Chapter 8Advising Travelers With Specific Needs
Pregnancy is an altered state of health that requires special considerations. With careful preparation, however, most pregnant women are able to travel safely.
The pre-travel evaluation of a pregnant traveler (Box 8-01) should begin with a careful medical and obstetric history, with particular attention to gestational age and evaluation for high-risk conditions. A visit with an obstetrician should be a part of the pre-travel assessment, which should include an ultrasound—to establish the gestational age of the pregnancy and identify any potential problems—and evaluation of the mother’s blood type and Rh status. The traveler should be provided with a copy of her prenatal records and physician’s contact information. Checking for immunity to various infectious diseases may obviate the need for some vaccines.
A review of the patient’s travel itinerary, including destinations, types of accommodation, and planned activities, should guide pre-travel health advice. Preparation includes educating the patient regarding avoidance of travel-associated risks, the management of minor pregnancy discomforts, and recognition of more serious complications. Bleeding, premature labor, and premature rupture of the fetal membranes are conditions that require urgent medical attention.
Pregnant travelers should pack a travel health kit that includes a blood pressure monitor, hemorrhoid cream, antiemetic drugs, prenatal vitamins, medication for vaginitis or yeast infection, talcum powder, and support hose, in addition to the items recommended for all travelers (see Chapter 2, Travel Health Kits).
Box 8-01. Pre-travel consultation checklist for pregnant travelers
- Ultrasound to establish a reliable due date and to confirm normal pregnancy
- Check for immunity to infectious diseases, for example, hepatitis A and B, rubella, varicella, measles, pertussis
- Update routine immunizations: tetanus-diphtheria-pertussis, influenza (inactivated), polio, including hepatitis A and B
- Destination risk considerations
- Infectious disease
- Outbreak of disease requiring a live virus vaccine
- Outbreak of a disease for which no vaccine is available but which has a high risk of maternal or fetal illness or death
- Sexually transmitted diseases
- Food and water precautions
- Insect exposure
- Environmental: altitude, heat, humidity, pollution
- Medical services available during transit and at destination
- Infectious disease
- Travel risk assessment
- Mode of travel, destination, length of travel, and style
- Planned activities such as climbing, water sports, snorkeling
- Supplemental travel insurance, travel health insurance, and medical evacuation insurance (research specific coverage information and limitations for pregnancy-related health issues)
- Signs and symptoms for which care should be sought immediately
- Pelvic or abdominal pain
- Rupture of membranes
- Symptoms of preeclampsia (unusual swelling, severe headaches, nausea and vomiting, vision changes)
- Vomiting, diarrhea, dehydration
- Symptoms of potential deep vein thrombosis or pulmonary embolism (unusual swelling of leg with pain in calf or thigh, unusual shortness of breath)
- Immunizations that reflect actual risk of disease and probable benefit
- Malaria chemoprophylaxis, if indicated
- Preventive measures to decrease the above risks
- Check airline and cruise line policies
- Letter confirming due date and fitness to travel
- Copy of medical records
- Letter for customs regarding medications
- Exemption letter or waiver for required vaccines
- Preparing for obstetric care
- Check coverage by medical insurance
- Arrange travel insurance, travel health insurance, and medical evacuation insurance
- Arrange medical assistance
- Arrange for obstetric care at destination
- Comfort arrangements
- Loose clothing and comfortable shoes
- Pillows, support hose
- Bottled water
- Upgrade flight seating if possible
- Lighten itinerary if not accustomed to planned activities
- Postpone travel if risks outweigh benefits
CONTRAINDICATIONS FOR TRAVEL DURING PREGNANCY
Although travel is rarely contraindicated during a normal pregnancy, complicated pregnancies require extra consideration and may warrant a recommendation that travel be delayed (Box 8-02). Pregnant travelers should be advised that the risk of obstetric complications is highest in the first and third trimesters.
