Precautions for Traveling While Pregnant

Once a pregnant woman has decided to travel - especially to underdeveloped countries - a number of issues need to be considered before her departure. She should check medical facilities at her destination to determine whether prenatal care will be available and, if so, who will provide it. For a woman in the last trimester of a pregnancy, medical facilities should be able to manage complications of pregnancy, toxemia, and cesarean sections.

She should also know before traveling whether blood is screened for HIV and hepatitis B at the destination. The pregnant traveler should be advised to know her blood type.

A pregnant woman should be advised to travel with at least one companion. 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 or pain, headaches, or visual problems.

Motor Vehicle Accidents
Motor vehicle accidents are a major cause of injury and death for pregnant women. When available, safety belts should be fastened at the pelvic area. Lap and shoulder restraints are best; in most accidents, the fetus recovers quickly from the safety belt pressure. However, even after seemingly mild blunt trauma, a physician should be consulted.

Air Travel
Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. Domestic travel is usually permitted until the pregnant traveler is in her 36th week of gestation, and international travel may be permitted until weeks 32-35, depending on the airline. A pregnant woman should be advised always to carry documentation stating her current gestational age and expected date of delivery.

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.

Since dehydration can increase the risk of blood clots, pregnant women should drink plenty of fluids during flights.

High Altitudes
All pregnant women should avoid altitudes >3,658 meters (>12,000 feet). In addition, altitudes >2,500 meters (>8,200 feet) should be avoided in late or high-risk pregnancy. Pregnant air travelers with medical problems that could be made worse by a low-oxygen, high-altitude environment but who must travel by air should be prescribed supplemental oxygen during air travel.

Food- and Water-borne Illness
Pregnant travelers should be extra cautious about food and water consumed while traveling. Travelers should boil any suspect drinking water rather than using water purifiers that contain iodine.

Dehydration from travelers' diarrhea can lead to increased risk for premature labor. Pregnant travelers should eat only well-cooked meats and pasteurized dairy products and avoid pre-prepared salads. This will help them avoid diarrheal disease as well as infections such as toxoplasmosis and Listeria, which can have serious consequences in pregnancy.

Oral rehydration with appropriate liquids is the usual therapy for travelers' diarrhea. Some diarrheal medications should not be used because of theoretical risks to the fetus. The antibiotic treatment of travelers' diarrhea during pregnancy can be complicated. Pregnant women should discuss these issues with their physicians before traveling.

Malaria
Malaria in pregnancy carries significant risk of illness and death for both the mother and the fetus. Pregnant women should be advised 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 following preventive approaches published by the Centers for Disease Control and Prevention (CDC), including personal protection to avoid infective mosquito bites and using protective malaria medication as directed. Because no preventive method is 100% effective, they should seek care promptly if symptoms of malaria develop.

Malaria must be treated as a medical emergency in any pregnant returning traveler.

Avoiding Insects
Like malaria, other illnesses carried by insects can be more severe in pregnancy, bear potential harm to the mother, the fetus, or both. Pregnant travelers should scrupulously avoid insects by wearing clothing that covers most of the body, making use of bed nets, using permethrin treatment for clothing and nets, and applying DEET-containing repellents. The recommendations for DEET use in pregnant women do not differ from those for non-pregnant adults. Women choosing lower concentrations of DEET must increase the frequency of application if staying outdoors for long periods.

Immunizations
Pregnant women should be advised to avoid live-virus vaccines (measles, mumps, rubella, varicella and yellow fever). Women should also avoid becoming pregnant within 1 month of having received one of these vaccines because of theoretical risk of transmission to the fetus. However, no harm to the fetus has been reported from the unintentional administration of these vaccines during pregnancy.

Ideally, all reproductive-aged women should be up to date on their routine immunizations, whether or not they are planning a pregnancy. Therefore, in the event of an unplanned pregnancy, most women would be prepared if international travel were needed.

The following information is intended for women who may require immunizations during pregnancy. 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.

