Although pregnancy is a normal state rather than a disabled condition, pregnant women need to consider the potential problems associated with international travel, as well as the quality of medical care available at the destination and during transit. According to the American College of Obstetricians and Gynecologists, the safest time for a pregnant woman to travel is during the second trimester (18-24 weeks) when she usually feels best and is in least danger of experiencing a spontaneous abortion or premature labor. Women in the third trimester (25-36 weeks) may be asked by their physicians to stay within 300 miles of home because of concerns about access to medical care in case of problems such as hypertension, phlebitis, or false or premature labor. The final decision to travel should be based on consultation with the woman's health care provider.

General Recommendations for Travel

Once a pregnant woman has decided to travel, a number of issues need clarification prior to departure (see Table 1). It is advisable for pregnant women to travel with a companion; in addition, attention to comfort becomes more important. The checklist (Table 2) provides a guideline for planning with regard to medical considerations.

Motor vehicle accidents are a major cause of morbidity and mortality. When available, seat belts should be fastened at the pelvic area. Lap and shoulder restraints are best; in most accidents, the fetus recovers quickly from the seat belt pressure. However, even after seemingly blunt, mild trauma, a physician should be consulted.

Typical problems of pregnant travelers are the same as those experienced at home: fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased frequency of urination and hemorrhoids. Signs and symptoms that indicate the need for immediate medical attention are bleeding, passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling, headaches or visual problems.

Table 1. Relative Contraindications to International Travel during Pregnancy

Patients with Obstetrical Risk Factors

History of miscarriage Incompetent cervix History of ectopic pregnancy (ectopic with present pregnancy should be ruled out prior to travel) History of premature labor or premature rupture of membranes History of or present placental abnormalities Threatened abortion or vaginal bleeding during present pregnancy Multiple gestation (more than one fetus) in present pregnancy History of toxemia, hypertension or diabetes with any pregnancy History of infertility or difficulty becoming pregnant Primigravida (woman who is pregnant for the first time) older than 35 years or younger than 15 years

Patients with General Medical Risk Factors

Valvular heart disease or congestive heart failure History of thromboembolic disease Severe anemia Chronic organ system dysfunction requiring frequent medical interventions

Patients Contemplating Travel to Destinations That May Be Hazardous

High altitudes Areas endemic for or with ongoing outbreaks of life-threatening food- or insect-borne infections Areas where chloroquine-resistant Plasmodium falciparum is endemic Areas where live-virus vaccines are required and recommended

Table 2. Checklist for the Pregnant Traveler

Make sure health insurance is valid while abroad and during pregnancy. Check to see if the policy covers a newborn should delivery take place. Obtain a supplemental travel insurance policy and a prepaid medical evacuation insurance policy. Check medical facilities at the destination. For women in the last trimester, medical facilities should be able to manage complications of pregnancy, toxemia and cesarean sections. Determine beforehand whether prenatal care will be required abroad and, if so, who will provide it. Make sure prenatal visits requiring specific timing are not missed. Check ahead of time whether blood is screened for HIV and hepatitis B at the destination. Pregnant travelers and their companions should know their blood types. Check facilities at the destination for availability of safe food and beverages, including bottled water and pasteurized milk.

Brest-Feeding and Travel

The decision to travel internationally while nursing brings another set of challenges. However, breast-feeding has nutritional and anti-infective advantages that serve an infant well while traveling. Supplements usually are not needed by breast-fed infants younger than 6 months, and breast-feeding should be maintained as long as possible. If supplementation is considered necessary, powdered formula that requires reconstitution with boiled water should be carried. For short trips, it may be feasible to carry an adequate supply of pre-prepared canned formula. Exclusive breast-feeding relieves concerns about sterilizing bottles and about availability of clean water.

Nursing women may be immunized for maximum protection, depending on the travel itinerary, but consideration needs to be given to the neonate who cannot be immunized at birth and who would not gain protection against many of these infections (e.g., yellow fever, measles, and meningococcal meningitis) through breast-feeding.

Neither inactivated nor live-virus vaccines affect the safety of breast-feeding for mothers or infants. Breast-feeding does not adversely affect immunization and is not a contraindication to the administration of any vaccines, including live-virus vaccines, to the breast-feeding woman. Although rubella vaccine virus may be transmitted in breast milk, the virus usually does not infect the infant, and if it does, the infection is well tolerated. Breast-fed infants should be vaccinated according to routine recommended schedules.

