65 The curse of dual disease during pregnancy is widely studied in the African region.23,59 Recent reports from India also explored the intricate correlation between HIV infection and TB in the context of pregnancy and the post-partum period.61,62 Among

HIV-infected Indian women, Gupta et al. found a high incidence of post-partum TB (five cases per 100 person-years).62 Furthermore, co-infection of TB has substantially increased post-partum maternal death (2.2-fold; 95%CI 0.6–3.8) and death of their infants (3.4-fold; BTK pathway inhibitors 95%CI 1.22–10.59). This raised a serious concern regarding the strategy of screening and managing latent TB during pregnancy in the context of India, and other South Asian countries, where isoniazid prophylaxis is not advocated at present in latent TB. The authors suggested

that active screening and targeted use of isoniazid preventive therapy among HIV-infected women in India should be considered to prevent post-partum maternal TB. In a subsequent article, Gupta et al.61 also reported Bortezomib concentration that maternal TB, mostly detected after delivery, is associated with increased mother-to-child transmission of HIV (30% vs 12%). Therefore, prevention of TB among HIV-infected mothers should be a high priority for communities with significant HIV/TB burden. Dual infection of TB and HIV-infection poses several unique challenges. Its management during pregnancy demands special expertise, judicial sequential combination of anti-TB drugs and anti-retroviral drugs, which is beyond purview of this current review.23,59 This issue was recently addressed elsewhere.59 It is increasingly evident that TB has many adverse effects on maternal and child health in high-prevalent countries, with HIV-infected mothers and their infants being

particularly vulnerable.66 These include not only direct effects, such as morbidity and mortality, but also multiple indirect effects see more that trap the woman in a vicious circle of perpetual poverty and vulnerability.67 As untreated or incompletely treated TB poses a great risk to pregnant women and their fetuses, all women with TB irrespective of sites involved must receive a full course of anti-TB drugs.68 According to the recent World Health Organization (WHO) recommendation, ‘A pregnant woman should be advised that successful treatment of TB with standard regimen is important for successful outcome of pregnancy.’69 Management of active TB during pregnancy is similar to that in non-pregnant women. With the exception of streptomycin, all first-line anti-TB drugs (isoniazid [H], rifampicin [R], ethambutol [E], and pyrazinamide [P]) are considered safe for use in pregnancy, and have no proven teratogenic effects.69–76 Streptomycin-induced fetal ototoxicity leading to hearing impairment and irreversible congenital deafness affects one in six neonates; therefore, it should not be used throughout pregnancy.