Box 8-02. Contraindications for travel during pregnancy
- Abruptio placentae
- Active labor
- Incompetent cervix
- Premature labor
- Premature rupture of membranes
- Suspected ectopic pregnancy
- Threatened abortion, vaginal bleeding
- Toxemia, past or present
- Abnormal presentation
- Fetal growth restriction
- History of infertility
- History of miscarriage or ectopic pregnancy
- Maternal age <15 or >35 years
- Multiple gestation
- Placenta previa or other placental abnormality
PLANNING FOR EMERGENCY CARE
Obstetric emergencies are often sudden and life-threatening. Travel to remote locations or areas in some developing countries where obstetric care may be less than the standard at home is inadvisable. For a woman in the third trimester of pregnancy, it is advisable to identify a medical facility in her destination that could manage complications of pregnancy, her delivery, a caesarean section, and neonatal problems. Some complications may be managed so that the mother could travel to a facility where she could receive advanced obstetric care, but some conditions are contraindications for any travel (Box 8-02). In such cases, it may be preferable to transport help to the patient rather than transport the patient.
Many general health insurance policies do not cover complications of pregnancy overseas. Supplemental travel health insurance should be strongly considered to cover both pregnancy-related problems and care of the neonate, as needed. Evacuation insurance with a policy that includes coverage of pregnancy-related complications is highly encouraged as well.
Pregnant women should be advised to wear seatbelts, when available, on all forms of transport, including airplanes, cars, and buses. A diagonal shoulder strap with a lap belt provides the best protection, with the straps carefully placed above and below the abdominal bulge. When only a lap belt is available, it should be worn low, between the abdomen and the pelvis.
Most commercial airlines allow pregnant travelers to fly until 36 weeks’ gestation. Some limit international travel earlier in pregnancy, and some require documentation of gestational age. Travelers should check with the airline to find out their specific requirements or guidance for pregnant women. Air cabins of most commercial jetliners are pressurized to 6,000–8,000 ft (1,829–2,438 m) above sea level; the lower oxygen tension should not cause fetal problems in a normal pregnancy, but women with preexisting cardiovascular problems, sickle cell disease, or severe anemia (hemoglobin <80 g/L) may experience the effects of low arterial oxygen saturation. Risks of air travel include potential exposure to communicable diseases, immobility, and the common discomforts of flying. Abdominal distention and pedal edema frequently occur. The pregnant traveler may benefit from an upgrade in airline seating and should seek convenient and practical accommodations (such as close proximity to the toilet). Loose clothing and comfortable shoes should be recommended.
Some experts report that the risk of deep vein thrombosis in pregnancy is 5–10 times higher than for nonpregnant women, estimated to be 1 in 1,000. Preventive measures include frequent stretching, walking and isometric leg exercises, and wearing graduated compression stockings.
Cosmic radiation during air travel poses little threat, but may be a consideration for pregnant travelers who are frequent fliers (such as air crew). Older airport security machines are magnetometers and are not harmful to the fetus. Newer security machines use backscatter x-ray scanners, which emit low levels of radiation; most experts agree that the risk of radiation exposure from these scanners is extremely low.
Cruise Ship Travel
Most cruise lines restrict travel beyond 28 weeks of pregnancy, and some as early as 24 weeks. Pregnant travelers may be required to carry a physician’s note stating that they are fit to travel and including the estimated date of delivery. Pregnant women should check with the cruise line to find out their specific requirements or guidance. The pregnant patient planning a cruise should be advised regarding motion sickness, gastrointestinal and respiratory infections, and the risk of falls on a moving vessel.
Air pollution may cause more health problems during pregnancy, as ciliary clearance of the bronchial tree is slowed and mucus more abundant. Body temperature regulation is not as efficient during pregnancy, and temperature extremes cause more stress on the gravid woman. In addition, an increase in core temperature, such as with heat prostration or heat stroke, may harm the fetus. The vasodilatory effect of a hot environment might also cause fainting. For these reasons, accommodation should be sought in air-conditioned quarters and activities restricted in hot environments.
