Pregnant Travelers

Pregnant Travelers

Madeline Y. Sutton

OVERVIEW

Since as many as 50% of pregnancies are unplanned, women of reproductive age should consider maintaining current immunizations during routine check-ups in case an unplanned pregnancy coincides with a need to travel. Because of the decreased risk to the unborn child, preconceptional immunizations are preferred to vaccination during pregnancy. A woman should defer pregnancy for ≥28 days after receiving live vaccines (such as measles-mumps-rubella or yellow fever) because of a theoretical risk of transmission to the fetus. However, small studies of women who received these vaccines unintentionally during pregnancy have not found a definitive link between the vaccines and poor pregnancy outcomes. Therefore, pregnancy termination is not recommended after an inadvertent exposure.
According to the American College of Obstetrics and Gynecology, the safest time for a pregnant woman to travel is during the second trimester, when she usually feels best and is in least danger of spontaneous abortion or premature labor. A woman in the third trimester should be advised to defer overseas travel because of concerns about access to medical care in case of problems such as hypertension, phlebitis, or premature labor. Pregnant women should be advised to consult with their health care providers before making any travel decisions. Collaboration between travel health experts and obstetricians is helpful in weighing benefits and risks based on destination and recommended preventive and treatment measures. Table 8-05 lists relative contraindications to international travel during pregnancy. In general, pregnant women with serious underlying illnesses should be advised not to travel to developing countries.

Table 8-05. Potential contraindications to international travel during pregnancy

OBSTETRIC 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 age ≥35 years or ≤15 years
  • 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 experiencing ongoing outbreaks of life-threatening foodborne or insectborne infections
  • Areas where chloroquine-resistant Plasmodium falciparum malaria is endemic
  • Areas where live virus vaccines are required or recommended
Abbreviation: NYHA, New York Heart Association.

PREPARATION FOR TRAVEL DURING PREGNANCY

Once a pregnant woman has decided to travel, a number of issues need to be considered before her departure:
  • An intrauterine pregnancy should be confirmed by a clinician and ectopic pregnancy excluded before beginning any travel.
  • General health insurance policies may or may not provide coverage of pregnancy-related problems while abroad. Pregnant travelers should inquire about what their health insurance policies cover and, if needed, obtain a supplemental policy for their trip. Many supplemental travel insurance policies and prepaid medical evacuation insurance policies do not cover pregnancy-related problems, so this issue should be clarified before obtaining a policy.
  • Check medical facilities at the destination. For a woman in the last trimester, medical facilities should be able to manage complications of pregnancy, toxemia, cesarean sections, and premature or ill neonates.
  • Determine beforehand whether prenatal care will be required while abroad and who will provide it. The pregnant traveler should make sure she does not miss prenatal visits requiring specific timing.
  • Determine beforehand whether blood is routinely screened for HIV and hepatitis B and C at the destination. Pregnant travelers should consider the safety of blood transfusions, if needed, when making plans for international travel. The pregnant traveler should also be advised to know her blood type, and Rh-negative pregnant women should receive anti-D immune globulin (a plasma-derived product) prophylactically at about 28 weeks’ gestation. The immune globulin dose should be repeated after delivery if the infant is Rh positive.
  • Determine if the traveler risks influenza on this trip, and recommend influenza vaccine accordingly.
  • Determine whether the prevalence of tuberculosis (TB) is high in the destination region and whether the planned itinerary will put the traveler at risk for TB. If exposure to TB is determined to be a risk, the pregnant traveler should receive skin testing before and after travel (see Chapter 3, Tuberculosis).

GENERAL RECOMMENDATIONS FOR TRAVEL DURING PREGNANCY

A pregnant woman should be advised to travel with at least one companion; she should also be advised that, during her pregnancy, her level of comfort may be adversely affected by traveling. Table 8-06 lists the most serious risks that pregnant women face during international travel.
Typical problems of pregnant travelers are the same as those experienced by any pregnant woman: fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased frequency of urination, and hemorrhoids. During travel, pregnant women can take preventive measures, including avoiding gas-producing food or drinks before scheduled flights (entrapped gases can expand at higher altitudes) and periodically moving the legs (to decrease venous stasis). Pregnant women should always use seatbelts while seated, as air turbulence is not predictable and may cause significant trauma.
Signs and symptoms that indicate the need for immediate medical attention are vaginal bleeding, passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual problems.

