19 Travel

& Pregnancy

If you are a healthy woman with an uncomplicated pregnancy, you do not neces-
sarily need to curtail reasonable travel. According to the American College of
Obstetricians and Gynecologists, the best time for travel is during the second tri-
mester when your body has adjusted to the pregnancy but is not so bulky that
moving about is difficult. The second trimester is also safer because the probability
of miscarriage is less. After the sixth month, the risk of premature labor and other
complications increase.
When to Limit Travel
A brief trip to major European cities during the second trimester represents a far
safer scenario than an extended trip to a developing country where you might have
potential exposure to exotic illnesses, as well limited access to medical care. If you
will be far away from expert medical and obstetrical care, and/or have increased ex-
posure to travel-related diseases, such as malaria, then you should consider deferring
travel until after delivery.
After the 28th week—Most obstetricians advise their patients not to travel be-
yond a 100-mile radius after the 28th week. Problems after this time include in-
creased risk of premature labor, preterm rupture of membranes, development of
hypertension, phlebitis, and increased risk of uterine and placental injury should
you be involved in a motor vehicle accident.
Pretravel Checklist
A careful assessment of your medical and obstetrical history, and your current state
of health, is mandatory prior to departure. It should include the following:
• Obstetrical history—Have you had any of the following conditions?
(1) spontaneous abortion (miscarriage) (2) ectopic pregnancy (3) toxemia
(4) premature labor (5) incompetent cervix (6) prolonged labor
(7) caesarean section (8) premature rupture of membranes
(9) uterine or placental abnormalities (10) hypertension
(11) pelvic inflammatory disease (12) phlebitis or pulmonary embolism
(13) D (Rho) negative blood group (14) severe morning sickness

• Medical history—Do you:

Travel & Pregnancy 251

 (1) Have diabetes? Take insulin? (2) Take medication for any other illness?
(3) Have symptomatic congenital or acquired heart disease?
(4) Have anemia, asthma, epilepsy, phlebitis, or any other significant medical
illnesses? (5) Get severe motion sickness? (6) Have significant allergies?
• The current pregnancy—Do you have any immediate obstetrical complications
(e.g., preeclampsia)?
• Personal comfort—Will it be manageable and acceptable during your trip?
• The duration of your trip—Will it be more than a few days? Will travel require
prolonged sitting?
• The destination—Is it more than 100 miles from home?
• The quality and availability of medical and obstetrical care in the countries on
your itinerary—Is it available and adequate?
Medical clearance for travel—After reviewing the foregoing checklists, your
doctor will be able to discuss with you the relative safety of your travel plans and
offer appropriate advice.
Prenatal Checkups
You should have your first prenatal appointment at 10 weeks. The fetal heart tones
are usually heard by this time, and their presence is reassuring that your pregnancy
is probably proceeding normally. Once fetal heart tones are heard, the chance of
spontaneous miscarriage is small. You then should have checkups every four
weeks until week 30, then every two weeks until week 36, then weekly until deliv-
ery. Travel plans should not interfere with these important checkups.
Pelvic ultrasound—Before leaving, discuss with your obstetrician the ad-
visability of having a pelvic ultrasound examination to check for tubal preg-
nancy, multifetal pregnancy, or placental abnormalities.
Medical Care Abroad
All travelers should ask “What will I do if an emergency arises?” Before leaving
home, learn as much as possible about the availability and quality of obstetrical
and medical care in the countries on your itinerary. Unfortunately, most doctors
won’t be of much help because few physicians or obstetricians are familiar with
foreign doctors and hospitals. A travelers’ clinic is better able to assist you. U.S.
Embassies and Consulates overseas usually have lists of local English-speaking phy-
sicians and can give a referral. (Ask which physicians the embassy staff personally
would use.)
IAMAT—Travelers can obtain a listing of English-speaking doctors overseas by
contacting IAMAT (the International Association for Medical Assistance to Trav-
elers) at 519-836-0102. The list is free but a membership donation to this tax-free
foundation is encouraged. Personal Physicians Worldwide in Washington, DC,
will identify and personally call physicians overseas to ensure their availability
during your trip. Travelers get a wallet card with the names and numbers of se-