Diphtheria-Tetanus
The combination diphtheria-tetanus immunization should be given if the pregnant traveler has not been immunized within 10 years, although preference would be for its administration during the second or third trimester.

Hepatitis A
Pregnant women without immunity to hepatitis A virus (HAV) need protection before traveling to developing countries. HAV is usually no more severe during pregnancy than at other times and does not affect the outcome of pregnancy. The effect of these inactivated virus vaccines on fetal development is unknown and is expected to be low.

Hepatitis B
The hepatitis B vaccine may be administered during pregnancy and is recommended for pregnant women at risk for hepatitis B virus infection. Exposed newborns need to be vaccinated and receive immune globulin as soon as possible.

Influenza
Because of the increased risk for influenza-related complications, women who will be beyond the first trimester of pregnancy (>14 weeks gestation) during the influenza season of their travel destination should be vaccinated, when vaccine is available.

Measles, Mumps, and Rubella
The measles vaccine, as well as the measles, mumps, and rubella (MMR) vaccines in combination, are live-virus vaccines and so they are contraindicated in pregnancy. However, in cases in which the rubella vaccine was unintentionally administered, no complications have been reported.

Meningococcal Meningitis
The meningococcal meningitis vaccine can be administered during pregnancy if the woman is entering an area where the disease is epidemic. Studies of vaccination during pregnancy have not documented adverse effects among either pregnant women or neonates and have shown the vaccine to be efficacious.

Pneumococcal
The safety of pneumococcal polysaccharide vaccine during the first trimester of pregnancy has not been evaluated, although no adverse fetal consequences have been reported after accidental vaccination during pregnancy. Women with chronic diseases (such as asplenia, or metabolic, renal, cardiac, or pulmonary diseases), smokers, and immunosuppressed women should consider vaccination.

Poliomyelitis
The pregnant traveler must be protected against poliomyelitis. Paralytic disease can occur with greater frequency when infection develops during pregnancy. Fetal damage has also been reported, with up to 50% mortality. If not previously immunized, a pregnant woman traveling to an area where polio still occurs should be advised to have at least two doses of vaccine one month apart before departure.

Typhoid
No data are available on the use of either typhoid vaccine in pregnancy. The injectable preparation is the vaccine of choice during pregnancy because it is inactivated and requires only one injection. The oral typhoid vaccine is not absolutely contraindicated during pregnancy, but it is live-attenuated and thus has theoretical risk. With either of these, the vaccine efficacy (about 70%) needs to be weighed against the risk of disease.

Varicella (Chickenpox)
Women who are pregnant or planning to become pregnant should not receive the varicella vaccine.

Yellow Fever
The safety of yellow fever vaccination during pregnancy has not been established, and the vaccine should be administered to a pregnant woman only if travel to an endemic area is unavoidable and if an increased risk for exposure exists.

If traveling to or through regions within a country where the disease is not a current threat but where policy requires a yellow fever vaccination certificate, pregnant travelers should be advised to carry a physician's waiver, along with documentation of the waiver on the immunization record.

In general, pregnant women should be advised to postpone travel to areas where yellow fever is a risk until after delivery.

General Considerations
Since as many as 50% of pregnancies are unplanned, reproductive-aged women should consider maintaining current immunizations during routine check-ups in case of an unplanned pregnancy and a need to travel. Preconceptional immunizations are preferred to vaccination of pregnant women, because they decrease risk to the unborn child.

Pregnant women considering international travel should be advised to evaluate 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 Obstetrics and Gynecology, 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 spontaneous abortion or premature labor.

A woman in the third trimester should be advised to stay within 300 miles of home because of concerns about access to medical care in case of problems such as hypertension, phlebitis, or premature labor. Pregnant women should be advised to consult with their health-care providers before making any travel decisions. In general, pregnant women with serious underlying illnesses should be advised not to travel to underdeveloped countries.

Information in this article has been provided by the Centers for Disease Control and Prevention.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.