

&gt; Direct from genital disease 

Infection control 
&gt; The most important measures are the early diagnosis, and prompt treatment and isolation of 

a woman with suspected pulmonary TB 
&gt; Early diagnosis in a low TB prevalence population such as Australia depends on recognition 

of risk factors for TB 

&gt; Overseas born   80 to 90 % of annual notifications are born overseas from high TB 
prevalence countries 

&gt; Recent arrival to Australia   the risk of TB reactivation is highest in the first 5 years 
after infection 

&gt; Recent contact with a pulmonary TB case  
&gt; Transmission-based airborne precautions should be used for all suspected or confirmed 

cases of pulmonary TB.  These include: 

&gt; Placement in a negative pressure single room with separate toilet facilities 

&gt; Use of N95 particulate filter masks for health care worker (fit testing required) and 
visitors and surgical masks for patients during movement within the hospital 

&gt; Staff who are immune-compromised should be advised about their increased susceptibility 
to TB infection and preferably not be involved in the direct care of infectious TB cases 

  

 
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Antenatal screening 
&gt; TB disease risk factors screening should be part of the antenatal workup 
&gt; Antenatal tuberculin skin test (TST) screening is not routinely done because it is not 

recommended to treat Latent Infection during pregnancy except in certain instances 
&gt; TST should be undertaken in those with a history of recent TB contact e.g. household or are 

HIV positive 

Risk factors for LTBI 
&gt; History of past TB contact 
&gt; In Australia, most TB (about 80 to 90 %) occurs in migrants, particularly from: 

&gt; South East Asia / Subcontinent 

&gt; Africa 

&gt; Papua New Guinea 
&gt; The risk of new migrants developing active TB is greatest in the first 2-5 years after arrival 
&gt; Immune-compromised women are at high risk of developing active TB if they are infected 

with M. Tuberculosis.  However the screening tests are less predictive and a careful history 
of TB exposure is required 

Maternal diagnosis 
&gt; Women who have symptoms and signs suspicious of active TB should be immediately 

referred to the Chest Clinic, Royal Adelaide Hospital, for further investigation 
&gt; To help confirm diagnosis: 

&gt; Obtain sputum x 3 for AFBs (early morning preferred) 

&gt; Chest X-ray with abdominal shielding 
&gt; Women with the following risk factors should be referred to The Chest Clinic, Royal 

Adelaide Hospital for further assessment:  

&gt; Women with HIV infection 

&gt; Recent arrival from area with a high prevalence of TB 

&gt; Women who have had close contact with infectious TB 

&gt; Positive TST (if this has recently been performed on site or elsewhere)  

Maternal management 
TB infection 
&gt; Providing there is no evidence of disease, prevention treatment of TB infection is offered (6-

9 months of Isoniazid) but usually deferred until 2-3 months postpartum 
&gt; Exceptions to this include: 

&gt; Immune-compromised persons especially those with HIV infection 

&gt; Persons with evidence of recent infection   

TB disease 
&gt; Treatment is with the standard 4 drug regimen that includes isoniazid, rifampicin, 

ethambutol and pyrazinamide (see below) 
&gt; All patients should be considered for directly observed therapy to ensure good adherence 

that minimises the risk of acquired drug resistance or relapse  
&gt; Advice on management should be sought from the SA TB Services at the Royal Adelaide 

Hospital Chest Clinic  

 
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Neonatal management 
&gt; The risk of congenital TB should be assessed by a Paediatrician at birth if: 

&gt; Maternal disseminated TB or pelvic TB 

&gt; Mother has pulmonary or extra-pulmonary disease diagnosed perinatal or 
immediately postpartum 

Evidence of congenital TB  
&gt; Congenital TB is difficult to distinguish from other congenital or neonatal infections and has 

a high mortality if not diagnosed and treated early.  Symptoms and signs are non-specific 
and include: 

&gt; Preterm birth / low birth weight  
&gt; Respiratory distress, fever, hepatomegaly and / or splenomegaly, poor 

feeding, lethargy are most frequent presenting features 
&gt; Other possible signs include: 

&gt; Lymphadenopathy, abdominal distention, ear discharge, typical 
maculopapular, umbilicated skin lesions 

Investigations 
&gt; Tracheal aspirate, gastric washings, urine and CSF specimens for acid fast bacillus (AFB) 

culture  
&gt; Placenta for AFB culture and histology 
&gt; Chest X-ray 
&gt; Complete blood picture (CBP), liver function tests (LFTs), inflammatory markers 

Management 
&gt; A four drug TB regimen that includes rifampicin, isoniazid, pyrazinamide* and an injectable 

agent such as streptomycin* or amikacin is recommended by the American Paediatric 
Society (Consult South Australian TB Services for further advice, RAH Chest Clinic) 

