Transcript Travel medicine and pregnancy Dr Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FACRRM Deputy Director and Associate Professor Anton Breinl Centre for Public Health.

Travel medicine and
pregnancy
Dr Peter A. Leggat
MD, PhD, DrPH, FAFPHM, FACTM, FACRRM
Deputy Director and Associate Professor
Anton Breinl Centre for Public Health and Tropical Medicine
James Cook University, Australia
About the author
Dr Peter Leggat has co-ordinated the Australian
postgraduate course in travel medicine since
1993. He has also been on the faculty of the
South African travel medicine course,
conducted since 2000, and the Worldwise New
Zealand Travel Health update programs since
1998. Dr Leggat has assisted in the
development of travel medicine programs in
several countries and also the Certificate of
Knowledge examination for the International
Society of Travel Medicine.
Objectives
In this session
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Examine travel medicine and briefly list some
of components that are needed in order to
give correct health advice in the context of the
pregnant traveler
Focus on some of the important issues in
travel medicine and pregnancy
Air travel
Travel insurance
Malaria
Immunizations
The Continuum of Travel Medicine
Pre-Travel
Preventive Medicine
Contingency
During Travel
Visitors
Planning
Treatment & Rehabilitation
(Leggat et al., 2005)
Post-Travel
General Approach to the
Traveller
Risk assessment,
determining the risks of the
destination, mode of travel
and the special conditions
of the traveler
Vaccinate when possible
and indicated;
Provide the traveler with
appropriate empirical selftreatment
Consider chemoprophylaxis
Consider any concerns
regarding underlying
conditions and possible
drug interactions
Consult experts in travel
medicine or specialty
areas as necessary
Educate the traveler
Remind the traveler that
these precautions are not
100% protective
(Ericsson, 2003)
What do we advise pregnant
travelers?
Travel medicine and Pregnancy
Mezger N et al. Travelling when pregnant. Rev Med
Suisse. 2005; 11: 1263-1266. (in French)
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Travel during the 2nd trimester
Favor comfortable type of travel, without long air or
road transportation
Avoid traveling if at risk pregnancy
Check for adequate insurance coverage
Choose destination where good health services exist
Avoid region of high malaria endemicity
For any vaccination or medication risks and benefits
should be carefully weighed, pregnant women are
more vulnerable and at higher risk of complications
When is the best time
to travel during pregnancy?
Air travel during pregnancy
ACOG committee opinion. Air travel during pregnancy. Int J
Gyn Obst 2002;76:338-339.
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“In the absence of obstetric or medical
complications, pregnant women can
observe the same general precautions for air
travel as the general population and can fly
safely up to 36 weeks of gestation.”
“Safest time is during the second trimester”
(18-24 weeks)
Air travel during pregnancy
AsMA. Medical Guidelines for airline travel. 2nd
Ed. 2003. http://www.asma.org
 “Pregnant women can normally travel
safely by air, however most airlines restrict
travel in late pregnancy”
After 28th week, doctor’s/midwife’s letter
confirming EDD
 Single pregnancies-flying permitted to end
36th weeks
 Multiple pregnancies-flying permitted to
end of the 32nd week
What do airlines actually
recommend?
Some clues given in “Airborn” study
Air travel during pregnancy
Breathnach F et al. Air travel in pregnancy: the 'air-born'
study. Ir Med J. 2004; 97: 167-168. (25% response)
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Three of seventeen (17.5%) airlines applied
no restrictions at all to pregnant passengers;
the remainder applied restrictions to air travel
with varying gestations (28 to 36 weeks).
A full delivery kit was carried by 5/17 airlines
(29%), and some form of training in the
management of a delivery was provided to
the cabin crew in 12/17 airlines (70%).
Experience of in-flight obstetric emergencies
was reported by 11/17 airlines (65%).
Air travel during pregnancy
ACOG (2002) gives further advice
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In-craft environmental conditions, such as low
cabin humidity and changes in cabin pressure,
coupled with the physiologic changes of
pregnancy, do result in maternal adaptations,
which could have transient effects on the fetus.
Pregnant air travelers with medical problems that
may be exacerbated by a hypoxic environment, but
who must travel by air, should be prescribed
supplemental oxygen during air travel.
Pregnant women at significant risk for pre-term
labor or with placental abnormalities should avoid
air travel.
