Nicole J. Cohen, MD: Hello, I'm Dr. Nicki Cohen from the US Centers for Disease Control and Prevention's (CDC's) Division of Global Migration and Quarantine. I'm joined by Dr. Denise Jamieson, an obstetrician from the CDC's Division of Reproductive Health. We are pleased to be here as part of the CDC Expert Commentary series on Medscape.
Today, we're going to discuss health issues facing pregnant women who are planning international travel. Thank you for joining me, Denise.
Denise J. Jamieson, MD, MPH: It's my pleasure, Nicki. Thank you for the chance to be here today to address this important topic.
Dr. Cohen: Obviously, a lot of considerations go into advising a pregnant traveler, but what would be some of the first things that you'd tell her?
Dr. Jamieson: I'd tell the woman to expect the usual problems of pregnancy -- fatigue, heartburn, leg cramps, frequent urination, and hemorrhoids -- but emphasize that the stress of international travel can exacerbate these conditions.
Dr. Cohen: I always encourage travelers to carry a travel health kit that contains basic first aid and medical supplies. A pregnant traveler may also want to include prenatal vitamins, talcum powder, acetaminophen, and a topical antifungal agent for vaginal yeast.
Dr. Jamieson: I agree. Another consideration is that pregnant women are at increased risk for venous thromboembolism during long periods of immobility. A pregnant woman should really avoid constrictive clothing around the waist or legs; drink plenty of water; walk every 30 minutes; and flex and extend her ankles during long flights or trips on buses, trains, or cars.
Dr. Cohen: Since you mentioned car trips, I want to point out that car accidents are the number one cause of preventable injury and death in all travelers regardless of whether they are pregnant.
Dr. Jamieson: Exactly. Pregnant women should always wear seatbelts. Lap and shoulder restraints are best. Also, they should be worn across the pelvis, not the abdomen. Fetuses usually recover quickly from seatbelt pressure, but a physician should be consulted after even mild trauma because of possible damage to the placenta.
Dr. Cohen: Another major concern for pregnant women is hepatitis E. Hepatitis E is self-limiting and not serious in most people. However, in a pregnant woman it can cause fulminant hepatitis and death. Women traveling to areas where hepatitis E is endemic should be very vigilant with food and water precautions.
Dr. Jamieson: I counsel all pregnant travelers to be careful with food and water because the consequences, such as listeriosis or toxoplasmosis, can be more serious than just diarrhea.
Dr. Cohen: I should point out that boiling is the preferred method of water purification for pregnant women to avoid long-term use of iodine purification.
Dr. Jamieson: If a pregnant woman develops traveler's diarrhea, oral rehydration is the mainstay of therapy. If she needs an antibiotic, azithromycin or a third-generation cephalosporin is probably the best option.
Dr. Cohen: Correct. Loperamide can be used if necessary, but bismuth subsalicylate is contraindicated.* Now thinking about travel to other countries, are there special considerations for a pregnant patient planning a trip to a developing country?
Dr. Jamieson: One of my first thoughts would be how far along she'd be when traveling. I usually suggest that early in the second trimester is the best time for a pregnant woman to travel. By then, morning sickness will probably have resolved and the risk for spontaneous abortion is lower.
If she were going to be traveling at the end of her second trimester or later, I would probably encourage her to reschedule the trip, especially if the travel were to an exotic destination. Medical care in those areas may not be adequate to manage any complications that could arise.
Dr. Cohen: That's a good point, Denise. Before she travels, a pregnant woman needs to plan for where and how to access emergency care if she needs it. Even in developed countries where modern care is available, a woman's health insurance may not pay for care. If a pregnant woman determines that she needs supplemental travel, medical, or evacuation insurance, she should confirm ahead of time that these policies cover problems related to the pregnancy and birth. They may not, and supplemental policies may not cover infants.
Dr. Jamieson: The CDC's Yellow Book has chapters that discuss how to obtain healthcare abroad and travel and evacuation insurance. This is a valuable resource to providers who see international travelers, and it's available online at www.cdc.gov/yellowbook.
Dr. Cohen: Now let's talk about vaccination. Patients usually want to know what shots they need in order to travel. There's always some risk/benefit consideration here, but the situation is even trickier with pregnant women.
Dr. Jamieson: That's absolutely right, Nicki. The CDC generally groups vaccines for pregnant women into 3 categories. Some vaccines are recommended for pregnant women at risk for diseases such as hepatitis A and B; tetanus, diphtheria, or Tdap; and seasonal influenza. Other vaccines are contraindicated in pregnant women: MMR [measles, mumps, and rubella], HPV [human papillomavirus], and varicella. For all other vaccines, pregnancy is considered a precaution and the vaccine should be given only if the benefits outweigh the risks.
Dr. Cohen: The Yellow Book lists all of these vaccines and their uses. However, I want to stress that there's no black-and-white list of vaccines that every pregnant traveler needs. The choices will be influenced by the travelers' itineraries, health status, and other factors. These decisions need to be made by travel medicine or infectious disease specialists in consultation with patients and their obstetricians.
Dr. Jamieson: I'm glad you brought up the consultation with travel medicine specialists, Nicki. Travel medicine providers can be a great source of advice, especially for primary care providers or obstetricians and gynecologists who may not have much experience with infectious diseases.
This brings me to another question: What if you had a patient who is planning to travel to an area where malaria is endemic?
Dr. Cohen: If it were chloroquine-sensitive malaria and the traveler were otherwise healthy, I wouldn't discourage travel. Chloroquine has been used for decades with no documents of increase in birth defects. In areas of chloroquine resistance, however, mefloquine is the only chemoprophylaxis available, and it can be difficult to tolerate. Doxycycline and primaquine are contraindicated in pregnancy, and atovaquone/proguanil is not recommended.
Dr. Jamieson: Regardless of chemoprophylaxis, pregnant travelers need to be advised about mosquito avoidance. No antimalarial drug is 100% effective, and proper use of insect repellent will also decrease the risk for other insect-borne diseases such as dengue. Repellents containing DEET [N,N-diethyl-meta-toluamide] are generally considered safe to use for pregnant women.
Dr. Cohen: We're about out of time. Thank you for joining us, Denise. This has been extremely informative. I think we've shown a lot of ways that travel medicine practitioners and obstetricians can work together to ensure the best outcomes for their pregnant travelers.
Dr. Jamieson: Thanks again for having me, Nicki. I'd just like to make one final point. We've been talking a lot about the risks of traveling while pregnant, but it's important to remember that with a few basic precautions, pregnant women can and do travel safely.
Dr. Cohen: Thank you for listening to this installment in our series on advising patients with special needs. Additional information can be found at the CDC's Travelers' Health Website.
*An earlier version of this commentary stated that Kaopectate® may be used to treat pregnant women. The current formulation of Kaopectate in the United States uses bismuth subsalicylate as its active ingredient and should not be given to pregnant women. The formulation marketed in Canada uses attapulgite as its active ingredient.