&gt; * Pyrazinamide and streptomycin are not registered in Australia but are 
available via the Special Access Scheme 

&gt; Exclusively breastfed infants should receive pyridoxine 5 mg daily 

&gt; Crush and dissolve one 25mg tablet in 5 mL water for injection to make a  
5 mg/mL solution. Administer 1 mL (5mg) and discard remainder5  

No evidence of TB  
&gt; Babies of women with confirmed pulmonary TB and taking effective treatment are not 

separated from the mother 

&gt; Commence oral Isoniazid (INH) 10 mg / kg daily 

&gt; Also add oral pyridoxine 5 mg daily  

&gt; Follow up with TST at 6 weeks, 3 and 6 months 

&gt; If TST is abnormal (? 5 mm), assess for disease, and use a low threshold for 4 
drug treatment if active TB cannot be confidently excluded.  Minimum will be 9 
months of INH in the healthy baby 

&gt; If TST is negative at 6 months INH can be discontinued 

&gt; Bacille Calmette-Gu rin (BCG) vaccine  is no longer routinely recommended 
but should be considered in those with a significant likelihood of future 
exposure to TB 

 
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Tuberculosis drugs and pregnancy 
First line drugs 

Isoniazid 
&gt; ADEC Category A.  Widely used in pregnancy since the 1970s for the treatment of active 

TB disease (5 mg / kg once daily, maximum 300 mg) 

&gt; Increased risk of hepatotoxicity has been reported in pregnancy 
(approximately 2 %)2 

&gt; Other side effects include nausea, rash arthralgia s, memory loss, peripheral 
neuropathy 

Rifampicin 
&gt; ADEC Category C.  Widely used in pregnancy since the 1970s for the treatment of active 

TB disease (10 mg / kg once daily, maximum 450 mg if &lt; 50 kg or 600 mg if ? 50 kg) 

&gt; Side effects: hepatotoxicity, bone marrow suppression, nausea rash and poly-
arthralgia 

&gt; Reported to cause haemorrhagic tendency in the newborn when given late in pregnancy. 

&gt; Give vitamin K supplementation to the mother if rifampicin is used in the last 
few weeks of pregnancy 

&gt; Administer vitamin K postpartum to the baby (as per NHMRC 
recommendations) 

&gt; Rifampicin is a powerful cytochrome inducer and has numerous drug interactions    

Pyrazinamide 
&gt; Not registered in Australia, available via the Special Access Scheme 
&gt; Limited pregnancy data available, but no reports of fetal malformations or significant 

adverse events (25 mg / kg once daily, maximum 2 g) 

&gt; Side effects   hepatotoxicity, rash, arthralgia s 

Ethambutol 
&gt; ADEC Category A.  Safe to use in pregnancy (15 mg / kg once daily) 

&gt; Side effects: optic neuritis (common), headache, confusion, nausea, vomiting 
and malaise 

Pyridoxine (B6) 
&gt; Used as a supplement with isoniazid to prevent peripheral neuropathy (25 mg once daily) 

Breastfeeding 
&gt; The above drug treatments (isoniazid, rifampicin, pyrazinamide, ethambutol and pyridoxine) 

are excreted in breast milk however breastfeeding should be encouraged. 
&gt; The amount of medication in the breast milk does not provide sufficient TB treatment or 

prophylaxis for the breastfed infant 
&gt; Breastfed babies that are not receiving TB drug therapy should be given 5mg of pyridoxine 

daily on the days that their mother receives her isoniazid therapy. 
&gt; If a breastfeeding mother and baby are both on anti-TB therapy, there is a small risk of toxic 

levels in the baby 
&gt; Where practical, advise the mother to take her medication immediately after a breastfeed to 

minimise this risk to the baby 

  

 
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Tuberculin skin test (TST) (mantoux skin test) 
Background 
&gt; Hypersensitivity to tuberculin Purified Protein Derivative (PPD) follows either natural 

infection with either Mycobacterium tuberculosis or with mycobacteria that induce cross-
reactivity, or Bacille Calmette-Guerin (BCG) vaccination 

&gt; The tuberculin (Mantoux) skin test is used: 

&gt; To detect latent infection in contacts of patients with tuberculosis (TB) and other 
potentially infected individuals 

&gt; As an aid to the diagnosis of TB 

&gt; As a prelude to vaccination with BCG3  

Tuberculin skin test (TST) 
&gt; The TST is not affected by pregnancy 
&gt; Intradermal injection (into the skin of the upper third of the flexor surface of the forearm, 

producing a peau d orange bleb 4 to 10 mm in diameter) of 0.1 mL of  5 Tuberculin Units / 
0.1mL solution of purified protein derivative (PPD), ( Tubersol  supplied by Sanofi-Pasteur) 
with induration measured at 48-72 hours. In certain circumstances, 2-step skin testing may 
be required. It is used to detect individuals previously infected who may test negative to 
tuberculin initially, but who show a strong reaction if the same procedure is repeated 1 to 2 
weeks later 

