Travel medicine and pregnancy

1
Travel medicine andpregnancy

• 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

2
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.

3
Objectives

• In this session
• 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

4
The Continuum of Travel Medicine
Pre-Travel
Visitors
Preventive Medicine
During Travel
Contingency Planning
Post-Travel
Treatment Rehabilitation
(Leggat et al., 2005)
5
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
  self-treatment
• 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)
6
What do we advise pregnant travelers?
7
Travel medicine and Pregnancy

• Mezger N et al. Travelling when pregnant. Rev Med
  Suisse. 2005 11 1263-1266. (in French)
• 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

8
When is the best time to travel during pregnancy?
9
Air travel during pregnancy

• ACOG committee opinion. Air travel during
  pregnancy. Int J Gyn Obst 200276338-339.
• 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)

10
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, doctors/midwifes letter
  confirming EDD
• Single pregnancies-flying permitted to end 36th
  weeks
• Multiple pregnancies-flying permitted to end of
  the 32nd week

11
What do airlines actually recommend?Some clues
given in Air-born study
12
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)
• 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).

13
Air travel during pregnancy

• ACOG (2002) gives further advice
• 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.

14
Air travel during pregnancy

• ACOG, 2002
• 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
• Pregnancy predisposes to a risk of superficial
  and deep venous thrombosis due to alterations in
  clotting factors and pressure of expanding uterus.

15
Air travel during pregnancy

• Freeman M et al. Does air travel affect pregnancy
  outcome? Arch Gynecol Obstet 2004269274-277.
  (small cohort study 222 pregnant women)
• 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

16
Air travel during Pregnancy

• Anderson (2001) citing CDC summarizes relative
  contraindications for travel during pregnancy
• Medical risk factors
• Obstetric risk factors
• Travel to destination that may be hazardous

17
Pregnancy and insurance

• Travel insurance is an important safety net for
  travelers
• 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

18
What do we know about pregnancy and travel
insurance?
19
Pregnancy and insurance

• Kingman CE et al. Travel in pregnancypregnant
  women's experiences and knowledge of health
  issues. J Travel Med 2003 10 330-333. (138
  pregnant women)
• 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
• gt 1/3 of the women traveled without sufficient
  insurance
• Only 1/3 sought advice prior to travel

20
Pregnancy and insurance

• Carroll D et al. The pregnant wilderness
  traveller. Travel Med Inf Dis (in press)
• 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.
• 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.

21
Pregnancy and insurance

• Leggat PA et al. Emergency assistance provided
  abroad to insured travellers from Australia.
  Travel Med Inf Dis. 200539-17 (gt2000 claims)
• 2.8 of travel insurance claims involving
  provision of emergency assistance were for
  obstetric problems

22
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
23
Pregnancy and insurance

• Take records (Carroll et al. op cit)
• Documentation concerning EDD and normality of
  pregnancy
• Copy of perinatal record
• Other documentation as needed for travel
• Know warning signs (Anderson, 2001)
• Bleeding, passing tissues or clots
• Abdominal pain or cramps
• Rupture of membranes
• Headache or visual changes

24
Pregnancy and travel kit

• Carroll et al (in press) op cit
• Take a travelers medical kit to manage common
  conditions

25
Pregnancy and antimicrobials

• Recommended
• Penicillins
• Aminoglycosides
• Cephalosporins
• Macolides
• Antifungals
• Metronidazole
• Praziquantel and other antiparasitics are
  probably safe

• Not recommended
• Kanamycin
• Streptomycin
• Tetracyclines
• Griseofulvin
• Quinolones (?safely)

WHO, 2005 op cit
antimalarials to be discussed separately
26
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)
• IAMAT (http//www.iamat.org)
• ISTM (http//www.istm.org)
• International SOS
• WWW resources
• http//www.obgyn.net/country/country.asp
  provides country specific information

Jothivijayarani, 2002 Op Cit
27
Pregnancy and malaria

• WHO. International Travel and Health. Geneva
  WHO, 2005.
• Travel to malaria-endemic areas should be
  avoided during pregnancy, if at all possible
• or intend to get pregnant (McGready et al,
  2004)
• Why?