Nursing women need to realize that their eating and sleeping patterns, as well as stress, will inevitably affect their milk output. They need to increase their fluid intake, avoid excess alcohol and caffeine, and, as much as possible, avoid exposure to smoke.

Specific Recommendations for Pregnancy and Travel

ROUTINE IMMUNIZATIONS

Because of the theoretical risks to the fetus from maternal vaccination, the risks and benefits of each immunization should be carefully reviewed. Ideally, all women who are pregnant should be up to date on their routine immunizations. In general, pregnant women should avoid live vaccines and women should avoid becoming pregnant within three months of having received one; however, no harm to the fetus has been reported from the accidental administration of these vaccines during pregnancy.

DIPHTHERIA/TETANUS

The combination diphtheria/tetanus immunization should be given if the traveler has not been immunized in the past 10 years, although preference would be for its administration during the second or third trimesters.

MEASLES/MUMPS/RUBELLA

Immunity to measles is essential for all travelers. Many young adults require immunization (and in some cases, reimmunization) for protection. The specific recommendations for different age groups depend on the traveler's country of origin, itinerary, and the epidemiology of measles in the country to be visited. The measles vaccine as well as the MMR (measles, mumps, and rubella combination) are live-virus vaccines and are contraindicated in pregnancy. Because of the increased incidence of measles in children in developing countries, its communicability, and its potential for causing serious consequences in adults, some authorities recommend delaying travel for nonimmune women until after delivery, when immunization can be given safely. However, in cases in which the rubella vaccine was accidentally administered, no complications were reported. If a pregnant woman has a documented exposure to measles, immune globulin should be given within a six-day period to prevent illness.

POLIO

It is important for the pregnant traveler to be protected against polio. Paralytic disease may occur with greater frequency when infection develops during pregnancy. Anoxic fetal damage has also been reported, with up to 50 percent mortality in neonatal infection. If not previously immunized, a pregnant woman should have at least two doses of vaccine before travel (day 0 and at one month). Despite being a live-virus vaccine, the oral preparation (OPV) is recommended when immediate protection is needed. The recommendation for the nonimmune pregnant traveler is 1 dose of OPV prior to travel followed by completion of the regimen after delivery. However, for routine boosting or for when immediate protection is not required, the inactivated vaccine (IPV) is preferred. There is no convincing evidence of adverse effects of either OPV or IPV in pregnant women or a developing fetus. However, it is prudent to avoid polio vaccination of pregnant women unless immediate protection is needed. In this case, OPV is the vaccine of choice.

Breast-feeding does not interfere with successful immunization against poliomyelitis with IPV or OPV. IPV may be administered to a child with diarrhea, and OPV may be administered to a child with mild diarrhea. Minor upper respiratory illnesses with or without fever, mild to moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and the convalescent phase of an acute illness are not contraindications for vaccination.

HEPATITIS B

The hepatitis B vaccine may be administered during pregnancy. For tourists or business travelers, it is not routinely recommended unless the woman will be working in a health care setting, is sexually active with new partners, is planning delivery overseas, or will be a long-term traveler. It is desirable, however, for everyone to be protected against hepatitis B.

PNEUMOCOCCAL/INFLUENZA

The pneumococcal and influenza vaccines should be given to all who would otherwise qualify for special protection against these diseases: pregnant women with chronic diseases or pulmonary problems. In general, women with serious underlying illnesses should not travel to developing countries when pregnant.

Travel-Related Immunizations During Pregnancy

YELLOW FEVER

The yellow fever vaccine should not be given to a pregnant woman unless travel to an endemic or epidemic area is unavoidable. In these instances, the vaccine can be administered. Although concerns exist, no congenital abnormalities have been reported after administration of this vaccine to pregnant women.

If traveling to or transiting regions within a country where the disease is not a current threat but where policy requires a yellow fever certificate, a physician waiver should be carried, along with documentation on the immunization record. In general, travel to areas where yellow fever is a risk should be postponed until after delivery, when the vaccine can be administered without concern of fetal toxicity. A nursing mother should also delay travel, as the neonate cannot be immunized because of the risk of vaccine-associated encephalitis. Breast-feeding is not a contraindication to the vaccine for the mother.