252 Travel & Pregnancy

lected physicians who are on the staff of the preferred hospitals at your destina-
tion. Tel: 888-657-8114.
Travel insurance—Travelers going to a lesser-developed country should pur-
chase a supplemental travel health insurance policy that provides a worldwide 24-
hour medical assistance hotline number. This type of policy puts you in telephone
contact with medical personnel who can help arrange emergency medical consul-
tation and treatment, monitor care, and provide emergency evacuation to a more
advanced medical facility, if necessary.
NOTE: Travel insurance policies won’t cover medical expenses associated with
a normal pregnancy (e.g., delivery). Some policies don’t cover complications in
the third trimester. Other policies don’t cover miscarriage, which is usually a first
trimester problem. Check if the policy covers the neonate. You should compare
the various policies and read their exclusions before buying one. The following
companies’ policies cover complications of pregnancy through the third trimes-
ter:

Worldwide Assistance Services, Inc. AEA International/ SOS

1133 15th St., Suite 400 Box 11568
Washington, DC 20005 Philadelphia, PA 31685
800-821-2828 800-523-8930

Calling home—Travelers should always carry their doctor’s telephone num-

ber or e-mail address with them. It’s usually possible to call the United States or
Canada when problems arise and the traveler wants direct advice from the physi-
cian who knows her best. In addition, providing the personal physician’s phone
number to overseas physicians may be extremely helpful during an emergency.
Obstetrical Emergencies
Review with your doctor those signs and symptoms that indicate a possible ob-
stetrical emergency and seek immediate, qualified obstetrical care if you have any
of the following:
• Vaginal bleeding
• Passing of tissue or blood clots
• Lower abdominal pain, cramps, or contractions
• Gush of watery fluid from vagina
• Headaches, blurred vision, ankle swelling, high blood pressure, or seizures
Other causes of illness should not be overlooked. Abdominal pain, for example,
does not necessarily indicate that you have an obstetrical emergency. You could
have appendicitis, a urinary tract infection, or merely simple indigestion. Diag-
nosing the cause of abdominal pain is usually more difficult during pregnancy.
Readily available, high-quality medical care is essential if you develop worrisome
symptoms.

Travel & Pregnancy 253

 Symptoms that may be no cause for concern (but if persistent should be evalu-
ated) include the following:
• Increased urination • fatigue • insomnia • heartburn • indigestion
• Constipation • slight increase in vaginal discharge
• Sore, bleeding gums • leg cramps • occasional mild dizziness
• Mild swelling around ankles • hemorrhoids

TRAUMA DURING PREGNANCY

Motor vehicle accidents—Accidents are the leading cause of death in travelers
under the age of 55, and motor vehicle accidents are responsible for most cases of
blunt trauma to pregnant women. Maternal mortality is increased sixfold and fe-
tal mortality fivefold when the woman is ejected from the vehicle. Consequently,
the use of seatbelts is recommended to decrease maternal and fetal trauma. Use
of a lap belt alone, however, has been implicated in placental injury and fetal inju-
ry. The best protection is provided by the diagonal shoulder strap with a lap belt.
The straps should be above and below the abdominal bulge, thus distributing the
energy of impact over the anterior chest and pelvis, as shown in Figure 17.1
Figure 17.1 Proper position of seat belt when pregnant.
Place the lap belt well below the abdomen and as low
as possible over the pelvic bones. A thin blanket be-
tween the belt and your body may increase comfort.