Air travel during pregnancy
ACOG, 2002
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Because air turbulence cannot be predicted and the
risk for trauma is significant, pregnant women
should be instructed to continuously use their seat
belts while seated, as should all air travelers.
Pregnant air travelers may take precautions to ease
in-flight discomfort, and although no hard evidence
exists, preventive measures can be employed to
minimize risks.
Anderson (2001) describes a possible risk
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Pregnancy predisposes to a risk of superficial and
deep venous thrombosis due to alterations in
clotting factors and pressure of expanding uterus.
Air travel during pregnancy
Freeman M et al. Does air travel affect pregnancy
outcome? Arch Gynecol Obstet 2004;269:274-277.
(small cohort study 222 pregnant women)
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Findings suggest that air travel is not
associated with increased risk of
complications for pregnancies that
reach 20 weeks' gestation.
But there are some relative
contraindications to travel
Air travel during Pregnancy
Anderson (2001) citing CDC
summarizes relative contraindications
for travel during pregnancy
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Medical risk factors
Obstetric risk factors
Travel to destination that may be
hazardous
Pregnancy and insurance
Travel insurance is an important safety net
for travelers
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Covers emergency medical and dental care
abroad (may also underwrite the treatment)
Provides emergency assistance hotline or
telephone number
Usually can arrange for aeromedical
evacuation where required
Leggat et al., 1999
What do we know about
pregnancy and travel
insurance?
Pregnancy and insurance
Kingman CE et al. Travel in pregnancy:pregnant women's
experiences and knowledge of health issues. J Travel Med
2003; 10: 330-333. (138 pregnant women)
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Long-distance travel is common in
pregnancy, and women are not always
adequately prepared in terms of
insurance and travel advice
Half had traveled abroad in this
pregnancy
> 1/3 of the women traveled without
sufficient insurance
Only 1/3 sought advice prior to travel
Pregnancy and insurance
Carroll D et al. The pregnant wilderness traveller. Travel
Med Inf Dis (in press)
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“Many travel insurance policies specifically
exclude pregnancy”.
“Finding coverage is usually expensive.”
Jothivijayarani A. Travel considerations during pregnancy.
Prim Care Update Ob/Gyns 2002; 9: 36-40.
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“Many insurance plans do not cover
pregnant women overseas and many plans
have gestational cutoff dates for travel,
beyond which they will not cover delivery
out of the area”.
Pregnancy and insurance
Leggat PA et al. Emergency assistance provided abroad
to insured travellers from Australia. Travel Med Inf Dis.
2005;3:9-17 (>2000 claims)
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2.8 % of travel insurance claims
involving provision of emergency
assistance were for obstetric
problems
What do we advise regarding
insurance?
Take out travel insurance (that covers
pregnancy if possible)
Regardless of insurance coverage, it is
always best to check in advance
regarding obstetrical care at the
destination or medical evacuation
should it become necessary.
Carroll et al. op cit
Pregnancy and insurance
Take records (Carroll et al. op cit)
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Documentation concerning EDD and normality of
pregnancy
Copy of perinatal record
Other documentation as needed for travel
Know warning signs (Anderson, 2001)
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Bleeding, passing tissues or clots
Abdominal pain or cramps
Rupture of membranes
Headache or visual changes
Pregnancy and travel kit
Carroll et al (in press) op cit
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Take a traveler’s medical kit to
manage common conditions
Pregnancy and antimicrobials*
Recommended
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Not recommended
Penicillins
Aminoglycosides
Cephalosporins
Macolides
Antifungals
Metronidazole
Praziquantel and other
antiparasitics are
probably safe
*antimalarials to be discussed separately
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Kanamycin
Streptomycin
Tetracyclines
Griseofulvin
Quinolones (?safely)
WHO, 2005 op cit
Pregnancy and insurance:
Last word-contingency plans
There are several agencies that may offer
emergency assistance/assist with
evacuation of pregnant women traveling
abroad (examples)
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IAMAT (http://www.iamat.org)
ISTM (http://www.istm.org)
International SOS
WWW resources
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http://www.obgyn.net/country/country.asp
provides country specific information
Jothivijayarani, 2002 Op Cit
Pregnancy and malaria
WHO. International Travel and Health.
Geneva: WHO, 2005.
