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      The pregnant traveller



The pregnant traveller

If you are pregnant and considering international travel, you are strongly advised to evaluate the potential problems associated with international travel as well as the quality of medical care available while travelling and at your destination. You should have a clear plan of action in the event of complications during travel or at your destination, and the names of doctors and hospitals able to handle these complications.

The safest time for a pregnant woman to travel is during the second trimester (18–24 weeks) when she is least likely to experience premature birth. A woman in the third trimester is advised to remain in close contact with medical care throughout her travels and, if there is any suggestion of serious complications, should not travel to developing countries.

Airline policy
From the QANTAS website:
There is no restriction for a normal uncomplicated pregnancy for domestic travel, but medical clearance is required if you wish to travel past the 36th week for uncomplicated multiple pregnancy or if you are having complications of pregnancy.
International travel is not permitted after the 36th week for routine pregnancies or the 32nd week for routine multiple pregnancies. Some countries place limitations on the entry of non-national pregnant women. It is best to check with the local consulate if in any doubt.

Preparation for travel
The pregnant traveller, like all travellers, should carry a first aid/medical kit appropriate to her destination. However, the following items should be added to the kit: antenatal folic acid and minerals if prescribed, antifungal creams for vaginal thrush infections, talcum powder, sunscreen with high SPF, and paracetamol (rather than aspirin).
Most medications should be avoided, if possible. Antimalarials and other medications should be included only on the advice of the travel health doctor. If travelling during the third trimester, a blood pressure monitor and urinary dipsticks, for the detection of urinary protein, may prove to be very useful.
Over the counter (OTC) self-treatment medications should be discussed with the attending doctor.

General Recommendations for Travel
Pregnant travellers are best to travel with a companion able to access medical care if problems arise.
Travelling companions should recognise the signs and symptoms indicating the need for immediate medical attention. These include vaginal bleeding or the passage of clots or tissue, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual problems.
They should also be aware that pregnant travellers may experience common less serious problems such as heartburn, fatigue, indigestion, constipation, vaginal discharge, leg cramps, frequency of urination and haemorrhoids.
Travel insurance is essential, particularly so for the pregnant traveller. Insurance should cover the whole pregnancy; including labor, delivery and medical care available at the destination.

Medical reasons to avoid travel
Pregnant women should consult with their health-care providers before making any travel decisions.
In general, pregnant women with serious underlying illnesses should be advised not to travel to developing countries.
Any pregnancy may experience complications such as hypertension, phlebitis, miscarriage or premature labour, urinary infections, etc. These complications may become a serious issue in countries lacking standard health care.
The following table is adapted from CDC: Health Information for International Travel 2003-2004, and lists relative contraindications to international travel during pregnancy.

Obstetrical risk factors General medical risk factors Travel to potentially hazardous destinations
  • History of miscarriage
  • Incompetent cervix
  • History of ectopic pregnancy (ectopic with current pregnancy should be ruled out before travel)
  • History of premature labor or premature rupture of membranes
  • History of or existing placental abnormalities
  • Threatened abortion or vaginal bleeding during current pregnancy
  • Multiple gestation in current pregnancy
  • Fetal growth abnormalities
  • History of toxemia, hypertension, or diabetes with any pregnancy
  • Primigravida at 35 years of age and older, or 15 years of age and younger
    •
  • History of thromboembolic disease
  • Pulmonary hypertension
  • Severe asthma or other chronic lung disease
  • Valvular heart disease (if NYHA class III or IV heart failure)
  • Cardiomyopathy
  • Hypertension
  • Diabetes
  • Renal insufficiency
  • Severe anemia or hemoglobinopathy
  • Chronic organ system dysfunction requiring frequent medical interventions
    •
  • High altitudes
  • Areas endemic for or with ongoing outbreaks of life-threatening food- or insect-borne infections
  • Areas where chloroquine-resistant Plasmodium falciparum malaria is endemic
  • Areas where live virus vaccines are required and recommended


A few issues for pregnant travellers
Calf exercise and frequent walking about the cabin of the aircraft helps reduce the risk of deep vein thrombosis. Drugs such as diuretics, alcohol and caffeine are best avoided while flying. If you have an increased risk of thrombosis, supportive stockings (eg JetSox) and anti-clotting agents should be considered and discussed with your doctor.
Seat belts in cars should always be used even in countries where they are not compulsory. Should an accident occur, a doctor should be consulted.
Contaminated food and water are potentially more harmful to pregnant women and must be carefully avoided. Severe traveller's diarrhoea may lead to premature labor and shock. (Azithromycin is the treatment of choice for traveller’s diarrhoea in pregnancy. Loperamide is thought to be safe for the control of diarrhœa during pregnancy but available data is minimal.) Hepatitis E (sometimes seen in Asia or Africa) has a case fatality rate of 17-33% in pregnancy and there is no vaccine available. Listeriosis is a serious infection in pregnancy (case fatality rate 30%) which may follow the ingestion of pre-prepared salads, ready to eat seafood, pre-cooked meats, soft cheeses and unpasteurised milk products.
Scuba diving at any depth should be avoided in pregnancy because of the risk of decompression syndrome in the fœtus.

