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Travel and pregnancy: advice for mothers-to-be

Carolyn Driver
RGN RM RHV FPCert
MSc(TravelMed)
Independent Travel Health Specialist Nurse
Cheshire
E:thecompany@driverc.freeserve.co.uk

Pregnancy is neither an illness nor a disability, but it is a condition that requires special consideration when it comes to travelling abroad. While in most cases pregnant women should be able to embark upon overseas travel, their advisors need to assess each patient individually and consider their medical and obstetric history, planned itinerary, destinations and ability to be flexible.(1)
The middle trimester is generally considered to be the safest time to travel, as the threat of possible miscarriage has passed and the increased weight will not limit the mother's activities. Initial investigations such as ultrasound scans should also have been performed by then confirming a uterine pregnancy. Interventions such as vaccination and taking of chemoprophylactic drugs are also best avoided in the first trimester.(2) During the third trimester obstetric complications such as pre-eclampsia, bleeding or premature labour are all issues that have to be considered. 
The pregnant traveller needs to ensure that she has adequate insurance cover (at least £2million) and may find that many companies do not routinely offer cover for the third trimester. Medical insurance is essential for travel anywhere outside the UK, but the traveller also needs to be aware that insurance is only as good as the local medical facilities available at the ­destination. 
Airlines vary as to the period of gestation when they no longer permit transport of pregnant women, so that must be checked. Commonly they will allow travel up to the 36th week of a healthy single pregnancy but require a medical certificate of fitness to fly after the 28th week. Cutoff times are significantly earlier for multiple pregnancies. Cruise lines also have similar restrictions on pregnant passengers.

Risk assessment
In addition to a thorough antenatal check before departure, a risk assessment is required for the pregnant traveller just as it is for any individual. Specific considerations include those listed in Table 1.

[[NIP16_table1_59]]

While many women may be most anxious about the issue of vaccine-preventable disease, they need to be advised about the many non-vaccine-preventable risks to their health. The physiological changes that occur during pregnancy can make women more susceptible to certain infections. The immune system is less efficient, and thus gastrointestinal and respiratory infections are common and can be significant during pregnancy. The discomfort associated with the growing uterus can be exacerbated during long journeys, and constipation and ankle oedema are more likely with the immobility of the journey and heat at the destination. Pregnancy increases the risk of deep vein thrombosis, so the pregnant traveller needs careful advice about the risk on long journeys. Flight socks have been proven to be effective and can improve comfort. However, if the individual has significant varicosities they may be better with full-length compression stockings than knee-length "travel socks".(3) Exercise during the journey should also be encouraged, as well as the need to remain well hydrated.

General precautions
Food and water precautions are essential, as traveller's diarrhoea is much more significant during pregnancy.  Sticking to safe water (bottled or boiled) and freshly cooked hot food is most important to reduce the risk.  Soft cheeses, foods that contain raw eggs, seafood and other raw foods (both unwashed and washed) should be avoided. Care should be taken while bathing and swimming to avoid swallowing water. Infections such as hepatitis E, which is transmitted in much the same way as hepatitis A, but for which there is no vaccine, carry a significantly higher mortality rate during pregnancy. Hands should be washed immediately before eating, preferably with soap and water, but alcohol-based cleansers are better if there is nothing else.(4)
If diarrhoea occurs then rehydration is most important, preferably with fluids that contain some sugar and a little salt. Whilst antidiarrhoeal agents such as loperamide would probably do no harm, their use should be reserved for really severe cases, and antibiotics  reserved for last-resort treatment. A pregnant woman whose diarrhoea does not subside within 48 hours or who is also vomiting should seek urgent medial advice. 
Respiratory infections are common during travel, and again the physiological changes in pregnancy can make a woman more susceptible. Influenza vaccination should be considered and advice on how to manage a severe cold or chest infection given. Decongestants and antihistamines may be used cautiously for symptomatic relief, but antibiotics should be reserved for lower respiratory tract infections only.
Sun care is important as hormonal changes can make the skin more vulnerable to the sun, while sunburn can contribute to dehydration. High-factor sunscreens should be used, as well as avoidance of exposure during the hottest part of the day.
Pregnancy can sap the energy, and this in combination with hot climates can seriously affect how much the traveller can accomplish - she should ensure she sets herself a realistic itinerary. Travel to high altitudes (>4,000m) is best avoided during pregnancy, and travel to altitudes of 2,500-3,000m should not be attempted in the third trimester. Adequate acclimatisation is essential before undertaking any physical exertion.