Table 8-06. Greatest risks for pregnant travelers

Motor vehicle accidents
  • Safety belts should be worn whenever possible.
  • Fasten seatbelts at the pelvic area, not across the lower abdomen. Lap and shoulder restraints are best.
  • In most accidents, the fetus recovers quickly from the safety belt pressure. However, consult a physician even for mild trauma.
Hepatitis E
  • Hepatitis E is not vaccine preventable and is especially dangerous in pregnant women.
  • As with other enteric infections, pregnant women should be advised that the best preventive measures are to avoid potentially contaminated water and food.
Scuba diving
  • Scuba diving should be avoided in pregnancy because of the risk of decompression syndrome in the fetus.

AIR TRAVEL DURING PREGNANCY

Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. The American College of Obstetricians and Gynecologists states that women with healthy, single pregnancies can fly safely up to 36 weeks’ gestation.
The lowered cabin pressure (kept at the equivalent of 5,000–8,000 ft [about 1,500–2,400 m]) has minimal effect on fetal oxygenation because of the favorable fetal hemoglobin-oxygen dynamics. If supplemental oxygen is required during flight because of preexisting medical conditions, arrangements for oxygen need to be made in advance. Severe anemia, sickle-cell disease or trait, or history of thrombophlebitis are relative contraindications to flying. Pregnant women with placental abnormalities or risks for premature labor should avoid air travel.

Airline Policies and Airport Security

Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking reservations, because some will require medical forms to be completed. Domestic travel is usually permitted until the pregnant traveler is in week 36 of gestation, and international travel may be permitted until weeks 32–35, depending on the airline. A pregnant woman should be advised to carry documentation stating the expected day of delivery, contact information for her obstetric provider, and her blood type. For pregnant flight attendants and pilots, work-related air travel is restricted by most airlines by 20 weeks’ gestation.
To date, airport security radiation exposure is minimal for pregnant women and has not been linked to an increase in adverse outcomes for unborn children. However, because of early reports of a possible association of radiation exposure during pregnancy with subsequent increased risk of childhood leukemia and cancer, a pregnant passenger may request a hand or wand search rather than being exposed to the radiation of the airport security machines.

General Tips

  • An aisle seat at the bulkhead will provide the most space and comfort, but a seat over the wing in the midplane region will give the smoothest ride.
  • A pregnant woman should be advised to walk every half hour during a smooth flight and flex and extend her ankles frequently to prevent phlebitis.
  • Dehydration can lead to decreased placental blood flow and hemoconcentration, increasing risk of thrombosis. Thus, pregnant women should drink plenty of fluids during flights.

TRAVEL TO HIGH ALTITUDES DURING PREGNANCY

There have been no documented reports of adverse pregnancy outcomes related to high-altitude exposure during pregnancy. High-altitude destinations, however, often are remote from medical care in an emergency, and any decision to trek or climb to high altitudes while pregnant should take into account the uncertainties of being in a remote environment while pregnant and the unknown possible effects of high altitude on the fetus. Conservative advice for pregnant women is to avoid altitudes >12,000 ft (3,658 m).

FOODBORNE AND WATERBORNE ILLNESS DURING PREGNANCY

Pregnant women should be advised of the following:
  • Adhere strictly to food and water precautions in developing countries, because the consequences of foodborne and waterborne illness may be more severe than diarrhea and may have serious sequelae (such as toxoplasmosis or listeriosis).
  • Boil suspect drinking water to avoid long-term use of iodine-containing purification systems. Iodine tablets can probably be used for travel up to several weeks, but congenital goiters have been reported in association with administration of iodine-containing drugs during pregnancy.
  • Oral rehydration (boiled or bottled water) is the mainstay of therapy for travelers’ diarrhea.
  • Bismuth subsalicylate compounds are contraindicated because of the theoretical risks of fetal bleeding from salicylates and teratogenicity from the bismuth.
  • The combination of kaolin and pectin may be used, and loperamide should be used only when necessary.
The combination of kaolin and pectin is no longer readily available in the United States. The formulation of Kaopectate currently marketed in the United States uses bismuth subsalicylate as the active ingredient and should not be given to pregnant women. The formulation marketed in Canada (also under the trade name Kaopectate) uses attapulgite as the active ingredient. Attapulgite is most likely safe to use in pregnant women because it adsorbs bacteria in the gut and does not enter systemic circulation, but it has not been assigned to a pregnancy category by the Food and Drug Administration. Formulations of attapulgite are not readily available in the United States. Updated August 16, 2011

  • The antibiotic treatment of travelers’ diarrhea during pregnancy can be complicated. Azithromycin or an oral third-generation cephalosporin may be the best option for treatment, if an antibiotic is needed.