Falls—Women in their third trimester tend

to have more falls. Eighty percent of these falls
occur after the 32nd week and are mostly due to
fatigue, a fainting spell, a protruberant abdomen,
a loss of balance and coordination, and increased
joint mobility, especially looseness of the pelvic joints. Most of these third trimes-
ter falls are usually minor but some might require you to undergo a brief period
of observation or fetal monitoring.
Abruptio placentae (placental separation)—A direct blow to your abdomen
is more apt to injure the placenta than the fetus. Mild abdominal trauma may
cause placental separation in 1% to 5% of cases. Major blunt abdominal trauma
causes separation in 20% to 50% of cases. Symptoms of abruptio placentae are
typically abdominal pain and vaginal bleeding.
Fetal monitoring—Early detection and treatment of abruptio placentae is criti-
cal in order to prevent fetal death and preserve the mother’s health. Fetal moni-
toring as early as the 20th week of pregnancy can predict abruptio placentae. Stud-
ies show that there is frequent uterine activity—more than eight uterine contrac-
tions per hour—during the first few hours of monitoring after trauma in virtually
all patients in whom abruptio placentae eventually occurs. Monitoring is advised,
however, only after the stage of fetal viability (approximately 24 weeks) since no

254 Travel & Pregnancy

therapy exists for the treatment of fetal distress prior to this developmental stage.
Concern for maternal health is the only indication for hospitalization prior to the
stage of fetal viability.
Ultrasound—Ultrasonography has been advocated to expedite the diagnosis
of abruption but may be unreliable. Fetal monitoring (cardiotocographic moni-
toring) is superior. Ultrasound is useful to (1) determine fetal well-being if moni-
toring is equivocal, (2) measure fetal heart rate and verify fetal cardiac activity if
fetal death is suspected, or (3) estimate the volume of amniotic fluid if there is a
question of ruptured membranes.
When to monitor—If you sustain a direct abdominal blow or a motor vehicle
accident (with or without direct abdominal trauma), then you should have con-
tinuous monitoring for at least 4 hours, provided the monitoring is begun
promptly after the injury.
If you sustain minor trauma, a short period of monitoring or observation is
usually indicated.
If fetal monitoring is not immediately possible, you should contact a physician
immediately if you have any of the following warning symptoms: vaginal bleed-
ing, leak of fluid from the vagina, decrease in or lack of fetal motion, severe ab-
dominal pain around the uterus, rhythmic contractions, dizziness, or fainting.

VACCINATIONS DURING PREGNANCY

If you are pregnant (or think you might be pregnant or anticipate you may
become pregnant while traveling), an immunization strategy for international
travel may present special problems. The problem is weighing the peril and ben-
efit of the vaccine against the risk of contracting a serious, possibly life-threaten-
ing infection. For many vaccines there are simply no studies documenting their
safety in pregnancy, but they are considered safe, on a theoretical basis if indicated
by the perceived risk. If possible, your immunizations should be given after the
first trimester.
Immunizations Routinely Given During Pregnancy
• Influenza: CDC recommends that all women who will be beyond the first tri-
mester of pregnancy (>14 weeks gestation) during the influenza season should be
immunized. If you are pregnant and have a medical condition that increases your
risk for complications from influenza, you should be vaccinated before the influ-
enza season, regardless of the stage of pregnancy. Be aware that the flu season in
the Southern Hemisphere is in our summer.
• Tetanus-Diphtheria (Td): This vaccine is routinely indicated for susceptible
pregnant women. It is even more important that your Td immunization be
current if there is the possibility that your delivery may occur under unhygienic
conditions.