Interpretation of tuberculin skin test positivity 
&gt; Induration (not erythema) ? 5 mm diameter in pregnant women with human 

immunodeficiency virus (HIV) infection, close contact with someone with infectious TB, or a 
chest X-ray suggestive of previous TB 

&gt; Induration (not erythema) ? 10 mm diameter in recent arrivals (&lt; 5 years) from high 
prevalence areas,  injecting drug users, residents / employees of prisons, homeless 
shelters, residential facilities for acquired immunodeficiency syndrome (AIDS) 

&gt; The reaction to PPD may be suppressed by viral infection, live vaccines (not used in 
pregnancy), recent surgery, sarcoidosis, immunosuppressant drugs and illnesses such a 
Hodgkin s disease, lymphoma and HIV infection. The reaction also wanes with age, so that 
most adults vaccinated with BCG in childhood have negative tuberculin reactions 

 
  
 
 
 

  

 
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References 
1. National TB Advisory Committee.  Position Statement on interferon-y release assays in 

the detection of latent TB infection.  CDI 2012; 36: 125-31. Available from URL:  
http://www.health.gov.au/internet/main/publishing.nsf/content/cda-cdi3601-pdf-
cnt.htm/$FILE/cdi3601i.pdf 

2. Friedman LN, Tanoue LT.  Tuberculosis in pregnancy.  Up to date [online] 2014 Mar 
[cited 2014 Apr 28]; [9 screens].  Available from URL:  
http://www.uptodate.com/contents/search 

3. National Health and Medical Research Council (NHMRC).  The Australian Immunisation 
Handbook, 10th ed. Canberra:  Australian Government Publishing Service; 2013.  
Available from URL:  
http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home 

Useful web sites: 
1. SA Health: Tuberculosis: symptoms, treatment and prevention.  Available from URL: 

http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/healt
h+topics/health+conditions+prevention+and+treatment/infectious+diseases/tuberculosis/t
uberculosis+tb+-+symptoms+treatment+and+prevention 

2. South Australian Infection Control guidelines.  Available from URL:  
http://www.health.sa.gov.au/infectioncontrol 

3. Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010).  
Available from URL:  http://www.nhmrc.gov.au/node/30290 

4. Queensland guidelines for the treatment of tuberculosis in pregnancy.  Available from 
URL:  http://www.health.qld.gov.au/ph/documents/qtbcc/31044.pdf 

5. National Health and Medical Research Council (NHMRC).  Vitamin K for newborn babies.  
October 2010.  Available from URL:  
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/CH38_vitamin_k_web.pd
f 

6. ASID Management of Perinatal Infections. Available at URL: 
https://www.asid.net.au/documents/item/368     

 
 
 

  

 
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Tuberculosis in pregnancy 
 
 

Acknowledgements 
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of 
clinicians and other stakeholders who participated throughout the guideline development 
process particularly:  

Write Group Lead 
Dr Rick Stapledon 
Dr Simon Cameron 
Prof Paul Goldwater 
 

Write Group Members 
Catherine Leggett 
 

Other major contributors 
SAPPG Work Group 2004-2014 
 

SAPPG Management Group Members 
Sonia Angus 
Dr Kris Bascomb 
Lyn Bastian 
Elizabeth Bennett 
Dr Feisal Chenia 
John Coomblas 
A/Prof Rosalie Grivell 
Dr Sue Kennedy-Andrews 
Jackie Kitschke 
Catherine Leggett 
Dr Anupam Parange 
Dr Andrew McPhee 
Rebecca Smith 
A/Prof John Svigos 
Dr Laura Willington 

  

 
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Document Ownership &amp; History 
Developed by: SA Maternal, Neonatal &amp; Gynaecology Community of Practice 
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au 
Endorsed by: SA Safety and Quality Strategic Governance Committee 
Next review due:  17 June 2019  
ISBN number:  978-1-74243-100-0 
PDS reference:  CG144 
Policy history: Is this a new policy (V1)?  N 
 Does this policy amend or update and existing policy?   Y  
 If so, which version? V3 
 Does this policy replace another policy with a different title?  N 
 If so, which policy (title)? 
 
 

 
 

Approval 
Date Version 

Who approved New/Revised 
Version Reason for Change 

15 Jun 2018 V3.1 SA Safety and Quality Strategic Governance Committee 
Review date extended to 5 years following 
risk assessment. New template. 

17 Jun 2014 V3 SA Safety and Quality Strategic Governance Committee Reviewed 

21 Apr 2009  V2 Maternal and Neonatal Clinical Network Reviewed 

27 Apr 2004  V1 Maternal and Neonatal Clinical Network Original approved version. 

 
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