Factors to Consider for International Traveling When Pregnant
Pregnant
women considering international travel should be advised
to evaluate the potential problems associated with international
travel as well as the quality of medical care available
at the destination and during transit. According to the
American College of Obstetrics and Gynecology, the safest
time for a pregnant woman to travel is during the second
trimester (18–24 weeks) when she usually feels best
and is in least danger of experiencing a spontaneous abortion
or premature labor. A woman in the third trimester should
be advised to stay within 300 miles of home 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 preventative and treatment measures.
Preparation for Travel
Once a pregnant woman has decided to travel, a number
of issues need to be considered before her departure.
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Ensure that her health insurance is valid while abroad
and during pregnancy, and that the policy covers a newborn
should delivery take place. In addition, a supplemental
travel insurance policy and a prepaid medical evacuation
insurance policy should be obtained, although most may
not cover pregnancy-related problems.
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Check medical facilities at her destination. For a woman
in the last trimester, medical facilities should be
able to manage complications of pregnancy, toxemia,
and cesarean sections.
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Determine beforehand whether prenatal care will be required
abroad and, if so, who will provide it. The pregnant
traveler should also make sure prenatal visits requiring
specific timing are not missed.
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Determine, before traveling, whether blood is screened
for HIV and hepatitis B at her destination. The pregnant
traveler and her companion(s) should also be advised
to know their blood types.
General Recommendations for Travel
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. 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.
Signs and symptoms that indicate the need for immediate
medical attention are bleeding, passing tissue or clots,
abdominal pain or cramps, contractions, ruptured membranes,
excessive leg swelling or pain, headaches, or visual problems.
Greatest Risks for Pregnant Travelers
Motor vehicle accidents are a major cause of morbidity
and mortality for pregnant women. When available, safety
belts should be fastened at the pelvic area. Lap and shoulder
restraints are best; in most accidents, the fetus recovers
quickly from the safety belt pressure. However, even after
seemingly blunt, mild trauma, a physician should be consulted.
Hepatitis E (HEV), which is not vaccine preventable, can
be especially dangerous for pregnant women, for whom the
case-fatality rate is 17%–33%. Therefore, pregnant
women should be advised that the best preventive measures
are to avoid potentially contaminated water and food,
as with other enteric infections.
Scuba diving at any depth should be avoided in pregnancy
because of the risk of decompression syndrome in the fetus.
Specific
Recommendations for Pregnancy and Travel
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 (ACOG) states that women can fly safely
up to 36 weeks gestation. The lowered cabin pressures
(kept at the equivalent of 1,524–2,438 meters [5,000–8,000
feet]) affect fetal oxygenation minimally because of the
favorable fetal hemoglobin-oxygen dynamics. If required
for some medical indications, supplemental oxygen can
be ordered 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. 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 her 36th week of gestation,
and international travel may be permitted until weeks
32–35, depending on the airline. A pregnant woman
should be advised always to carry documentation stating
her expected date of delivery.
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. The safety belt should always be fastened at
the pelvic level. 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
Acclimatization
responses at altitude act to preserve fetal oxygen supply,
but all pregnant women traveling to high altitude should
avoid altitudes > 4,000 meters (13,123 feet) In addition,
altitudes >2,500 meters (8,200 feet) should be avoided
in late or high-risk pregnancy. All pregnant women who
have recently traveled to a higher altitude should postpone
exercise until acclimatized.
Breast-Feeding and Travel
The
decision to travel internationally with a nursing infant
produces its own challenges. However, breast-feeding has
nutritional and anti-infective advantages that serve an
infant well while traveling. Moreover, exclusive breast-feeding
relieves concerns about sterilizing bottles and availability
of clean water. Supplements are usually not needed by
breast-fed infants <6 months of age, and breast-feeding
should be maintained as long as possible. If supplementation
is considered necessary, powdered formula that requires
reconstitution with boiled water should be carried. For
short trips, it may be feasible to carry an adequate supply
of pre-prepared canned formula.
Nursing women may be immunized routinely, based on recommendations
for the specific travel itinerary. However, consideration
needs to be given to the neonate who cannot be immunized
at birth and who would not gain protection against many
infections (e.g., yellow fever, measles, and meningococcal
meningitis) through breast-feeding. Neither inactivated
nor live virus vaccines affect the safety of breast-feeding
for mothers or infants. Breast-feeding does not adversely
affect immunization and is not a contraindication to the
administration of any vaccines, including live virus vaccines.
Although rubella vaccine virus may be transmitted in breast
milk, the virus usually does not infect the infant and,
if it does, the infection is well tolerated. Breast-fed
infants should be vaccinated according to recommended
schedules.
Nursing women should be advised that disruptions of eating
and sleeping patterns, as well as other stressors, may
affect their milk output. They need to increase their
fluid intake, avoid excess alcohol and caffeine, and,
as much as possible, avoid exposure to tobacco smoke.
A nursing mother with travelers' diarrhea should not stop
breast-feeding, but should increase her fluid intake.
Breast-feeding is desirable during travel and should be
continued as long as possible because of its safety and
a lower incidence of infant diarrhea.
Women traveling with neonates or infants should be advised
to check with their pediatricians regarding any medical
contraindictions to flying. Infants are particularly susceptible
to pain with eustachian tube collapse during pressure
changes. Breast-feeding during ascent and descent relieves
this discomfort.