Pregnant women should avoid activities at high altitude unless trained for and accustomed to such activities. Women unaccustomed to high altitudes may experience exaggerated breathlessness and palpitations. The common symptoms of acute mountain sickness (insomnia, headache, and nausea) are frequently also associated with pregnancy, and it may be difficult to distinguish the cause of the symptoms. No studies or case reports show harm to a fetus if the mother travels briefly to high altitudes during pregnancy. However, it may be prudent to recommend that pregnant women not stay at sleeping altitudes >12,000 ft (3,658 m), if possible. Although compelling reasons to use acetazolamide may exist, most experts recommend simply a slower ascent with adequate time for acclimatization. Probably the largest concern regarding high-altitude travel in pregnancy is that many high-altitude destinations are inaccessible and far from medical care.
Pregnant travelers should be discouraged from undertaking unaccustomed vigorous physical activity. Swimming and snorkeling during pregnancy are generally safe, but waterskiing has resulted in falls that inject water into the birth canal. Most experts advise against scuba diving for pregnant women because of the risk of fetal gas embolism during decompression. Riding bicycles, motorcycles, or animals presents risk of trauma to the abdomen.
Pregnant women who develop travelers’ diarrhea or other gastrointestinal infection may be more vulnerable to dehydration than are nonpregnant travelers. Strict hand hygiene and food and water precautions should be stressed (see Chapter 2, Food & Water Precautions). Bottled or boiled water is preferable to chemically treated or filtered water. Iodine-containing compounds should not be used to purify water for pregnant women because of potential effects on the fetal thyroid (see Chapter 2, Water Disinfection for Travelers). The treatment of choice for travelers’ diarrhea is prompt and vigorous oral hydration; however, azithromycin may be given to pregnant women if clinically indicated. Use of bismuth subsalicylate is contraindicated.
Hepatitis A and E are both spread by the fecal-oral route. Hepatitis A has been reported to increase the risk of placental abruption and premature delivery. Hepatitis E is more likely to cause severe disease during pregnancy and may result in a case-fatality ratio of 15%–30%; when acquired during the third trimester, it is also associated with fetal complications and fetal death. Some foodborne illnesses of particular concern during pregnancy include toxoplasmosis and listeriosis. The risk during pregnancy is that the infection will cross the placenta and cause spontaneous abortion, stillbirth, or congenital infection. Risk of fetal infection increases with the length of gestation, but severity of infection is decreased. The patient should be warned, therefore, to avoid unpasteurized cheeses and undercooked meat products. Parasitic diseases are less common but may cause concern, particularly in women who are visiting friends and relatives in developing areas. In general, intestinal helminths rarely cause enough illness to warrant treatment during pregnancy. Most intestinal helminths, in fact, can safely be addressed with symptomatic treatment until the pregnancy is over. On the other hand, protozoan intestinal infections, such as Giardia, Entamoeba histolytica, and Cryptosporidium, often do require treatment. These parasites may cause acute gastroenteritis, chronic malabsorption resulting in fetal growth restriction, and in the case of E. histolytica, invasive disease, including amebic liver abscess and colitis. Pregnant women are advised to avoid swimming or wading in freshwater lakes, streams, and rivers that may harbor schistosomes.
Pregnant women should avoid mosquito bites when traveling in areas endemic for arboviruses or malaria. Preventive measures include the use of bed nets and insect repellents and wearing protective clothing (see Chapter 2, Protection against Mosquitoes, Ticks, & Other Insects & Arthropods).
Respiratory and urinary infections and vaginitis are also more likely to occur and to be more severe in pregnancy.
Various systems are used to classify drugs in regard to their safety in pregnancy. In most cases, it is preferable to refer to specific data regarding the effects of a given drug during pregnancy rather than simply to depend on a classification.
