The pregnant traveller: Travel Health: NEVDGP

Information mostly taken from: "International Travel and Health" (WHO year book)
Australian Immunisation Handbook, 9th Edition - 4/2008 - Part 2 & Part 3 (large pdf files)
Centre for Disease Control, USA - www.cdc.gov/travel Travel Health Seminar Oct 96, June 97,Feb 98, March 99, May 2000, August 2002 & March 2005 - Victorian Medical Postgraduate Foundation.
Manual of Travel Medicine, Melbourne, Oct 2004. Updated 06/09/2006. Additional references & disclaimer.

THE PREGNANT TRAVELLER

GENERAL ADVICE
The pregnant traveller faces a variety of health hazards, and travelling during pregnancy, particularly to tropical areas in developing countries, should only be undertaken if it is truly necessary. Health hazards include the problems of air travel itself and an increased susceptibility to certain infectious diseases. The safest time for pregnant women to travel is during the second trimester. Don't travel during the last six weeks of your pregnancy.

NAUSEA AND VOMITING
The tendency to nausea and vomiting in early pregnancy may be aggravated by travel.
Apart from maxolon, drugs given for motion sickness should he avoided during the first trimester. Consult your obstetrician about any medication you plan to use. Carry your medications with you rather than packing them in your check-on luggage.

ACTIVITIES
Exercising within the limits of your fitness and comfort is generally a good idea.
Vigorous exercise like running may cause hyperthermia (high body temperature). This can be dangerous to the developing baby. Saunas and very hot tubs should also be avoided for this reason especially in the first 3 months.
Swimming is an excellent exercise for the pregnant traveller, but water-skiing and other activities with an increased risk of injury are best avoided.
Scuba diving to depths greater than 18 m (60 ft) is not considered safe.
Vacationing at high altitudes. particularly greater than 3000 m, is best avoided.

AIR TRAVEL
Up to 24 weeks gestation: No restrictions unless complicating obstetric or medical risk factors exist.
24-36 weeks gestation: No restrictions unless complicating obstetric or medical risk factors exist. The pregnant traveller should carry a letter from her obstetrician.
After 36 weeks gestation: Air travel is discouraged unless unavoidable, If travel is essential, a doctor's letter is required by all airlines.

GENERAL INFORMATION
Most commercial jetliners are pressurised to about 1600 to 2300 m. Above 1600 m there is a risk of hypoxia (low oxygen), especially if the traveller is anaemic.
It is advisable to sit in the non-smoking area, and wear your seat belt low around your pelvis.
Carbonated drinks are best avoided as they may cause gaseous distension which can be uncomfortable.
A particular problem of long haul air travel is deep vein thrombosis (blood clot in the legs). Sitting in a cramped position for a long period favours the development of thrombosis. Take an aisle seat and stand up and walk about the cabin regularly. Tense up your legs and wriggle your toes from time to time.
Dehydration also predisposes to thrombosis, and the low humidity in aircraft is said to aggravate dehydration. (not according to WHO). Avoid fluids not containing alcohol (or caffeine). Taking half an aspirin daily does not reduce the risk of thrombosis (blood clot) occurring in the legs. Those who have a past history of deep vein thrombosis should consider the use injectable low molecular heparin. (safe in pregnancy) Discuss this with your doctor.

VACCINATIONS .. see also 9th edition handbook 4/2008 - pregnancy and vaccination table
It is preferable to avoid vaccinations, in the first 3 months of pregnancy and to avoid live viral vaccines, particularly (MMR) throughout pregnancy. Avoid vaccines which may be associated with a febrile reaction (fever) in the first 3 months of pregnancy, eg. old typhoid injection.
Safe Vaccines: (after the 1st 3 months) - Immune globulin, aDT, IPV, Hep A, Hep B, Typhium Vi, Meningococcal and Rabies. OPV (Sabin) is not contraindicated ( WHO* ) although some authorities remain cautious... Influenza may be a serious infection in pregnancy and influenza vaccine is indicated.
Unsure Vaccines: Yellow Fever, BCG, oral typhoid and JE vaccine should only be given if substantial risk of infection.
Boosterix (dTpa): Before planning pregnancy, or for both parents as soon as possible after delivery of an infant, (preferably prior to hospital discharge), unless contraindicated. This recommendation is based on evidence from a study of infants hospitalised with pertussis around Australia in 2001, which indicated that parents were the presumptive source of infection in over 50% of cases. ( page 136 Australian Immunisation Handbook, 8th Edition 9/2003)

TRAVELLER'S DIARRHOEA (See the pamphlet on Traveller's Diarrhoea.)
Most episodes of diarrhoea are short-lived and require no particular treatment The need to treat diarrhoea depends on either its severity or persistence. Transmission is mostly via contaminated food or water.

OTHER FOOD SELECTION
Avoid dehydration in pregnancy. Severe dehydration increases the risk of miscarriage.
Eating uncooked meat may cause toxoplasmosis, an infection that can affect the foetus.
Listerosis can be avoided by not eating (see also pamphlet)

Drugs such as diphenoxylate (Lomotil) & loperamide (Imodium) should be avoided.

MALARIA
Doxycycline is contraindicated during pregnancy and Mefloquine is not approved for the first 3 months of pregnancy although recent reports suggest that it is probably safe. Chloroquine with or without Proguanil and meticulous avoidance of mosquito bites is safe in pregnancy. Malarone (Atovaquine + proguanil) is class B2 & azithromycin B1, and their use cannot be recommended as yet because of very little data. Azithromycin may be recommended *WHO (under "Amounts of ORS solution to drink")
If emergency self-treatment for malaria is required for a pregnant woman, quinine is preferred.

OTHER INFECTIONS
A wide range of conditions are more severe in pregnancy. Many infections adversely affect the baby as well as the mother. Pregnant travellers should therefore take particular care to avoid biting insects and to disinfect minor cuts and abrasions. The use of Iodine as a water steriliser is best avoided as this can affect the baby's thyroid gland. Pregnant women, already prone to thrush, should be aware of the increased risk in the tropics.

HEPATITIS E
Hepatitis E, formerly called non-A, non-B hepatitis is particularly serious in the 2nd & 3rd trimesters of pregnancy. Epidemics have occurred in Afghanistan, Bangladesh, western China, Eritrea, Ethiopia, India, Indonesia, Iran, Kenya , Mexico, Myanmar, Nepal, Pakistan, Somalia, Sudan, and the Asian republics of the former USSR. It is probably widespread in Asia, north and sub-Sahara Africa, and the eastern Mediterranean area.
There is no treatment available and 15-20% of women will die from fulminant hepatitis. *. As it is spread in the same way as Hepatitis A (ie. by contaminated food or drink) the need to eat and drink safely and observe good hygiene is paramount. Again reconsider the need to travel whilst pregnant. * WHO year book - www.who.int/ith/chapter05_04.html#hepatitise

Medical Examination after travel: It is advisable (if not essential) to visit your local doctor promptly if you

suffer from a chronic disease, such as cardiovascular disease, diabetes mellitus, chronic respiratory disease;

experience illness in the weeks following their return home, particularly if fever, persistent diarrhoea, vomiting, jaundice, urinary disorders, skin disease or genital infection occurs;

consider that you may have been exposed to a serious infectious disease while travelling;

have spent more than 3 months in a developing country.