Travel & Pregnancy 255

Immunizations That May Be Administered during Pregnancy, But
Only If Indicated By a Definite Increased Risk of Exposure
• Cholera: This vaccine is no longer available in the United States and is not
recommended for travel. There is no data regarding its safety in pregnancy.
• Hepatitis A: The safety of hepatitis A vaccine during pregnancy has not been
determined, but the theoretical risk to the fetus is expected to be very low. Rec-
ommended if you are not immune and plan to travel to a developing country.
• Hepatitis B: Hepatitis B vaccine is considered safe and may be administered in
pregnancy if indicated by the risk of exposure.
• Japanese Encephalitis: Significant side effects are possible, including fever, an-
gioedema, and hypotension. There is no data regarding safety in pregnancy. You
should receive this vaccine only if travel to an endemic area is unavoidable and
your risk of exposure will be significant.
• Lyme Disease: Vaccination of women who are known to be pregnant is not
recommended.
• Meningococcal: This vaccine may be given during pregnancy if you have a
substantial risk of exposure.
• Pneumococcal (polysaccharide): If you are a candidate for this vaccine, usu-
ally because of a chronic infectious or metabolic state, every attempt should be
made to administer it before you become pregnant. The vaccine may be given
during pregnancy if you have a substantial risk of exposure.
• Polio: A one-time booster with IPV (inactivated polio vaccine) is indicated
prior to international travel.
• Rabies: This vaccine, by either the intramuscular or intradermal route, may be
given if there is potential risk of exposure.
• Typhoid: The Typhim Vi injectable vaccine is indicated for travelers at risk. It
is safe and requires only a single dose. The oral Ty21a vaccine (Vivotif-Berna) is
not routinely recommended since it is a live-bacterial vaccine.
• Yellow Fever: Although this is a live-virus vaccine, you should receive it if you
will be at significant risk in a yellow fever endemic area. Ideally, travel to areas
requiring yellow fever vaccination should be delayed until after delivery.
Per WHO, yellow fever vaccine may be given after the sixth month of preg-
nancy if there is substantial risk of exposure. Get a waiver letter from your physi-
cian if vaccine is required solely to comply with international travel requirements.
Immunizations Contraindicated During Pregnancy
• Measles, Mumps, Rubella (MMR): These are live-virus vaccines and should
never be given alone, or in combination, in pregnancy. If you are not sure about
your immunization status, you can be tested for immunity to these diseases. Do
not become pregnant for at least 3 months after receiving this vaccine.
• Varicella (Chickenpox): This is a live-virus vaccine and should never be given
in pregnancy. If you are not sure about your immunization status, you can be

256 Travel & Pregnancy

tested for immunity. Chickenpox is a particularly serious disease in pregnancy and
every attempt should be made to give this vaccine before any pregnancy. Avoid
becoming pregnant for at least 1 month after receiving this vaccine.

MALARIA
Malaria is the most important insect-transmitted disease you need to avoid, espe-
cially the falciparum variety. The disease is more severe in pregnancy, due in part
to a decrease in immunity that allows a higher percentage of red blood cells to be
infected by parasites, as well as the fact that the placenta is a preferential site of
sequestration of parasitized red blood cells.
Maternal complications of falciparum malaria include profound hypoglycemia
(low blood sugar), increased anemia, kidney failure, adult respiratory distress syn-
drome, shock, and coma. Maternal mortality rates up to 10% can occur. Obstet-
rical complications of malaria include spontaneous miscarriage, premature deliv-
ery, stillbirth, and neonatal deaths. Vivax malaria is associated with greater ane-
mia and lower birthweight, but not miscarriage or stillbirth.
You are best advised to avoid elective travel to malarious areas, especially areas
where chloroquine-resistant malaria is endemic (e.g., sub-Saharan Africa,
Oceania). If you must travel to a malarious area, it is imperative to (1) prevent
mosquito bites and (2) take an effective prophylactic drug.
Prevention
Mosquito bites—Protection against insect bites is important in the tropics.
Malaria, dengue fever, Lyme disease, and other insect-transmitted diseases can se-
riously affect both you and the fetus. The first line of defense against malaria—and
the best—is to prevent bites by mosquitoes. You should apply an insect repellent
containing 30%–35% of DEET to exposed skin and treat your clothing with per-
methrin. This combination is 99%–100% effective in preventing mosquito bites.
You should spray residential living areas and sleeping quarters with an insecticide
(e.g., RAID™ Flying Insect Spray). Mosquito nets, especially if sprayed or impreg-
nated with permethrin, have been shown to reduce markedly the incidence of
malaria in endemic areas. Vigorous insect-bite prevention measures will not only
help prevent malaria but also reduce your risk of other insect-transmitted diseases
such as dengue and leishmaniasis.
Don’t rely on Avon’s Skin-So-Soft to prevent disease-causing mosquito bites.
It is relatively ineffective and lasts only one-half hour.
Drug prophylaxis—Chloroquine is the drug of choice when traveling to areas
endemic for vivax malaria and chloroquine-sensitive falciparum malaria.
Chloroquine and proguanil are probably safe to take during pregnancy but the
combination is only about 70% (or less) effective against chloroquine-resistant
falciparum malaria in Africa. Atovaquone/proguanil (Malarone) is
contraindicated for prophylaxis.

