Medical and Surgical Complications in Pregnancy
A primigravida female in 1st trimester is diagnosed having sputum positive pulmonary tuberculosis. Which of the following would be most appropriate line of treatment?
|A||Defer the Rx to 2nd trimester|
|B||Start with category1 antitubercular regimen|
|C||Start with category3 antitubercular regimen|
|D||Start with category3 antitubercular regimen|
Give category 1 drugs in first trimester.
TB during pregnancy and whilst breastfeeding
Streptomycin should not be given during pregnancy. Other drugs are safe. Breast feeding should continue regardless of the mother’s TB status. All anti TB drugs are compatible with breast feeding and a woman taking them can safely continue to breast feeD.
Treatment Categories and Drug Regimens
1. Standardized Treatment Regimens are one of the pillars of the DOTS strategy
2. Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Streptomycin are the primary Antitubercular drugs useD. Most DOTS regimens have thrice-weekly schedules and typically last for 6 to 8 months, with an initial Intensive phase and a Continuation phase.
3. Based on the Nature/severity of the disease and the Patients' exposure to previous anti-tubercular treatments, RNTCP classifies tuberculosis patients in to three Treatment Categories.
New sputum smear-positive
Seriously ill sputum smear-negative Seriously ill extra-pulmonary
New Sputum Positive/Negative HIV Positive
Sputum smear-positive Relapse
Sputum smear-positive Failure
Sputum smear-positive Treatment after default
Sputum smear negative Others/Chronic
New sputum smear-negative, not seriously ill
New extra-pulmonary, not seriously ill
2H3R3Z3E3 + 4H3R3
2H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3
2H3R3Z3 + 4H3R3
2 months Intensive phase + 4 months continuation phase
Four drugs at Thrice-weekly Schedule
3 months Intensive phase + 5 months continuation phase
Five drugs at Thrice-weekly Schedule
2 months Intensive phase + 4 months continuation phase
Two drugs at Thrice-weekly Schedule
a. This is used for new patients who are sputum smear-positive or seriously ill sputum smear-negative or seriously ill EP TB patients.
b. Treatment is given in two phases - Intensive Phase (IP) and Continuation Phase (CP).
c. IP consists of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol, given under direct observation three times a week, on alternate days.
d. IP is given for two months (8 weeks; 24 doses).
e. At the time of the 22nd dose, the patient is referred for follow-up sputum examination so that the results are available by the end of IP (24th dose).
f. If follow-up sputum examination is negative, CP is started and consists of 4 months of treatment (18 weeks; 54 doses) with Isoniazid and Rifampicin, given three times a week on alternate days.
g. During CP, at least the first dose of every week is directly observed. Follow up sputum examinations are done two months into the start of and at the end of CP.
a. If the sputum smear is positive after 2 months of treatment, IP drugs are extended for another one month (12 doses from a prolongation pouch) before starting CP.
b. A follow up sputum examination is repeated at end of the extended IP (3 months).
c. This helps in assessment of the progress of treatment and sputum conversion rate. Irrespective of the smear status, the patient is put on CP drugs and the next follow up sputum examination is done at 5 months.
a. If the sputum smear is positive after 5 months or more of starting treatment, the treatment outcome of the patient is declared as ‘failure’ and (s) he is started afresh on CAT II treatment.
b. In the rare situation in which a CAT I smear-positive patient has a negative sputum smear after 2 months of treatment and a positive sputum smear after 4 months of treatment, another sputum smear should be examined at 5 months.
c. If this is also positive, the patient is considered a treatment ‘failure’ and is started afresh on CAT II treatment.
a. This is used to treat retreatment cases namely ‘Relapse’, ‘Failure’, ‘Treatment after Default’ and ‘Others’. Such patients are generally sputum smear-positive.
b. The IP consists of two months (8 weeks; 24 doses) of Isoniazid, Rifampicin, Pyrazinamide, Ethambutol and streptomycin; all given under direct observation three times a week on alternate days.
c. This is followed by another one month (4 weeks; 12 doses) of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol, all of which are given under direct observation three times a week on alternate days.
d. This is immediately followed by CP, which consists of 5 months (22 weeks; 66 doses) of Isoniazid, Rifampicin and Ethambutol given three times a week on alternate days, the first dose of every week being directly observed.
e. If the sputum smear is positive after 3 months of treatment, the four oral IP drugs are continued for another one month (4 weeks; 12 doses) before starting the 5-month CP.
a. Patients who have been previously treated are at an increased risk of having drug resistant bacilli.
b. For this reason, such patients are given a more intensive regimen, namely CAT II.
c. Experience in India and elsewhere has shown that CAT II treatment, if taken regularly by the patient, is effective and results in curing most patients.
Patients who relapse generally have better outcomes than those who are Failure or Treatment after Default cases, but even these latter types of patients respond well to treatment, provided they take it regularly and are well supervised.
1. This is used for patients who are smear-negative PTB or EP TB, and are not seriously ill. The IP lasts for 2 months (8 weeks; 24 doses) with Isoniazid, Rifampicin and Pyrazinamide given under direct observation three times a week on alternate days.
2. This is followed by CP, which consists of 4 months (18 weeks; 54 doses) of Isoniazid and Rifampicin given three times a week on alternate days, with at least the first dose of every week being directly observed.
3. If a patient receiving CAT III regimen has a positive sputum smear at any stage of the treatment, (s) he should be declared a failure, re-registered, and treated afresh with the CAT II regimen.