4 10.2. Rifampicin. This is also believed to be safe in pregnan- cy, though in an unknown proportion of cases, there may be an increased risk of haemorrhagic disorders in the new- born (some authorities prescribe supplemental vitamin K (10 mg/day) for the last four to eight weeks of pregnancy.) while some other researchers reported the possibility of limb deformity but none of these are in excess of what is obtained in the normal population. 10.3. Ethambutol. The retrobulbar neuritis that may compli- cate the use of this drug in adults generated the fear that it may interfere with ophthalmological development when used in pregnancy but this has not been demonstrated when the standard dose is used. This was also conﬁrmed in experi- mental studies on some abortuses [47]. 10.4. Pyrazinamide. The use of pyrazinamide in pregnancy was avoided by many physicians for a long time due to un- availability of adequate data on its teratogenicity. Presently, many international organizations now recommend its use, including the International Union Against Tuberculosis And Lung diseases (IUATLD), British Thoracic Society, American Thoracic Society, the World Health Organisation as well as the Revised National Tuberculosis Control Programme of India. There are no reports of signiﬁcant adverse events from the use of this drug in the treatment of TB in pregnant women despite its use as part of the standard regimen in many countries [48]. Its use is particularly indicated in women with tubercu- lous meningitis in pregnancy, HIV coinfection, and sus- pected INH resistance [49–52]. Breastfed infants of mothers on antituberculous therapy should, however, be monitored for jaundice, which may suggest drug-induced hepatitis, as well as joint pains resulting from drug-induced hyperuri- caemia. 10.5. Streptomycin. The drug has been proven to be poten- tially teratogenic throughout pregnancy. It causes fetal mal- formations and eighth-nerve paralysis, with deﬁcits ranging from mild hearing loss to bilateral deafness. Many centres are against the use of this drug in pregnancy [49, 53, 54]. 11. Multidrug-Resistant Tuberculosis in Pregnancy (MDR-TB) Pregnant women with MDR-TB have a less favourable prog- nosis [55]. They may sometimes require treatment with second-line drugs, including cycloserine, oﬂoxacin, ami- kacin, kanamycin, capreomycin, and ethionamide. The safety of these drugs is unfortunately not well-established in preg- nancy [49]. Para-amino salicylic acid had been used as combination therapy with INH in pregnancy in the past without any sig- nificant teratogenic side eﬀects, though maternal gastroin- testinal side eﬀects may be pronounced. Ethionamide is associated with growth retardation, cen- tral nervous system and skeletal abnormalities in animal studies involving rats and rabbits [56, 57]. Human studies Journal of Pregnancy also demonstrated increased central nervous system defects following its use in early pregnancy [58]. Its use is, therefore, not recommended in pregnancy. Therapeutic abortion has been proposed as an option of management for these women [59], as MDR-TB poses more risk to the woman and the society at large. Another option is to delay initiating treatment to the second trimester where possible [10]. Individualised Treatment Regimen (ITR) using various combinations of the 2nd line antituberculous agents based on their susceptibility proﬁle had, however, been tried in some pregnant women with no adverse obstetric outcome [60]. The outlook for those patients is expected to improve as experience and knowledge in the management of the condi- tion increases. 12. Treatment of TB in Lactating Women Breastfeeding is simply the cheapest and healthiest way to feed a baby. The ﬁnal decision on breastfeed must, therefore, be taken with necessary input from the neonatologists, ob- stetricians, and pharmacologists. The American Academy of Pediatrics recommends that women with tuberculosis who have been treated appropriately for two weeks or more and who are not considered contagious may breastfeed [61], while the RNTCP recommends breast-feeding of neonates regardless of the mother’s TB status [62]. Antituberculous drugs are excreted into breast milk, though the dose is less compared with the therapeutic dose for infants. Breastfed infants may receive as much as 20% of the therapeutic dose of INH for infants, while other anti- tuberculous drugs are less excreted. No toxicity has been reported from this small concentration in breast milk [49]. Caution must, however, be exercised as the breast milk dose may contribute to the development of abnormally high plas- ma levels in newborns who are on antituberculous medica- tions. To minimise this possibility, the mother may take her medications immediately after a feed and substitute a bottle for the next feed. She may then return to her usual pattern of feeding [49, 63]. Pyridoxine deﬁciency may cause seizures in the newborn. Supplemental pyridoxine should, therefore, be administered to infants on INH or whose mother is taking the drug. Breastfeeding may be discouraged in women who are yet to commence treatment at the time of delivery and those who are still actively excreting the bacillus while coughing. It may also be discouraged as part of a prevention of mother to child transmission in HIV coinfection and women with tuberculo- sis of the lactiferous ducts or glands. In the absence of evidence of congenital tuberculosis, isoniazide (10 mg/kg/day) should be commenced at birth and continued for six months. Clinical or radiological fea- tures of active tuberculosis and a positive tuberculin skin test are indications for a full course of anti-tuberculous treat- ment. The tuberculin skin test and chest X-rays are done at 6 weeks, 12 weeks, and 6 months. The baby is vaccinated with BCG at 6 months if these tests are negative. The baby is, how- ever, changed to multiple drug therapy if any of these tests turn positive during the period of monitoring.