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 while abroad and during pregnancy. 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 a 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 hepatitis 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 when influenza season begins and ends in the destination region and administer influenza vaccine accordingly.
- Determine whether the destination region has high prevalence of tuberculosis and whether the planned itinerary will put the traveler at risk for TB. If exposure to TB is determined to be a risk (see the Tuberculosis section in Chapter 5), the pregnant traveler should receive skin testing before and after travel.
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 8-5 lists the greatest 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 avoidance of gas-producing food or drinks before scheduled flights (entrapped gases can expand at higher altitudes) and periodic movement of 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.
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 with healthy, single pregnancies can fly safely up to 36 weeks’ gestation.
- The lowered cabin pressure (kept at the equivalent of 1,524–2,438 m [5,000–8,000 ft]) has minimal effect on fetal oxygenation because of the favorable fetal hemoglobin-oxygen dynamics.
- If supplemental oxygen is going to be required during flight due to pre-existing 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, working air travel is restricted by most airlines by 20 weeks’ gestation.
Airport security radiation exposure is minimal for pregnant women and has not been linked to an increase in adverse outcomes for unborn children to date. However, because of early reports of a possible association of radiation exposure during pregnancy and 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 altitude 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 above 3,658 m (12,000 ft).
Food 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 may be more severe than diarrhea and may have serious sequelae (e.g., toxoplasmosis, 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 is the mainstay of therapy for travelers’ diarrhea (i.e., boiled water, bottled carbonated beverages).
- 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 antibiotic treatment of travelers’ diarrhea during pregnancy can be complicated. Azithromycin or an oral third-generation cephalosporin may be the best options for treatment if an antibiotic is needed.
Malaria during Pregnancy
Advise pregnant women to avoid travel to malaria-endemic areas if possible. Women who do choose to go to malarious areas can reduce their risk of acquiring malaria by taking appropriate malaria chemoprophylaxis and following insect precautions presented in the Malaria section and the Protection Against Mosquitoes, Ticks, and Other Insects and Arthropods section in Chapter 2.
- 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 has been used for malaria chemoprophylaxis 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 the first trimester.
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 need to 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 8-6 provides information on the half-lives of selected antimalarial drugs. After two, four, and six 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. Atovoquone/proguanil is currently 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).
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 or bacterial vaccines or toxoids. The benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm.
The following table is intended for women who may require immunizations during pregnancy (Table 8-7). 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.
