Tuberculosis (TB) in pregnancy can pose significant diagnostic and therapeutic challenges. We report a 29-year-old Caucasian woman at 25 weeks’ gestation diagnosed with concurrent laryngeal and pulmonary tuberculosis. Standard anti-tuberculous therapy was initiated; however, treatment was complicated by drug-induced liver injury secondary to pyrazinamide, requiring regimen modification. The pregnancy was further complicated by intrahepatic cholestasis of pregnancy, making differentiation between this and medication-related hepatotoxicity clinically challenging. This case underscores the complexity of managing active tuberculosis and overlapping hepatic pathology during pregnancy and highlights the importance of close multidisciplinary care to optimize maternal and fetal outcomes.