Travel & Pregnancy 257

 Mefloquine (Lariam), when used for prophylaxis, is the drug of choice for travel
to areas with chloroquine-resistant falciparum malaria. Mefloquine has not been
associated with an increase in spontaneous miscarriage, congenital malformations,
or adverse postnatal outcomes. It is considered safe for use during the second and
third trimesters by the Centers for Disease Control and Prevention (CDC) as well
as the World Health Organization. As inadvertent use of mefloquine during the
first trimester has not been documented to cause an excess of maternal or fetal
problems, many travel medicine physicians will prescribe mefloquine during the
first trimester when exposure to chloroquine-resistant falciparum malaria is un-
avoidable. Delay in travel until the second trimester, however, is recommended.
Mefloquine is only 50% effective against P. falciparum along the borders of
Thailand with Cambodia and Myanmar, and travel to these border areas should
be avoided.
You should not take doxycycline for prophylaxis because this drug can stain
the teeth of the developing fetus and cause retardation of bone growth. However,
doxycycline or tetracycline may be needed for adjunct treatment (with quinine or
quinidine) of life-threatening chloroquine-resistant falciparum malaria, although
there may be alternatives (see Chapter 6).
Treatment of Malaria
Uncomplicated chloroquine-sensitive P. vivax and chloroquine-sensitive
P. falciparum should be treated with a 3-day course of chloroquine. Uncompli-
cated chloroquine-resistant P. falciparum can be treated with mefloquine or oral
quinine plus pyrimethamine/sulfadoxine (P/S) or clindamycin. (A recent study
has suggested that high-dose mefloquine treatment is associated with increased
risk of fetal death.) In the Amazon Basin and Southeast Asia, P/S may not be ef-
fective. Falciparum malaria contracted in Thailand can be treated with quinine
and clindamycin, but quinine-resistant malaria is increasing in this region.
Atovaquone/proguanil (Malarone) is rated Cataegory C for use in pregnancy,
and should be used only if the potential benefits outweigh the possible risks.
Complicated falciparum malaria requires parenteral therapy with quinidine
plus doxycycline or clindamycin. Appropriate treatment to save the mother takes
precedence over concerns about drug-related fetal toxicity, and individual circum-
stances will dictate what regimen is best in a given situation. When possible, ma-
laria in pregnancy is best treated by an expert in this area.
Radical Cure
Primaquine should not be used during pregnancy because it may precipitate
glucose-6-PD-induced hemolytic anemia in the fetus. If you have been treated
for P. vivax or P. ovale malaria, you should continue chloroquine prophylaxis until
after delivery when you can be treated with primaquine.

