Q: My 34 years old wife is three months pregnant. This is her second pregnancy. Her last pregnancy (3 years back) led to a missed abortion in the 12th week of gestation. Hence the doctor has now put her on progesterone therapy once in 15 days for the past one month. One and half months back, enlargement of cervical and auxiliary lymph nodes were noticed. The gynaecologist referred her to a physician. He physically examined her and asked for a Mantoux test. Her ESR was 42 mm at 1 hour (previously when checked by the gynaecologist during first month of gestation it was 28 mm at 1 hour). The physician after seeing the ESR and PPD came to the conclusion that my wife was affected with tuberculosis (TB). She had no other symptoms of TB. He prescribed Forecox 2 tablets daily each containing Isoniazid (225 mg), Rifampicin (150 mg), Ethambutol (400 mg) and Pyrazinamide (750 mg). I have read that isoniazid, rifampicin, ethambutol is safe during pregnancy and poses no teratogenic problem. But with respect to pyrazinamide, literature gives little information regarding its safety and some say it is not recommended. My wife has started taking tuberculosis therapy since last two days. What are the side effects of this therapy? Please advise.

A:There are several issues that need attention:

1. ESR is not diagnostic of tuberculosis at all,
2. Mantoux is indicative but not fully diagnostic.

Before putting a female at 34 years age during first trimester of pregnancy on ATT, one should have a firm, conclusive diagnosis. Why not do a quick lymph node biopsy? Please keep in mind that a patient will need to be on anti-TB therapy for at least 6 months with unknown consequences to the fetus. Drug regulators have contraindicated the use of rifampicin and pyrazinamide during pregnancy. Even when using isoniazid, one needs to be very cautious. In animal studies, isoniazid has shown foeticidal property though there are no known malformations in the baby. Once the diagnosis of TB is firmly established, then good clinical practice demands that to-be-mother's welfare takes precedence over the fate of pregnancy. The mere fact that the patient had one miscarriage does not call for use of oral progesterone. This hormone is to be given only when there is documented deficiency; otherwise the side effects (including loss of pregnancy, hirsutism in female baby etc.) are far worse than any claimed benefits propagated by drug companies with obvious commercial interests.