28
Pregnancy and malaria

• WHO. International Travel and Health. Geneva
  WHO, 2005.
• Malaria increases risk of
• maternal death,
• miscarriage,
• stillbirth, and
• low birth weight with associated risk of neonatal
  death

29
Pregnancy and malaria

• WHO. International Travel and Health. Geneva
  WHO, 2005.
• 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

30
Pregnancy and malaria

• WHO. International Travel and Health. Geneva
  WHO, 2005.
• Therefore, in relation to travelers, WHO
  recommends Any pregnant woman with severe
  falciparum malaria should be transferred to
  intensive care

31
What do we advise if a pregnant traveler must go
to a malarious area?
32
Pregnancy and malaria

• Personal Protective Measures
• Avoidance
• Clothing
• Insecticides
• DEET

33
Pregnancy and malaria

• McGready R et al. Safety of insect repellent
  N,N-diethyl-M-toluamide (DEET) in pregnancy. Am J
  Trop Med Hyg 2001 65 285-289. (20 solution of
  DEET applied by women during 2nd and 3rd
  trimester)
• 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

34
Pregnancy and malaria

• McGready R et al. Malaria and the pregnant
  traveller. Travel Med Inf Dis 20042127-142.
• 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

35
Pregnancy and malaria
Chemoprophylaxis Recommended options for
chloroquine resistant areas
X
Mefloquine 250mg weekly 2nd/3rd trimester
Malarone 250mg/100mg daily (from 2000)
Doxycycline 100mg daily
?

• Alternatives include
• chloroquine 300mg weekly proguanil 200mg daily
• Sulfadoxine-Pyrimethamine

X
36
The flip side. What
if the woman is wanting to become pregnant?
37
Pregnancy and malaria
Drug Half-life Time to wait before conceiving
Mefloquine 14-21 days 3 months
Doxycycline / tetracycline 12-24 hours 1 week
Malarone / Atovaquone 2-3 days 2 weeks
Proguanil 14-21 hours 1 week
McGready et al., 2004. Op Cit WHO, 2005 Op Cit
38
What if the pregnant woman gets malaria?

• WHO (2005)
• Take standby drug
• Seek medical attention as soon as possible

39
Pregnancy and malaria treatment

• Recommended
• Chloroquine
• Chloroquine plus proguanil
• Mefloquine (2nd and 3rd trimester)
• Artemisinin
• Clindamycin (limited data)
• Quinine
• Sulfadoxine-pyrimethamine

• Non-recommended
• Doxycycline
• Tetracycline
• Artemether/lumfantrine (Coartem)
• Atovaquone plus proguanil (Malarone)
• Primaquine
• Tafenoquine

WHO, 2005. Op Cit
40
Pregnancy and malaria treatment

• WHO. International Travel and Health. Geneva
  WHO, 2005.
• 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.

41
What about vaccination during pregnancy?
42
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
43
Pregnancy and vaccination

• WHO. International Travel and Health. Geneva
  WHO, 2005.
• 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

44
Pregnancy and vaccination
WHO, 2005. Op Cit
45
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 (15-30).
  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.

46
Travel medicine and Pregnancy

• Mezger N et al. Travelling when pregnant. Rev Med
  Suisse. 2005 11 1263-1266. (in French)
• 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

47
Further Reading

• Anderson S. Womens health and travel. In.
  Zuckerman JN. Principles and Practice of Travel
  Medicine. John Wiley and Sons Ltd, 2001 381-422.
• 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

48
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. Womens 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 2004269274-277.
• Jothivijayarani A. Travel considerations during
  pregnancy. Primary Care Update Obstetrics and
  Gynecology. 2002 9 36-40.
• Kingman CE, Economides DL. Travel in
  pregnancypregnant 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. 2005111263-6.
• Steffen R, DuPont HL. Travel medicine whats
  that? J Travel Med 199411-3.
• World Health Organization. International Travel
  and Health. Geneva WHO, 2005. URL
  http//www.who.int/ith