Vaccines
Pregnant travellers should avoid the use of live vaccines. These include measles, mumps and rubella (Priorix), chickenpox vaccine (Varilrix, Varivax) the live influenza vaccine (FluMist - not available in Australia), oral polio (Sabin - not available in Australia), the live cholera vaccine (Orochol), the live typhoid vaccine (Typh-Vax), BCG and the yellow fever vaccine (Stamaril, Arilvax). If these vaccines are considered essential, the risks must be weighed against the benefits. Alternatives may be available.
Yellow fever vaccine should be used in pregnancy only if travel to an infected area cannot be avoided. Ideally, vaccination should be deferred for nine months after delivery.
A recent study in Brazil showed the vaccine used (in that country) to be effective and very safe during pregnancy. A similar study using Stamaril has not been carried out. Most killed vaccines are considered safe during pregnancy, but should be avoided during the first trimester. The benefits and risks of vaccination should be discussed with the attending doctor. In some instances, little information is available.
CDC produces an excellent guide to the use of vaccines in pregnancy (pdf).

Travel to malarial areas
Because malaria carries a significant morbidity and mortality for both mother and foetus and no prophylactic medication is guaranteed to be effective, the pregnant traveller is advised not to travel to malarial areas.
If travel cannot be delayed, the following suggestions from the CDC Yellow Book will reduce the risk of disease.

Reducing the risk
1. Remain indoors between dusk and dawn;
2. If outdoors at night, wear light-coloured clothing, long sleeves, long pants, and shoes and socks;
3. Stay in well-constructed housing with air-conditioning and/or screens;
4. Use permethrin-impregnated bed nets; and
5. Use insect repellents containing DEET as recommended for adults, sparingly, but as needed. (Studies of the effects of tropical strength DEET during the first trimester are inconclusive, but lower concentrations (<20%) in more frequent applications are thought to be safe. The effect of DEET on the foetus is not known.)

Prophylactic medication
It is important to understand that the malaria parasites are often unaffected by some medications. Doctors often refer to falciparum malaria as being ‘chloroquine-sensitive’ or ‘chloroquine-resistant’. Pregnant women are encouraged not to visit areas where chloroquine-resistant P.falciparum occurs.
Additionally, some malaria is resistant to other drugs. You should discuss with your travel doctor or GP, the nature of the malaria at your destination and the best medication, if any, for you.
Some medications have been shown to be safe during the latter stages of pregnancy while others are definitely not safe.
Never take medications recommended by friends or locals, without first consulting with your doctor.

The following are brief notes on commonly prescribed medications for the prevention of malaria.
Chloroquine (Chlorquin) – category D
Avoid during conception. Small risk of neurological damage to the foetus during pregnancy. Ineffective in most areas. Taken weekly. Commence 1 week before departure and continue for 4 weeks after leaving malarial area.
Mefloquine (Lariam) – category B3
Not recommended in 1st trimester, otherwise safe. Taken weekly. Commence 1-2 weeks before travelling and continue for 4 weeks after leaving malarial area.
Proguanil (Paludrine) – category B2
Safe during pregnancy. Use only in combination with chloroquine. Folate supplementation required. Two tablets daily.
Atovaquone-proguanil combination (Malarone) – category B2
Folate supplementation required. Safety in pregnancy has not been established. 1 tablet daily 1-2 days before entering malarial area and continuing for seven days after leaving.

Not recommended during pregnancy.
Doxycycline (Doryx, Doxy-100, Vibramycin) - category D
Not safe during pregnancy. Dangers for mother and foetus.


Treatment medication
The treatment of malaria during pregnancy requires urgent and specialised care.


Further information:

Pregnancy, breast feeding
CDC: Pregnancy, Breast-Feeding, and Travel

The travelling woman
Better Health Channel

Drugs and Pregnancy
The Royal Women's Hospital, Melbourne

Tips for the Pregnant Traveller
babycenter