Food & Waterborne Illness during Pregnancy
Pregnant travelers should be advised to exercise dietary
vigilance while traveling during pregnancy because dehydration
from travelers' diarrhea can lead to inadequate placental
blood flow and increased risk for premature labor. Drinking
water should be boiled 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. Pregnant
travelers should eat only well-cooked meats and pasteurized
dairy products, while avoiding pre-prepared salads; this
will help to avoid diarrheal disease as well as infections
such as toxoplasmosis and Listeria, which can
have serious sequelae in pregnancy. Pregnant women should
be advised not to use prophylactic antibiotics for the
prevention of travelers' diarrhea.
Oral rehydration 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, but loperamide should
be used only when necessary. The antibiotic treatment
of travelers' diarrhea during pregnancy can be complicated.
An oral third-generation cephalosporin may be the best
option for treatment if an antibiotic is needed.
Travel-Related Immunization during Pregnancy
Immune Globulin Preparations
No
known fetal risk exists from passive immunization of pregnant
women with immunoglobulin preparations. Administration
of immune globulin can be used pre-exposure as protection
against Hepatitis A or for postexposure management for
other viral diseases.
Bacille Calmette-Guerin
BCG vaccine, used
outside the United States for the prevention of tuberculosis,
can theoretically cause disseminated disease and, thus,
affect the fetus. Although no harmful effects to the fetus
have been associated with BCG vaccine, its use is not
recommended during pregnancy. Skin testing for tuberculosis
exposure before and after travel is preferable when the
risk is high.
Hepatitis A
Pregnant women without
immunity to hepatitis A virus (HAV) need protection before
traveling to developing countries. HAV is usually no more
severe during pregnancy than at other times and does not
affect the outcome of pregnancy. There have been reports,
however, of acute fulminant disease in pregnant women
during the third trimester, when there is also an increased
risk of premature labor and fetal death. These events
have occurred in women from developing countries and might
have been related to underlying malnutrition. HAV is rarely
transmitted to the fetus, but this can occur during viremia
or from fecal contamination at delivery. Immune globulin
is a safe and effective means of preventing HAV, but immunization
with one of the HAV vaccines gives a more complete and
prolonged protection. The effect of these inactivated
virus vaccines on fetal development is unknown and is
expected to be low; the production methods for the vaccines
are similar to that for IPV, which is considered safe
during pregnancy.
Japanese Encephalitis
No information is
available on the safety of Japanese encephalitis vaccine
during pregnancy. It should not be routinely administered
during pregnancy, except when a woman must stay in a high-risk
area. If not mandatory, travel to such areas should be
postponed until after delivery and until the infant is
old enough to be safely vaccinated (1 year).
Meningococcal Meningitis
The polyvalent meningococcal
meningitis vaccine can be administered during pregnancy
if the woman is entering an area where the disease is
epidemic. Studies of vaccination during pregnancy have
not documented adverse effects among either pregnant women
or neonates. Based on data from studies involving the
use of meningococcal vaccines administered during pregnancy,
altering meningococcal vaccination recommendations during
pregnancy is unnecessary.
Rabies
Because of the potential
consequences of inadequately treated rabies exposure and
because there is no indication that fetal abnormalities
have been associated with cell culture rabies vaccines,
pregnancy is not considered a contraindication to rabies
postexposure prophylaxis. If the risk of exposure to rabies
is substantial, preexposure prophylaxis may also be indicated.
Typhoid
There are no data
on the use of either typhoid vaccine in pregnancy. The
Vi capsular polysaccharide vaccine (ViCPS) injectable
preparation is the vaccine of choice during pregnancy
because it is inactivated and requires only one injection.
The oral Ty21a typhoid vaccine is not absolutely contraindicated
during pregnancy, but it is live-attenuated and thus has
theoretical risk. With either of these, the vaccine efficacy
(about 70%) needs to be weighed against the risk of disease.
Yellow Fever
The safety of yellow
fever vaccination during pregnancy has not been established,
and the vaccine should be administered to a pregnant woman
only if travel to an endemic area is unavoidable and if
an increased risk for exposure exists. In these instances,
the vaccine can be administered, and infants born to these
women should be monitored closely for evidence of congenital
infection and other possible adverse effects resulting
from yellow fever vaccination. Although concerns exist,
no congenital abnormalities have been reported after administration
of this vaccine to pregnant women. Further, serologic
testing to document an immune response to the vaccine
can be considered, because the seroconversion rate for
pregnant women may be lower than in other healthy adults.
If traveling to or transiting regions within a country where the disease is not a current threat but where policy requires a yellow fever vaccination certificate, pregnant travelers should be advised to carry a physician's waiver, along with documentation (of the waiver) on the immunization record.
In general, pregnant women should be advised to postpone travel to areas where yellow fever is a risk until 9 months after delivery, hen vaccine can be administered to the mother without concern of fetal toxicity and when there is low risk of vaccine-associated encephalitis for the infant.
The Travel Health Kit during Pregnancy
Additions and substitutions to the usual travel health kit need to be made during pregnancy and nursing. Talcum powder, a thermometer, oral rehydration salt (ORS) packets, prenatal vitamins, an antifungal agent for vaginal yeast, acetaminophen, and a sunscreen with a high SPF should be carried. Women in the third trimester may be advised to carry a blood-pressure cuff and urine dipsticks so they can check for proteinuria and glucosuria, both of which would require attention. Antimalarial and antidiarrheal self-treatment medications should be evaluated individually, depending on the traveler, her trimester, the itinerary, and her health history. Most medications should be avoided, if possible.
(Source: Center
for Disease Control)
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