258 Travel & Pregnancy

 DRUG USE GUIDELINES
In general, drugs should be taken only if the severity of the symptoms, or the threat
to the mother’s health, outweighs the possible risk of fetal damage. As with man-
agement of illnesses at home, you should employ nondrug remedies when pos-
sible. For example, you can use warm compresses for muscle aches instead of an
analgesic. However, if you develop a serious or life-threatening illness, such as an
infection, appropriate drugs should not be withheld because of concerns about
fetal toxicity.
Drugs for Pain
Acetaminophen (Tylenol)—Safe, in moderation. Analgesic of choice for mild to
moderate pain. Kidney disease in the neonate can occur with daily high doses.
Acetaminophen with codeine—Safe.
Aspirin—Avoid, especially in the last trimester. May increase incidence of bleed-
ing, especially maternal and neonatal blood loss following delivery. Data from a
study of 58,000 pregnancies also suggest that taking aspirin in the last trimester is
likely to increase the duration of labor. Aspirin is a potent prostaglandin synthetase
inhibitor, and it has been associated with premature closure of the ductus arteriosus.
Low-dose aspirin—60–100 mg daily reduces incidence of pregnancy-induced hy-
pertension; may be indicated for women at risk of developing preeclampsia.
Should be used only as recommended by your obstetrician.
Nonsteroidal anti-inflammatories (NSAIDs, e.g., ibuprofen)—Avoid, due to
increased bleeding potential. Theoretically, any NSAID can cause premature duc-
tal closure. Nonsteroidal drugs, however, are not considered to be teratogenic.
Opioids—Considered safe.
Drugs for Diarrhea and Vomiting
Azithromycin (Zithromax)—Considered safe, although studies are lacking. In
Thailand, azithromycin was superior to ciprofloxacin in the treatment of
campylobacter enteritis. Other studies have demonstrated some effectiveness
against shigella as well as salmonella and E. coli.
Bismuth subsalicylate (Pepto Bismol)—Avoid (contains salicylate).
Furazolidone—Furazolidone is a broad-spectrum antibiotic effective against
many diarrhea-causing pathogens (E. coli, salmonella, shigella, V. cholerae).
Furazolidone is 80% effective against Giardia lamblia. No reports of teratogenicity,
carcinogenicity, or other adverse fetal effects.
Lomotil—Avoid. Contains atropine. More potential side effects than loperamide.
Loperamide (Imodium)—Acceptable for watery diarrhea. Avoid with diarrhea
associated with a high fever and/or bloody stools.
Metronidazole (Flagyl)—Acceptable for the treatment of giardiasis or invasive
amebiasis. Although there is some concern about the use of metronidazole be-
cause it is carcinogenic in rodents and mutagenic in certain bacteria, a recent analy-

Travel & Pregnancy 259

sis of seven studies suggested that there is no increase in birth defects among in-
fants exposed to metronidazole during the first trimester.
Paromomycin—This is an oral aminoglycoside that is nonabsorbed from the
intestinal tract and considered to be safe during pregnancy for the treatment of
intraluminal, noninvasive amebiasis. As an alternative to metronidazole, it is 60%
to 70% effective. Paromomycin can also be used for the treatment of giardiasis.
Piperazines and phenothiazines (Antivert, Compazine)—Acceptable. No re-
ported increased risk of congenital anomalies.
Quinolones—Quinolones are not contraindicated during pregnancy, but they are
Category C drugs. According to the Physicians Desk Reference (PDR) “There are
no adequate or well-controlled studies in pregnant women. Quinolone antibiot-
ics should be used during pregnancy only if the potential benefit justifies the po-
tential risk to the fetus.” Quinolone antibiotics should not be withheld arbitrarily,
especially in the presence of serious illness.
Trimethoprim/sulfamethoxazole (e.g., Bactrim, Septra)—In studies of infants
exposed to trimethoprim/sulfamethoxazole during early pregnancy, the frequency
of congenital abnormalities was not increased. Sulfonamides, however, should be
avoided at term due to the risk of hyperbilirubinemia.
Drugs for Altitude Sickness
Acetazolamide (Diamox)—Avoid in first trimester. Acetazolamide is associated
with limb abnormalities in animals. A sulfa analog.
Calcium channel blockers (e.g., nifedipine)—No increased risk of fetal anoma-
lies, but decrease in fetal blood flow is possible.
Dexamethasone (Decadron)—Considered to be safe. No association with
congenital anomalies has been reported.
Sleeping Pills & Tranquilizers
Alcohol—Teratogenic; avoid, even in small amounts.
Benzodiazepines—Avoid. One study associated diazepam with cleft lip.
Drugs for Motion Sickness, Coughs & Colds
Dramamine, meclizine—Considered safe. Use if motion sickness is a significant
problem.
Antihistamines—Probably safe, but Benadryl is in Category C.
Cough medicines with iodine—Avoid. Excess iodine may affect fetal thyroid
development. Cough preparations with guaifensin and dextromethorphan are
acceptable.
Decongestants—Pseudoephedrine (Sudafed) and oxymetazoline (Afrin) are
considered safe.