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“Travel to malaria-endemic
areas should be avoided
during pregnancy, if at all
possible”
“…or intend to get
pregnant” (McGready et al,
2004)
Why?
Pregnancy and malaria
WHO. International Travel and Health. Geneva:
WHO, 2005.
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Malaria increases risk of
maternal death,
miscarriage,
stillbirth, and
low birth weight with associated
risk of neonatal death
Pregnancy and malaria
WHO. International Travel and Health. Geneva:
WHO, 2005.
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“Pregnant women with falciparum
malaria
May rapidly develop any of the clinical
symptoms of severe malaria
Are particularly susceptible to
hypoglycemia and pulmonary edema
May develop postpartum hemorrhage
and hyperpyrexia leading to fetal
distress”
Pregnancy and malaria
WHO. International Travel and Health. Geneva:
WHO, 2005.
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Therefore, in relation to travelers,
WHO recommends
“Any pregnant woman with
severe falciparum malaria should
be transferred to intensive care”
What do we advise if a
pregnant traveler must go to
a malarious area?
Pregnancy and malaria
Personal Protective Measures
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Avoidance
Clothing
Insecticides
DEET
Pregnancy and malaria
McGready R et al. Safety of insect repellent N,N-diethyl-Mtoluamide (DEET) in pregnancy. Am J Trop Med Hyg 2001;
65: 285-289. (20% solution of DEET applied by women
during 2nd and 3rd trimester)
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Well accepted and no adverse effects in
women
No increase in LBW, prematurity or
congenital abnormality
DEET does cross placenta (8% of cord
samples), although blood levels low
More information needed on safety of DEET
in 1st trimester
Pregnancy and malaria
McGready R et al. Malaria and the pregnant
traveller. Travel Med Inf Dis 2004;2:127-142.
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“Chemoprophylactic and treatment
options for pregnant women (or those
planning to conceive) are extremely
limited and lag behind what can
currently be offered to non-pregnant
travellers”
Pregnancy and malaria
Chemoprophylaxis
Recommended options
for chloroquine resistant areas
Mefloquine
Doxycycline
Malarone
250mg weekly
2nd/3rd trimester
100mg daily
250mg/100mg daily
(from 2000)
Alternatives include:
− chloroquine 300mg weekly + proguanil 200mg daily
− Sulfadoxine-Pyrimethamine
The flip side….
What if the woman is
wanting to become
pregnant?
Pregnancy and malaria
Drug
Half-life
Mefloquine
14-21 days
Time to wait
before conceiving
3 months
Doxycycline /
tetracycline
Malarone /
Atovaquone
Proguanil
12-24 hours
1 week
2-3 days
2 weeks
14-21 hours
1 week
McGready et al., 2004. Op Cit;
WHO, 2005 Op Cit
What if the pregnant woman
gets “malaria”?
WHO (2005)
Take standby drug
 Seek medical attention as soon as
possible
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Pregnancy and malaria treatment
Recommended
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Chloroquine
Chloroquine plus proguanil
Mefloquine (2nd and 3rd
trimester)
Artemisinin
Clindamycin (limited data)
Quinine
Sulfadoxine-pyrimethamine
Non-recommended
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Doxycycline
Tetracycline
Artemether/lumfantrine
(Coartem)
Atovaquone plus
proguanil (Malarone)
Primaquine
Tafenoquine
WHO, 2005. Op Cit
Pregnancy and malaria treatment
WHO. International Travel and Health. Geneva: WHO,
2005.
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“Because of the risk of quinine induced
hyperinsulinemia and hypogycemia,
artesunate and artemether are the drugs of
choice for treatment of severe malaria in the
2nd and 3rd trimester.
Data on the use of artemisinin derivatives in
the 1st trimester are limited.
However, neither quinine nor artemisinin
derivatives should be withheld in any
trimester if they are considered life saving
for the mother.”
What about vaccination during
pregnancy?
“Pregnancy should not deter a
women from receiving vaccines
that are safe and will protect her
health and that of her child.”
WHO, 2005 op cit
Pregnancy and vaccination
WHO. International Travel and Health. Geneva:
WHO, 2005.