Analgesics that can be used during pregnancy include acetaminophen and some narcotics. Aspirin may increase the incidence of abruption, and other antiinflammatory agents could cause premature closure of the ductus arteriosus. Constipation may require a mild bulk laxative. Several simple remedies are often effective in relieving the symptoms of morning sickness, and these may prevent motion sickness. Nonprescription remedies include ginger, which as a powder can be mixed with food or drinks such as tea. It is also available in candy, such as lollipops. Similarly, pyridoxine (vitamin B6) is effective in reducing symptoms of morning sickness and is available in tablet form, as well as lozenges and lollipops. Antihistamines, such as meclizine and dimenhydrinate, are often used in pregnancy and appear to have a good safety record.
In the best possible scenario, a woman should be up-to-date on routine vaccinations before she becomes pregnant. The most effective way of protecting the infant against many diseases is to immunize the mother. Tetanus, diphtheria, and pertussis (Tdap) vaccine, if not previously received, is recommended during pregnancy for women to protect the woman from getting pertussis and to pass protective antibiotics to her newborn. To optimize the concentration of maternal antibodies transferred to the fetus, Tdap should be given preferably during the third or late second trimester (after 20 weeks’ gestation). Annual influenza vaccine (inactivated) is recommended during any trimester if pregnancy coincides with influenza season. Certain vaccines, including meningococcal polysaccharide (MPSV4), inactivated polio vaccine (IPV), and hepatitis A and B vaccines, that are considered safe during pregnancy may be indicated based on risk. Rabies postexposure prophylaxis with rabies immune globulin and vaccine should be administered after any moderate- or high-risk exposure to rabies; preexposure vaccine may be considered for travelers when the risk of exposure is substantial.
Most live-virus vaccines, including measles-mumps-rubella (MMR) vaccine, varicella vaccine, and live attenuated influenza vaccine (LAIV), are contraindicated during pregnancy; the exception is yellow fever vaccine, for which pregnancy is considered a precaution by Advisory Committee on Immunization Practices (ACIP). If travel is unavoidable, and the risks for yellow fever virus exposure are felt to outweigh the risks of vaccination, a pregnant woman should be vaccinated. If the risks for vaccination are felt to outweigh the risks for yellow fever virus exposure, pregnant women should be issued a medical waiver to fulfill health regulations. Because pregnancy might affect immunologic function, serologic testing to document an immune response to yellow fever vaccine should be considered. Postexposure management of a nonimmune pregnant woman exposed to measles or varicella may be managed by administering immune globulin (IG) within 6 days for measles or varicella-zoster IG within 10 days for varicella. Women planning to become pregnant should be advised to wait 4 weeks after receipt of a live-virus vaccine before conceiving. For certain travel-related vaccines, including Japanese encephalitis vaccine and typhoid vaccine, data are insufficient for a specific recommendation for use in pregnant women. A summary of current ACIP guidelines for vaccinating pregnant women is available at www.cdc.gov/vaccines/pubs/preg-guide.htm.
Malaria may be much more serious in pregnant than in nonpregnant women. Malaria in pregnancy may be characterized by heavy parasitemia, severe anemia, and sometimes profound hypoglycemia, and may be complicated by cerebral malaria and acute respiratory distress syndrome. Placental sequestration of parasites may result in fetal loss due to abruption, premature labor, or miscarriage. An infant born to an infected mother is apt to be of low birth weight, and, although rare, congenital malaria is a concern.
Because no prophylactic regimen provides complete protection, pregnant women should avoid or delay travel to malaria-endemic areas. However, if travel is unavoidable, pregnant women should take precautions to avoid mosquito bites, and use of an effective prophylactic regimen is essential.
Chloroquine and mefloquine are the drugs of choice for pregnant women for destinations with chloroquine-sensitive and chloroquine-resistant malaria, respectively. Doxycycline is contraindicated because of teratogenic effects on the fetus after the fourth month of pregnancy. Primaquine is contraindicated in pregnancy because the infant cannot be tested for G6PD deficiency, putting the infant at risk for hemolytic anemia. Atovaquone-proguanil is not recommended because of lack of available safety data. A list of the available antimalarial drugs and their uses and contraindications during pregnancy can be found in Table 3-10 and in Chapter 3, Malaria.
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