MALARIA DURING PREGNANCY

Advise pregnant women to avoid travel to malaria-endemic areas if possible. Women who choose to go to areas with malaria can reduce their risk of acquiring malaria by taking appropriate malaria chemoprophylaxis and following insect precautions (see Chapter 2, Protection against Mosquitoes, Ticks, and Other Insects and Arthropods and Chapter 3, Malaria). Pregnant women should use insect repellents as recommended for adults sparingly, but as needed. Pyrethrum-containing house sprays may also be used indoors, if insects are a problem.

Antimalarial Medications

For pregnant women who travel to areas with chloroquine-sensitive Plasmodium falciparum malaria, chloroquine can be taken for malaria chemoprophylaxis, since it has been used for decades with no documented increase in birth defects. For pregnant women who travel to areas with chloroquine-resistant P. falciparum, mefloquine should be recommended for chemoprophylaxis. Evidence suggests that mefloquine prophylaxis causes no significant increase in spontaneous abortions or congenital malformations when taken during pregnancy. (Updated October 26, 2011)
Because there is no evidence that chloroquine and mefloquine are associated with congenital defects when used for prophylaxis, CDC does not recommend that women planning pregnancy wait a specific period of time after their use before becoming pregnant. However, if women or their health care providers wish to decrease the amount of antimalarial drug in the body before conception, Table 8-07 provides information on the half-lives of selected antimalarial drugs. After 2, 4, and 6 half-lives, approximately 25%, 6%, and 2%, respectively, of the drug remain in the body.
Doxycycline and primaquine are contraindicated for malaria prophylaxis during pregnancy, because both may cause adverse effects on the fetus. Atovaquone-proguanil is not recommended for use by pregnant women to prevent malaria because of the lack of safety studies during pregnancy.

Treatment and Management

Malaria must be treated as a medical emergency in any pregnant traveler. A woman who has traveled to an area that has chloroquine-resistant strains of P. falciparum should be treated as if she has illness caused by chloroquine-resistant organisms. The management of malaria in a pregnant woman should include frequent blood glucose determinations and careful fluid monitoring (being careful not to give too much intravenous fluid).

Table 8-07. Half-lives of selected antimalarial drugs

DRUG HALF LIFE
Atovaquone 2–3 days
Chloroquine Can extend 6–60 days
Doxycycline 12–24 hours
Mefloquine 2–3 weeks
Primaquine 4–7 hours
Proguanil 14–21 hours
Pyrimethamine 3–4 days
Sulfadoxine 6–9 days

IMMUNIZATIONS FOR PREGNANT TRAVELERS

Risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists of risk from vaccinating pregnant women with inactivated virus, bacterial vaccines, or toxoids. The benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, infection would pose a risk to the mother or fetus, and the vaccine is unlikely to cause harm.
Table 8-08 is intended for women who may require immunizations during pregnancy. Pregnant travelers may visit areas of the world where diseases eliminated by routine vaccination in the United States are still endemic, and therefore may require immunizations before travel.