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Killed or inactivated vaccines, toxoids and
polysaccharides can generally be given during
pregnancy, as can oral polio vaccine
Live vaccines are generally contraindicated
because of largely theoretical risks to the baby
However risk and benefits need to be examined in some
individual cases
Yellow fever vaccination may be considered after the 6th
month of pregnancy, when the risk of exposure is
deemed greater than the risk to the fetus
Pregnant women should be advised not to travel to areas
where there is a risk of exposure to yellow fever
Pregnancy and vaccination
WHO, 2005.
Op Cit
In brief, examples of other
conditions of concern
Anderson, 2001
 MVA are a common cause of trauma and
death for all travelers
 “Hepatitis E virus acquired during pregnancy
has a particularly high case fatality rate (1530%). Transmission of the virus occurs
through fecal-oral exposure.”
WHO, 2005
 In infection with American trypanosomiasis,
“congenital infection is possible, due to
parasites crossing the placenta during
pregnancy.”
Travel medicine and Pregnancy
Mezger N et al. Travelling when pregnant. Rev
Med Suisse. 2005; 11: 1263-1266. (in French)
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Travel during the 2nd trimester
Favor comfortable type of travel, without long air or
road transportation
Avoid traveling if at risk pregnancy
Check for adequate insurance coverage
Choose destination where good health services exist
Avoid region of high malaria endemicity
For any vaccination or medication risks and benefits
should be carefully weighed, pregnant women are
more vulnerable and at higher risk of complications
Further Reading
Anderson S. Women’s health and travel. In.
Zuckerman JN. Principles and Practice of Travel
Medicine. John Wiley and Sons Ltd, 2001: 381422.
World Health Organization. International Travel
and Health. Geneva: WHO, 2005. URL:
http://www.who.int/ith
Centers for Disease Control and Prevention.
Health Information for International Travel. URL:
http://www.cdc.gov/travel
References
ACOG committee opinion. Air travel during pregnancy. Int J Gynaecol Obstet 2002 76: 338-339.
AsMA. Medical Guidelines for airline travel. 2nd Ed. 2003. http://www.asma.org
Anderson S. Women’s health and travel. In. Zuckerman JN. Principles and Practice of Travel
Medicine. John Wiley and Sons Ltd, 2001: 381-422.
Breathnach F, Geoghegan T, Daly S, Turner MJ. Air travel in pregnancy: the 'air-born' study. Ir
Med J. 2004; 97: 167-168.
Carroll D, Van Gompel. The pregnant wilderness traveller. Travel Medicine and Infectious
Disease. (in press)
Ericsson CD. Travellers with pre-existing medical conditions. Int J Antimicrob Agents. 2003; 21:
181-188.
Freeman M, Ghidini A, Spong CY, Tchabo N, Bannon PZ, Pezzullo JC. Does air travel affect
pregnancy outcome? Arch Gynecol Obstet 2004;269:274-277.
Jothivijayarani A. Travel considerations during pregnancy. Primary Care Update Obstetrics and
Gynecology. 2002; 9: 36-40.
Kingman CE, Economides DL. Travel in pregnancy:pregnant women's experiences and
knowledge of health issues. J Travel Med 2003; 10: 330-333.
Leggat PA, Carne J, Kedjarune U. Travel insurance and health. J Travel Med 1999; 6: 243-248.
Leggat PA, Ross MH, Goldsmid JM. Introduction to travel medicine. In: Leggat PA, Goldsmid
JM, editors. Primer of travel medicine, 3rd ed. rev. Brisbane: ACTM Publications; 2005: 3-21.
Leggat PA, Griffiths R, Leggat FW. Emergency assistance provided abroad to insured travellers
from Australia. Travel Medicine and Infectious Disease. 2005; 3: 9-17.
McGready R, Ashley EA, Nosten F. Malaria and the pregnant traveller. Travel Med Inf Dis 2004;
2: 127-142.
McGready R, Hamilton KA, Simpson JA et al. Safety of insect repellent N,N-diethyl-M-toluamide
(DEET) in pregnancy. Am J Trop Med Hyg 2001; 65: 285-289.
Mezger N, Chappuis F, Loutan L. Travelling when pregnant. Rev Med Suisse. 2005;11:1263-6.
Steffen R, DuPont HL. Travel medicine: what’s that? J Travel Med 1994;1:1-3.
World Health Organization. International Travel and Health. Geneva: WHO, 2005. URL:
http://www.who.int/ith