Pregnant mother narrates ordeal with TB, HIV infections

As she drew closer to me slouched in a wheel chair, I saw a severely emaciated woman.  I had earlier been told she was five months pregnant so I couldn't help but rush my gaze to her tummy. It was so flat.  I wondered how she could be pregnant.

On speaking, her voice was no louder than a whisper. How could I do the interview when I could barely hear a word she said? All visitors to the TB ward wear a respirator (mask) to prevent them from catching infection though the safety is still not 100% guaranteed, and the patients too are required to wear a mask. With both of us in masks, I had to lean dangerously closer in order to hear her story.  

Martha Kyomugisha, 24, was admitted to Mulago about a month ago, unconscious. Just three months earlier, she was a healthy mother of two, working as a bursar at a primary school in Busega. When it was time for Christmas holidays, she came back to Najjanankumbi, her parents' home.

"I was fine but developed a cough for which I got drugs but it wasn't responding…" she narrated as her eyes welled with tears. It took about five minutes of silence for us to resume our conversation.

"Then it turned into malaria, or so I thought but still no change when I got drugs. Last month I was so badly off I became unconscious and was brought here and referred to the TB ward," she narrates.

She says her legs were swollen, painful and she had no appetite at all. To add to the distress of suffering TB, she was told that she was pregnant!

She was worried about the health of her baby, but when the doctors counseled her about the possibility of having a healthy baby even with tuberculosis. She was started on the treatment which she adheres to religiously.

She says when I ask her about her baby, "We will be fine," though her eyes well up again. Despite her low weight, she feels much better compared to when she was admitted and has actually been discharged but is awaiting a blood transfusion.

Dr Alphonse Okwera, the Head of the National TB referral Treatment Centre at Mulago Hospital

After a rather short interview, she already seems tired and cannot wait to be wheeled back to the ward. Before she is wheeled back to the ward, I ask to take her picture and she says she can only allow one that doesn't show her face, as she doesn't want everyone out there to know her health status.

The TB burden

According to Dr Alphonse Okwera, the Head of the National TB referral Treatment Centre at Mulago Hospital, Uganda gets about 50,000 new cases of tuberculosis every year, 15% of whom are children. It's caused by a bacterium that spreads from person to person through droplets released into the air.

"Any cough that persists for more than two weeks and does not respond to antibiotics should be investigated further because it could be tuberculosis," Okwera warns. He continues that people with reduced immunity are the most at risk of catching the disease, such as people suffering from HIV, Diabetes mellitus, drunkards, cancer patients, the malnourished and pregnant women among others.

He continues that pregnant mothers are vulnerable as they too have an element of reduced immunity and when HIV positive, the chances of acquiring tuberculosis are greater.

Treatment of TB in pregnant mothers

Okwera say drugs used in treatment of TB in pregnant mothers is same as for women that are not pregnant.

Dr Anna Nakanwagi-Mukwaya, the country director of International Union Against Tuberculosis and Lung Disease says that when a mother is not diagnosed early, TB has adverse effects on both the mother and fetus.  

"When a mother is not healthy she cannot have a healthy baby. She is susceptible to suffering a miscarriage," says Nakanwagi

Nakanwagi says babies born of such mothers may be of low birth weight and the mother could also die during pregnancy because of low immunity.

Consequently, Okwera notes that treatment should start as early as possible.

"The aim of treatment is to make the mother less infectious and reduce chances of the baby catching the disease," says Okwera.

However, treatment does not start in the first trimester because that is when the baby's system is developing.

"The cells are dividing to form the parts and these drugs can affect the development of the baby. For example, one can get a blind baby, or babies with disfigured limbs or babies born with missing organs," Okwera explains.

He notes that after three months, though the drugs do cross the placental barrier to the baby, but the level of concentration is not harmful. By the time of delivery, the mother has finished their six month long treatment and can freely interact with the baby.

However, depending on the severity of illnesses, the medical workers may not wait for the three months to elapse before starting the mother on treatment.

When mother is still sick after birth

However, when the TB is not diagnosed early enough and a mother is still ill when the baby comes, caution has to be taken to prevent the mother from transmitting the bacteria to her baby. For starters, the baby should be given the BCG jab, to protect them from tuberculosis.

"The baby should then be kept away from the mother, and only brought to her for breastfeeding, in an open air environment," says Okwera.

Okwera further explains that since TB is airborne when the mother coughs in open air, the air carries it away, hence the risk of transmitting it is very minimal.

What's more, the mother is advised to wear a respirator (mask) while in contact with the baby, because it reduces the chance of transmission by 95%. It must fit well and testing is always done to ensure its tight enough, as it's not a one size fits all.

Some drugs may go to the breast milk but Okwera notes that studies have shown the level concentration doesn't harm the baby.

Treatment of tuberculosis

Treatment for TB takes six months. A TB patient needs to take several drugs at once i.e. Isoniazid, Rifampicin, Ethambutol and Pyrazinamide for two months, after which two of the drugs—Ethambutol and pyrazinamide — are taken off the list and the patient  keeps on rifampicin and isoniazid for another four more months.

Strategies in place

Nakanwagi says that in Uganda, unfortunately not much has been done about TB in pregnancy.

"It could be because of too many demands on the health system. The health system is dealing with so many issues but it could also be because not everyone is aware of the impact of TB in pregnancy," says Nakanwagi.

Indeed, Dr Frank Mugabe, the acting National TB and Leprosy program manager at the ministry of Health says that it's only recently, this year, that a program encompassing TB screening for mothers was started.

"We started the strategy to integrate TB into maternal, adolescent and child health because we know that HIV positive mothers are more likely to catch TB," says Mugabe.

He further explains that mothers who are screened and found with the TB infection are put on isoniazid for six months as a way of prevention. Those with full blown tuberculosis are started on full treatment.

Currently, the ministry of health has availed1,300 diagnostic facilities with basic microscopes at sub county level as well as 105 gene expert machines to different hospitals, such that mothers who present with symptoms of TB are investigated further.

 For general TB control, the ministry of health has also put in place intensified case of finding strategies such as administering screening forms to all patients at the outpatient HIV clinics in the various hospitals.

Furthermore, Mugabe notes that close contact investigation of confirmed patients is taking place, to catch more TB cases.

"When a patient has TB, we investigate all their close contacts for infection as well," says Mugabe.