Vaccines
During the risk assessment recommended vaccines will be identified, and a decision on whether they should be administered has to be made by balancing the degree of risk of the potential infection against possible risks to the pregnancy. Inactivated vaccines should pose no special risk during pregnancy, and although some physicians prefer to wait until the second or third trimester to administer them, no increased risk has been demonstrated when they have been given earlier.(5) Live vaccines are relatively contraindicated in pregnancy, but yellow fever vaccine should be considered if a woman is intending to travel to an area where that disease is endemic. Anecdotal evidence of this vaccine being administered during pregnancy suggests that there is little risk to the pregnancy, whereas infection with yellow fever could be life-threatening.(5) It is also worth remembering that, as there is a slight immunosuppression during pregnancy, it may be that vaccination at this time will not be as effective as it is in the nonpregnant state.
The role of the healthcare professional in this scenario is to inform the individual of the risks of the infections and facilitate informed choice about whether or not to receive the vaccines. If the traveller opts not to receive any specific vaccines then information reducing the risk of infection should be reinforced, such as bite avoidance measures, food and water precautions, personal hygiene and personal safety.

Malaria prevention
If the traveller's plans take her to an area where chloroquine-resistant malaria exists, she needs to understand the degree of risk she is taking. Malaria can be catastrophic to both mother and fetus, and chemoprophylaxis is essential. Much the best course of action would be to choose an alternative destination or postpone the trip until after the birth. However, if this is not possible then she must be encouraged to use chemoprophylaxis and take adequate bite avoidance precautions.
While many women are quite rightly cautious about taking medication during pregnancy, this is a situation where the risk of the disease significantly outweighs the risk of the medication. In the UK the only medication that is effective against Plasmodium falciparum and that is licensed for use in pregnancy is mefloquine (Larium; Roche). This drug is licensed during the second and third trimester, although there are limited data suggesting that it is safe in the first trimester as well.(6) Mefloquine has a reputation for causing significant adverse events, but a recent comparison study has demonstrated it to be no worse than chloroquine.(7) Atovoquone and proguanil (Malarone; Glaxo Wellcome) is currently not licensed for use in pregnancy. The two components when used separately have not been associated with teratogenicity, but as yet there are no data on the combined form and pregnancy. If a woman has contraindications to mefloquine, her physician may make the decision to prescribe atovoquone and proguanil on the basis that the potential risk of the medication is significantly less than the potential for malaria. They would, however, be prescribing "off licence", which both they and the traveller should be aware of.
Bite avoidance measures are vital when travelling to tropical areas to prevent the many insect-borne infections that exist as well as malaria. The mainstay of bite avoidance is the use of insect repellents on any exposed skin and sleeping under a permethrin-treated mosquito net unless in a fully air-conditioned room. Pregnant women often need to get up several times during the night to empty their bladder, so they must be aware of the need to apply insect repellent before retiring and ensuring that they tuck their mosquito net in adequately each time they return to bed.
Insect repellents should contain DEET at around 20-30% as this is proven to be the most effective product and there has been no evidence of toxicity when used in the recommended quantities.(2) When going outside between dusk and dawn it is important to cover up as much as possible with suitable clothing, and the use of plug-in vaporisers or knock-down fly sprays can help to keep indoor areas free of insects.

General advice
It is advisable that the traveller attempts to locate a source of antenatal care at her destination that she can use if the need arises. She should carry her antenatal documentation with her, along with her record of vaccinations. She should be aware of the risk of blood- borne viruses from any invasive treatment that may be offered in developing countries and avoid parenteral treatments wherever possible.
The Blood Care Foundation is an organisation that arranges for fully screened blood to be sent anywhere in the world in the case of an emergency, and it would be useful for the traveller to investigate this option before departure, especially if she will be away during the third trimester.

Conclusion
There is no reason why a pregnant woman should miss out on the opportunity to travel. However, she should avoid unnecessary risks to the health of both herself and her unborn child. Careful choice of destination and thorough planning are required to ensure the trip is both enjoyable and safe.

[[NIP16_table2_61]]

Reference

  1. Kozarsky PE, Van Gompel A. Pregnancy, ­nursing, ­contraception and travel. In: Dupont H, Steffen R, editors. Textbook of travel medicine and health. 2nd ed. Ontario (BC): Decker; 2001.
  2. Mackell SM, Anderson SA. The pregnant and breast-feeding traveller. In: Keystone JS, Kozarsky PE, et al, editors. Travel medicine. Philadelphia: Mosby; 2004.
  3. Wilson-Howarth J. Advising pregnant women about travelling ­overseas. Pulse 27 May 2003:50-4.
  4. Carroll C. Traveler's ­diarrhea. www.pregnanttraveler.com
  5. Atkinson WL, Pickering LK, et al. General ­immunization practices. In: Plotkin SA, Orenstien WA, editors. Vaccines. 4th ed. Philadelphia: Saunders; 2004.
  6. Accessed at: http://www.cdc.gov/travel/diseases/malaria/index.htm#chemopregnancy
  7. Schlagenhauf P, Tschopp A, et al. Tolerability of malaria ­chemoprophylaxis in non-immune travellers to sub-Saharan Africa: multicentre, randomised, double blind, four arm study. BMJ 2003;327:1078.

Resources
Blood Care Foundation
W:www.bloodcare.org.uk
Centers for Disease Control and Prevention
W:www.cdc.gov/travel/pregnant.htm
Fit for Travel
W:www.fitfortravel.scot.nhs.uk
The Pregnant Traveller
W:www.pregnanttraveller.com