Travel medicine and Pregnancy PowerPoint Presentation

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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

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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.

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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

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The Continuum of Travel Medicine During Travel Preventive Medicine Contingency Planning Treatment & Rehabilitation Visitors Post-Travel Pre-Travel (Leggat et al., 2005)

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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)

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What do we advise pregnant travelers?

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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

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When is the best time to travel during pregnancy?

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Air travel during pregnancy ACOG committee opinion. Air travel during pregnancy. Int J Gyn Obst 2002;76:338-339. “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)

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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

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What do airlines actually recommend? Some clues given in “Air-born” study

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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%).

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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.

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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.

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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) 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

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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

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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

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What do we know about pregnancy and travel insurance?

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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) 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

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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”.

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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) 2.8 % of travel insurance claims involving provision of emergency assistance were for obstetric problems

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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

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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

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Pregnancy and travel kit Carroll et al (in press) op cit Take a traveler’s medical kit to manage common conditions

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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

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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

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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?

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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

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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”

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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”

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What do we advise if a pregnant traveler must go to a malarious area?

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Pregnancy and malaria Personal Protective Measures Avoidance Clothing Insecticides DEET

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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

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Pregnancy and malaria McGready R et al. Malaria and the pregnant traveller. Travel Med Inf Dis 2004;2:127-142. “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”

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Chemoprophylaxis Recommended options for chloroquine resistant areas Mefloquine 250mg weekly 2nd/3rd trimester Malarone 250mg/100mg daily (from 2000) Doxycycline 100mg daily Pregnancy and malaria Alternatives include: chloroquine 300mg weekly + proguanil 200mg daily Sulfadoxine-Pyrimethamine X ? X

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The flip side…. What if the woman is wanting to become pregnant?

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Pregnancy and malaria McGready et al., 2004. Op Cit; WHO, 2005 Op Cit

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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 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

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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.”

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What about vaccination during pregnancy?

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“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

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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

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Pregnancy and vaccination WHO, 2005. Op Cit

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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.”

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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

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Further Reading Anderson S. Women’s 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

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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