A Newborn's Death From Tuberculosis No One Caught in Pregnancy

Perinatal tuberculosis — TB passed to a baby before or around birth — is life-threatening: about half of babies with congenital or neonatal TB die. Finding and treating TB before and during pregnancy is what prevents it. This case shows what happens when that doesn't happen.

Why TB in pregnancy is easy to miss

• In 2022, the World Health Organization counted 10.6 million new TB cases worldwide, a third of them in women — but those figures don't record pregnancy. CDC has only recently added pregnancy status to U.S. TB reporting, and because TB in pregnancy is thought to be rare in the U.S., its harms are probably not well understood.
• A 2017 meta-analysis of 13 studies covering about 123,000 pregnancies in several countries linked TB during pregnancy with higher odds of maternal illness and death — including hospital admission, anemia of pregnancy, cesarean birth, miscarriage, preterm birth, low birthweight and TB in the newborn.
• Diagnosis can be delayed because TB symptoms overlap with pregnancy symptoms, and because clinicians are reluctant to order chest x-rays during pregnancy.

The case

The mother. She underwent in vitro fertilization for infertility in her home country, India — which accounted for 27% of the world's TB cases in 2022 — and came back to the United States a month before giving birth. At her U.S. prenatal visits she had too little weight gain, severe vomiting (hyperemesis) and a chronic cough; the cough was put down to gastroesophageal reflux. Her routine pregnancy tests were normal. No one tested her for TB infection.

Her waters broke early, at 33 weeks, and she had an uncomplicated vaginal delivery of a healthy-looking baby, with a normal-looking placenta.

The baby.

The mother, again. Her chest x-ray showed nodular opacities in both lungs; her sputum showed acid-fast bacilli and tested positive for M. tuberculosis by PCR and culture. She recovered after a full course of treatment for drug-susceptible pulmonary TB — the same treatment she would have received had it been diagnosed during pregnancy. The only other person in the household had neither TB disease nor latent infection.

The missed clue: infertility

TB usually attacks the lungs, but it can strike any organ system, including the reproductive system — sometimes with no sign in the lungs at all. In women it can cause infertility, pain, a pelvic mass or menstrual problems. In India, TB is considered the likely cause of infertility in nearly a quarter (24.2%) of women with infertility. A chest x-ray picks up genitourinary TB in only 10%–75% of cases, so an infertility work-up that looks for TB may need pelvic imaging, and samples taken by laparoscopy and endometrial biopsy for smear microscopy, PCR, culture and histology.

What the authors conclude

• This death might have been prevented by TB prevention or treatment during the infertility evaluation or the pregnancy.
• Clinicians should consider TB when evaluating infertility — or a history of it — in women from countries where TB is endemic.
• Everyone, pregnant people included, should be considered for TB evaluation, based on:
• • risk factors for infection: living now or in the past in a country with high TB incidence, a homeless shelter or a correctional facility;
  • risk factors for progression to disease once infected: diabetes, HIV infection or substance use disorder.

Sources

Based on Miele K, Rock RB, LaCourse SM, Ashkin D, Armitige LY, Pomputius W, Goswami ND, "Notes from the Field: Undiagnosed Tuberculosis During Pregnancy Resulting in a Neonatal Death — United States, 2021," MMWR volume 72, number 49, Centers for Disease Control and Prevention, with authors from CDC, Hennepin Healthcare, the University of Washington, the Southeastern and Heartland National Tuberculosis Centers and Children's Minnesota; a work of the United States government in the public domain.