Table 8-08. Vaccination during pregnancy

VACCINE/IMMUNOBIOLOGIC TYPE USE
Immune globulins, pooled or hyperimmune Immune globulin or specific globulin preparations If indicated for pre- or postexposure use. No known risk to fetus
Vaccination of pregnant women is recommended
Hepatitis B Recombinant or plasma-derived Recommended for women at risk of infection
Influenza1 Inactivated whole virus or subunit All people >6 months, including women who will be or are pregnant during the flu season (September–March), regardless of trimester, and women at high risk for pulmonary complications, regardless of trimester
Tetanus-diphtheria (Td) Toxoid If indicated, such as lack of primary series or no booster within past 10 years
Tetanus-diphtheria-pertussis (Tdap) Toxoid, acellular Not contraindicated, but no data are available on safety, immunogenicity, and outcomes of pregnancy. ACIP recommends Td when tetanus and diphtheria protection are required but Tdap to add protection against pertussis in some situations. Second or third trimester is preferred.
Hepatitis A Inactivated virus No data are available on safety in pregnancy. Because hepatitis A vaccine is produced from inactivated hepatitis A virus, the theoretical risk of vaccination should be weighed against the risk of disease. Consider immune globulin rather than vaccine.
Pregnancy is a Precaution, and Under Normal Circumstances, Vaccination Should Be Deferred; Vaccine Should Only Be Given when Benefits Outweigh Risks
Japanese encephalitis Inactivated virus No data are available on safety in pregnancy. Pregnant women who must travel to an area where the risk is high should be vaccinated when the theoretical risks are outweighed by the risk of disease.
Meningococcal meningitis Polysaccharide Meningococcal conjugate vaccine (MenACWY) is preferred for adults; however, no data are available on safety and immunogenicity in pregnant women. Meningococcal polysaccharide vaccine (MPSV4) can be administered during pregnancy if the woman is entering an epidemic area. Indications for prophylaxis are not altered by pregnancy; vaccine is recommended in unusual outbreak situations.
Pneumococcal Polysaccharide The safety of pneumococcal (PPV23) vaccine during the fi rst trimester of pregnancy has not been evaluated, although no adverse events have been reported after inadvertent vaccination during pregnancy. Women with chronic diseases, smokers, and immunosuppressed women should consider vaccination.
Polio, inactivated Inactivated virus Indicated for susceptible pregnant women traveling in endemic areas or in other high-risk situations.
Rabies Inactivated virus Indications for postexposure prophylaxis not altered by pregnancy. If risk for exposure to rabies is substantial, preexposure prophylaxis may also be indicated.
Typhoid (ViCPS) Polysaccharide If indicated for travel to endemic areas
Typhoid (Ty21a) Live bacterial No data are available on safety in pregnancy; theoretical risk exists, because it is a live-attenuated vaccine.
Yellow fever Live attenuated The safety of YF vaccination in pregnancy has not been studied in a large prospective trial. If travel is unavoidable and the risks for YFV exposure outweigh the vaccination risks, a pregnant woman should be vaccinated. If the risks for vaccination outweigh the risks for YFV exposure, a pregnant woman should be issued a medical waiver to fulfill health regulations. If a pregnant woman is vaccinated, her infant should be monitored after birth for evidence of congenital infection and other possible adverse effects resulting from YF vaccination. Pregnancy may interfere with the immune response to YF vaccine; therefore, serologic testing to document a protective immune response to the vaccine should be considered (see Chapter 3, Yellow Fever for more details).
Pregnancy is a Contraindication to Vaccination; Vaccine Should Not Be Administered to Pregnant Women
Tuberculosis (BCG) Attenuated mycobacterial Contraindicated due to theoretical risk of disseminated disease. Skin testing for tuberculosis exposure before and after travel is preferable when the risk of possible exposure is high.
Measles-mumps-rubella Live attenuated virus Contraindicated. Vaccination of susceptible women should be part of postpartum care. Unvaccinated women should delay travel to countries where measles is endemic until after delivery. Unvaccinated pregnant women with a documented exposure to measles should receive immune globulin within 6 days to prevent illness.
Human papillomavirus Recombinant quadrivalent Contraindicated. The vaccine has not been causally associated with adverse outcomes of pregnancy; however, additional information is needed for further recommendations. Pregnancy testing is not needed before vaccination.
Varicella Live attenuated virus Contraindicated. Vaccination of susceptible women should be considered postpartum. Unvaccinated pregnant women should consider postponing travel until after delivery, when the vaccine can be given safely.
Influenza1 Live attenuated virus, including intranasal preparations Contraindicated during pregnancy; postpartum and breastfeeding mothers may receive live attenuated virus vaccines.
Abbreviations: ACIP, Advisory Committee on Immunization Practices; BCG, Bacillus Calmette-Guérin; YF, yellow fever; YFV, yellow fever virus.
1Starting with the 2010–11 influenza season, most influenza vaccines will offer protection against both seasonal and H1N1 influenza virus strains.

TRAVEL HEALTH KITS FOR PREGNANT WOMEN

Additions and substitutions to the usual travel health kit (see Chapter 2, Travel Health Kits) need to be made during pregnancy. Talcum powder, a thermometer, oral rehydration salt packets, prenatal vitamins, a topical antifungal agent for vaginal yeast, acetaminophen, and a sunscreen with a high SPF should be included. Women in the third trimester may be advised to carry a blood-pressure cuff and urine dipsticks and be trained to use this equipment to check for hypertension, proteinuria, and glucosuria, any of which would require prompt medical attention. Antimalarial and antidiarrheal self-treatment medications should be evaluated individually, depending on the traveler’s itinerary and her health history. Medications should only be used after consultation with a physician.

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