HEPATITIS A

Pegnant women without immunity to hepatitis A need protection before traveling to developing countries. Hepatitis A is usually no more severe during pregnancy than at other times and does not affect the outcome of pregnancy. There have been reports, however, of acute fulminant disease in pregnant women during the third trimester, when there is also an increased risk of premature labor and fetal death. These events have occurred in women from developing countries and may have been related to underlying malnutrition. The hepatitis A virus is rarely transmitted to the fetus, but this can occur during viremia or from fecal contamination at delivery. Immune globulin is a safe and effective means of preventing hepatitis A, but immunization with one of the hepatitis A vaccines gives a more complete and prolonged protection. The effect of these inactivated virus vaccines on fetal development is unknown, but the production methods for the vaccines are similar to that for IPV, which is considered safe during pregnancy.

TYPHOID

The older injectable typhoid vaccine is not recommended during pregnancy because of febrile reactions, which can result in spontaneous abortions. It can be administered intradermally with less risk of systemic symptoms. The safety of the oral typhoid vaccine in pregnancy is not known. Nonetheless, neither of these is absolutely contraindicated during pregnancy, according to the Advisory Committee on Immunization Practices (ACIP). The Vi injectable preparation may be the vaccine of choice because it is inactivated and requires only one injection. With any of these, the vaccine efficacy (about 70 percent) needs to be weighed against the risk of disease.

MENINGOCOCCAL MENINGITIS

The polyvalent meningococcal meningitis vaccine may be administered during pregnancy if the woman is entering an area where the disease is endemic. The vaccine's safety during pregnancy has not been conclusively determined.

RABIES

The cell-culture rabies vaccines may be given during pregnancy for either pre- or postexposure prophylaxis.

JAPANESE ENCEPHALITIS

No information is available on the safety of Japanese encephalitis vaccine during pregnancy. It should not be routinely administered during pregnancy, except when a woman must stay in a high-risk area. If not mandatory, travel to such areas should be delayed.

MISCELLANEOUS

There are no data available on the use of plague vaccine for pregnant women. BCG (Bacillus Calmette-Guérin) vaccine for the prevention of tuberculosis can theoretically cause disseminated disease and thus affect the fetus; skin testing for tuberculosis exposure before and after travel is preferable when the risk is high. Therefore, neither of these vaccines is recommended.

Table 3. Vaccination During Pregnancy
	Vaccine	Use during pregnancy
Cholera	Inactivated bacterial	Data on safety in pregnancy are not available. Should weigh the theoretical risk of vaccination against the risk of disease.
Hepatitis A	Inactivated virus	Data on safety in pregnancy are not available. Should weigh the theoretical risk of vaccination against the risk of disease.
Hepatitis B	Subunit virus	Administer if indicated
Immune globulins, pooled or hyperimmune	Immune globulin or specific globulin preparations	Administer if indicated
Influenza	Inactivated whole virus or subunit	Administer if indicated
Japanese encephalitis	Inactivated virus	Data on safety in pregnancy are not available. Should weigh the theoretical risk of vaccination against the risk of disease.
Measles	Live-attenuated virus	Contraindicated
Meningococcal meningitis	Polysaccharide	Administer if indicated
Mumps	Live-attenuated virus	Contraindicated
Plague	Inactivated bacterial	Data on safety in pregnancy are not available. Should weigh the theoretical risk of vaccination against the risk of disease.
Pneumococcal	Polysaccharide	Administer if indicated
Polio, inactivated	Inactivated virus	Administer if indicated
Polio, oral	Live-attenuated virus	Administer if indicated
Rabies	Inactivated virus	Administer if indicated
Rubella	Live-attenuated virus	Contraindicated
Tetanus-diphtheria	Toxoid	Administer if indicated
Typhoid	Inactivated bacterial	Data on safety in pregnancy are not available. Should weigh the theoretical risk of vaccination against the risk of disease.
Typhoid (Ty21a)	Live bacterial	Data on safety in pregnancy are not available. Should weigh the theoretical risk of vaccination against the risk of disease.
Varicella	Live-attenuated virus	Contraindicated
Yellow fever	Live-attenuated virus	Administer if indicated

Malaria During Pregnancy

Malaria in pregnancy carries significant morbidity and mortality for both the mother and the fetus. Because no antimalarial agent is 100 percent effective, it is imperative that pregnant women use personal protective measures when traveling through a malaria-endemic area. Pregnant women should remain indoors between dusk and dawn, but if outdoors at night, should wear light-colored clothing, long sleeves, long pants, and shoes and socks. Pregnant women should sleep in air-conditioned quarters or use screens and permethrin-impregnated bed nets.

Pyrethrum-containing house sprays or coils also should be used indoors if insects are a problem. Insect repellents containing a low percentage of DEET (recommendations vary from 10 percent to 35 percent) can be used on the skin. Nursing mothers should be careful to wash repellents off hands and breast skin prior to handling infants.

