Pregnancy and Travel
Special risks exist for the pregnant international traveler. Some infections are more severe in pregnancy. Immunizations and medications available for prevention and/or treatment may be harmful to the developing fetus.
Travel should be avoided by pregnant women with complicated medical needs (high risk pregnancy, history of spontaneous abortions, multiple births).
The travel medicine practitioner should assist the pregnant traveler in learning:
Level of medical care available at destination
Medical insurance coverage for pregnancy, labor, and delivery
Possible complications that could arise
Danger signs of a problem pregnancy
Names of hospitals and doctors at the destination
Advising the patient to carry a copy of her medical and obstetrical records including blood type and Rh.
Travel during the second trimester is safest. Risks of miscarriage are highest in first trimester. Risks of premature labour, preterm rupture of membranes, hypertension, phlebitis, uterine and placental injury in an MVC are highest in the third trimester.
In general, live vaccines should be avoided (such as measles, mumps, rubella, oral cholera, oral typhoid, varicella). However, Yellow fever vaccine may be given to individuals who are at high risk as there have never been any reports of fetal abnormalities in women who have received the vaccine. It is preferable to give Yellow Fever vaccine after 6 months. Consider providing a letter of medical exemption to pregnant patients at low risk, entering counties with border requirements.
Non-live vaccines (TdP, Hep A & B, meningitis, rabies, influenza, pneumococcal pneumonia, injectable typhoid) are felt to be safe if indicated, but it is prudent to wait until the second trimester if possible.
There is little to no experience with Japanese Encephalitis vaccine in pregnancy, so it should be used only if the risk of exposure is high. The same is true of Lyme disease vaccine.
In general, pregnant women should not travel to malarious are unless the travel is absolutely necessary. Malaria can cause more severe problems in pregnant women than those who are not pregnant.
Malaria increases the risk of maternal death, fetal prematurity, miscarriage, and stillbirth.
Chloroquine has not been shown to be harmful to the fetus during pregnancy.
Mefloquine is considered safe, however, there are not extensive date on its safe use during pregnancy, especially during the first trimester.
Chloroquine and proguanil in combination can be used, but has relatively low efficacy where there is chloroquine resistance, so should be avoided
Doxycycline, atovaquone/proguanil and primaquine should not be used during pregnancy.
The safety of DEET in pregnancy has not been established. It should be used sparingly and in low concentration (<30%).
Permethrin-impregnated clothing, bed nets and pyrethrum mosquito coils are safe in pregnancy.
Severe travelers diarrhea may lead to premature labor and shock.
Azithromycin is considered to be the treatment of choice for TD in pregnancy although studies are lacking (500mg po the first day, then 250 po daily for 2 more days)
Quinolones (norfloxacin, ciprofloxacin, ofloxacin are not considered safe in pregnancy.
Loperamide is thought to be safe during pregnancy, but should be used sparingly due to lack of data.
Metronidazole has been used safely in pregnancy but is generally recommended only in severe protozoal infections causing weight loss and malnutrition.
Paromomycin is safe although often unsuccessful.
Tetracycline and doxycycline should not be used in pregnancy.
Travel during final month of pregnancy is generally prohibited by airlines.
A woman who plans to fly during the last 3 months of pregnancy will need a letter from her OB-GYN indicating her due date.
Give advice on leg exercises, support hose, good hydration to reduce risk of thrombosis.
Most cruise liners will carry pregnant women up to the seventh month.
Pregnant women should not sit for prolonged periods in an automobile because of risk of thrombosis.
Vehicles in developing countries may not have 3 point restraint safety belt which are recommended for pregnant women
Motion sickness can be treated or prevented safely with meclizine or dimenhydrinate.
Skiing, scuba diving water skiing and high altitude travel are not advisable during pregnancy.
Avoid hot tubs, saunas and vigorous exercise in hot and humid climates,
1) Medical Reference Guide, Shoreland, 2000 & recent updates
2) International Travel and Health. Vaccine Requirements and Health Advice., WHO, 1999
3) Canadian Immunization Guide, Health Canada, 2002
4) International Travel Health Guide, Stuart Rose, 2001
5) The Travel Doctor, Mark Wise, 2002
6) Health Canada Web site
7)
CDC Web site
Submitted by Dr. Lisa White, Ottawa