Journal of Pregnancy 8. Diagnosis of Tuberculosis in Pregnancy 9. Culture 3 To diagnose this condition, history of exposure to individuals with chronic cough or recent visit to areas endemic with tu- berculosis should be obtained. History of symptoms, which is likely to be the same as in nonpregnant women, is also essential. Caution must, however, be exercised, as these symptoms may be nonspeciﬁc in pregnancy [27, 28]. These symptoms include night sweat, evening pyrexia, haemopt- ysis, progressive weight loss, and chronic cough of over 3 weeks duration. There may also be a history of ineﬀective attempts at antibiotics therapy [27, 29]. In pregnant women with suggestive symptoms and signs of TB, a tuberculin skin test should be carried out. This has since been accepted to be safe in pregnancy [21, 30]. The debate, however, is about the sensitivity of tuberculin test during pregnancy. Earlier reports suggested diminished tu- berculin sensitivity in pregnancy [31], while recent studies revealed no signiﬁcant diﬀerences in the pregnant and non- pregnant populations [27, 32–35]. The two types of tuberculin skin tests are discussed below. 8.1. Tine Test. This test utilises an instrument with multiple needles that are dipped in a puriﬁed form of the TB bacteria called old tuberculin (OT). The skin is pricked with these needles and the reaction is analysed 48–72 hours later. It is, however, no longer popular except in large population screening. 8.2. Mantoux Test. A single-needle intradermal injection of 0.1 mL of puriﬁed protein derivative (5 Tuberculin units) is administered, and the skin reaction is analysed 48–72 hours later, based on the largest diameter of the indurations de- veloped. It is a more accurate and reproducible test than the Tines test. False-positive results may be obtained in individuals who had previously been vaccinated with the BCG vaccine, those with previously treated tuberculosis, as well as in people with infection from other Mycobacterium species. False negatives on the other hand are commonly due to a compromised im- mune system and technical errors [36]. A chest radiograph with abdominal lead shield may be done after the tuberculin skin testing, though pregnant women are more likely to experience a delay in obtaining a chest X-ray due to concerns about fetal health [27]. Microscopic examination of sputum or other specimen for Acid-fast bacilli (AFB) remains the cornerstone of labo- ratory diagnosis of TB in pregnancy. Three samples of spu- tum should be submitted for smear, culture, and drug-sus- ceptibility testing. Staining for AFB is also done, using the Ziehl-Neelsen, ﬂuorescent, Auramine-Rhodamine, and the Kinyoun techniques [37]. Light-emitting diode (LED) ﬂuo- rescent microscopy has recently been introduced to improve diagnosis [37]. According to the WHO’s 2009 report on global TB control, the percentage of new cases of smear-posi- tive TB detected ranged between 56 and 68%. The staining techniques may, therefore, not suﬃcient for the diagnosis of TB, as smear-negative cases will be missed [37]. The traditional culture on Lowenstein-Jensen’s medium may take 4–6 weeks to obtain a result. This may, however, still be useful in cases of diagnostic doubts and management of suspected drug-resistant tuberculosis [38]. Newer diagnostic tools are now available to facilitate diagnosis, including the liquid Bactec culture medium, which has been endorsed by WHO. Other culture media that could be used include the modiﬁed Lowenstein’s medium, Petragnani medium, Tru- deau Committee medium, Peizer’s medium, Dubos Middle- brook media, Tarshis blood agar, Middlebrook’s 7-H3, Mid- dlebrook’s 7-H9, and Middlebrook’s 7H-10 media [38]. Liq- uidisation and decontamination with N-Acetytl-L-Cysteine in 1% Sodium Hydroxide solution before inoculation may enhance sensitivity [38]. M. tuberculosis produces niacin and heat-sensitive cata- lase and it lacks pigment. It may, therefore, be diﬀerentiated from other mycobacterium species using these features. Others include reduction of nitrates and its isoniazide sen- sitivity, which may, however, not be reliable in cases of INH resistance. Molecular Line Probe Assay (LPA) as well as the use of polymerase chain reaction (PCR) are presently facilitating the speciﬁc identiﬁcation of the tubercle bacilli [37]. 10. Treatment of Tuberculosis “Untreated tuberculosis represents a far greater hazard to a pregnant woman and her fetus than does treatment of the disease” [39]. The management of tuberculosis in pregnancy is a mul- tidisciplinary approach, with the team comprising the obste- trician, communicable disease specialty personnel, neonatol- ogists, counselling unit, and public health oﬃcials. Treatment is achieved through the use of Directly Ob- served Therapy, Short Course (DOTS). This therapy entails the use of combination therapy for at least 6 months, de- pending on the combination of antituberculous agents that are available. This combination includes isoniazide and ri- fampicin compulsorily, supported by ethambutol and pyraz- inamide [40–44]. For patients with drug-susceptible TB and good drug adherence, these regimens will cure around 90% of TB cases. Treatment is done on out-patient basis, unless otherwise in- dicated [37]. The use of these ﬁrst-line antituberculous drugs in preg- nancy are considered safe for the mother and the baby by The British Thoracic Society, International Union Against Tuberculosis and Lung Disease, and the World Health Or- ganisation [16, 45]. 10.1. Isoniazide. INH is safe during pregnancy even in the ﬁrst trimester, though it can cross the placenta [11]. The women must, however, be followed up because of the possi- bility of INH-induced hepatotoxicity. Pyridoxine supple- mentation is recommended for all pregnant women taking INH at a dose of 50 mg daily [39, 46].