Chloroquine and proguanil have been used by pregnant women for malaria chemoprophylaxis for decades with no documented increase in birth defects. Mefloquine has been recommended for chemoprophylaxis during the second and third trimesters. Women in the first trimester should be discouraged from visiting areas where chloroquine-resistant malaria occurs. However, if they do travel to these areas, experience suggests that mefloquine causes no significant increase in spontaneous abortions (miscarriages) or congenital malformations (birth defects) among women who have inadvertently taken the drug during this period.

Nursing mothers should take the usual adult dose of antimalarial appropriate for the country to be visited. The amount of medication in the breast milk will not be helpful or harmful to the infant. Therefore, the breast-feeding child needs his or her own prophylaxis.

Any pregnant traveler returning with malaria from an area where chloroquine-resistant Plasmodium falciparum is endemic should be treated as a medical emergency and as if she had illness due to chloroquine-resistant organisms. Because of the serious nature of malaria, quinine or intravenous quinidine should be used and should be followed by Fansidar®, or even doxycycline, despite concerns regarding potential fetal problems. Frequent glucose levels and careful fluid monitoring often require intensive care supervision.

Travelers' Diarrhea During Pregnancy

Dietary vigilance should be adhered to while traveling during pregnancy because dehydration due to travelers' diarrhea (TD) can lead to inadequate placental blood flow. Potentially contaminated water should be boiled. Iodine-containing purification systems should not be used long term. Iodine tablets can probably be used for short-term travel up to several weeks, but congenital goiters have been reported in association with administration of iodine-containing drugs during pregnancy. Eating only well-cooked meats and pasteurized dairy products, as well as avoiding pre-prepared salads, should help avoid diarrheal disease, as well as infections such as toxoplasmosis and listeria, which can have serious sequelae in pregnancy. It is not recommended that pregnant women use prophylactic antibiotics for the prevention of TD.

Oral rehydration is the mainstay of TD therapy. Bismuth subsalicylate compounds are contraindicated due to the theoretical risks of fetal bleeding from salicylates and teratogenicity from the bismuth. The combination of kaolin-pectin may be used, and loperamide should be used only when necessary. The antibiotic treatment of TD during pregnancy can be complicated. An oral third-generation cephalosporin may be the best option for treatment if an antibiotic is needed.

Breast-feeding is desirable during travel and should be continued as long as possible because of its safety and its lower incidence of infant diarrhea. A nursing mother with TD should not stop breast-feeding but should increase her fluid intake.

Air Travel During Pregnancy

Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. The lowered cabin pressures (kept at the equivalent of 5,000 to 8,000 feet or 1,524 to 2,438 meters) affect fetal oxygenation minimally because of the fetal hemoglobin dissociation curve. Severe anemia (Hgb 0.5 g/dL), sickle-cell disease or trait, a history of thrombophlebitis, or placental problems are relative contraindications to flying; however, supplemental oxygen may be ordered in advance. Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking reservations, as some will require medical forms to be completed. Domestic travel is usually permitted until 36 weeks gestation, and international travel may be curtailed after the 32nd week. Pregnant women should always carry documentation stating their expected date of delivery.

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 walk every half hour during a smooth flight and flex and extend the ankles frequently to prevent phlebitis. The seat belt should always be fastened at the pelvic level. Fluids should be taken liberally because of the dehydrating effect of the low humidity in aircraft cabins.

Women traveling with infants should keep in mind that newborns (younger than 6 weeks old) should not fly because their alveoli are not completely functional. Infants are particularly susceptible to pain with eustachian tube collapse during pressure changes, and breast-feeding during ascent and descent relieves this discomfort.

The Travel Health Kit During Pregnancy

Additions and substitutions to the usual travel health kit need to be made during pregnancy and nursing. Talcum powder, a thermometer, oral rehydration packets, multivitamins, an antifungal agent for vaginal yeast, acetaminophen, insect repellent containing a low percentage of DEET, and sunscreen with a high SPF (sun protection factor) should be carried. Women in their third trimester may want to carry a blood pressure cuff and urine dipsticks to check for proteinuria and glucosuria, both of which would require attention. Antimalarial and antidiarrheal self-treatment medications should be evaluated individually, depending on the traveler, her trimester, the itinerary, and her health history. Most medications should be avoided, if possible.

Source: National Center for Infectious Diseases, Centers for Disease Control and Prevention