260 Travel & Pregnancy

Drugs for Malaria and Other Infections
Atovaquone/proguanil (Malarone)—Safety in pregnancy has not been estab-
lished; may be suitable for treatment in select circumstances.
Cephalosporins—Safe.
Chloroquine—Considered to be safe.
Clindamycin—No studies of adverse embryofetal effects. This drug is a good
alternative to doxycycline for the treatment of falciparum malaria when used in
combination with quinine or quinidine.
Diloxanide—Avoid.
Erythromycin—Considered safe. If used to treat maternal syphilis, however, ad-
equate fetal blood levels may not be achieved since little drug passes the placenta.
Halofantrine—Avoid. Halofantrine is embryotoxic.
Iodoquinol—Avoid.
Mefloquine—Considered safe during second and third trimesters. The use of
mefloquine during the first trimester should be reserved for women with unavoid-
able travel to areas at high risk for chloroquine-resistant falciparum malaria.
Nitrofurantoin—Selected by many obstetricians as the initial choice for most
urinary tract infections. Congenital anomalies not reported.
Penicillin, ampicillin, amoxicillin—Considered safe. This includes the newer
penicillins such as piperacillin, as well as those combined with b-lactamase inhibi-
tors, clavulanic acid, and sulbactam.
Praziquantel—Probably safe. Use only if clearly indicated.
Primaquine—Avoid until after delivery. May cause hemolytic anemia in G-6-PD-
deficient fetus.
Proguanil—Probably safe.
Pyrimethamine/sulfadoxine (Fansidar)—Safe as single-dose (3-tablet) presump-
tive treatment of malaria. This drug is no longer recommended for prophylaxis.
Quinine and quinidine—Indicated for treatment of chloroquine-resistant
falciparum malaria. A study in Thailand found no deleterious effect of quinine
on the fetus or increased incidence of drug-induced abortion. Quinine may in-
crease incidence of hypoglycemia in the pregnant patient with malaria.
Sulfisoxazole (Gantrisin)—Acceptable. Avoid at term.
Tetracycline, doxycycline—Avoid unless needed for adjunctive treatment of
chloroquine-resistant falciparum malaria or other life-threatening infectious dis-
eases (e.g., ehrlichiosis).
Other Drugs
Iodine tablets and iodine-resin water purifiers—Do not use for more than
three weeks in any 6-month period as sole source of purified water. Excess iodine
can theoretically cause fetal goiter, but little or no data are available in pregnant
travelers using iodine for water purification. Boiling water remains the mecha-
nism of choice for longer-term water purification.

Travel & Pregnancy 261

 NOTE: Prolonged use (>2 years) of demand-release iodine-resin filters by
Peace Corps workers in Africa resulted in a four-fold increased risk of goiter and
thyroid dysfunction (Lancet 1998). Attaching a carbon cartridge to an iodine-resin
filter device will reduce iodine concentration in the treated water.
DEET—Considered safe when used according to the directions on label. There
are no reports of teratogenicity nor are there any EPA warnings about the use of
DEET during pregnancy.

EXERCISE AND PREGNANCY

Labor is aptly named. Childbearing takes a lot of stamina, and it’s no surprise
that exercise is appropriate for a healthy pregnant woman. Today, when more
and more women are active and sports-minded, many obstetricians say that strenu-
ous exercise, even running or jogging, is not harmful to the fetus and may even
help build stamina for labor and recovery afterward. But how much exercise is
too much? And who should avoid exercise? Guidelines set forth by the American
College of Obstetricians and Gynecologists (ACOG) recommend the following:
• Maternal heart rates during exercise should not exceed 150 beats per minute.
• Strenuous activities should not exceed 15 minutes in duration.
• Avoid hyperthermia. Body temperature should not exceed 38°C (101.4°F).
• No exercise should be performed in the supine position after the fourth month.
Some authorities believe, however, that the 15-minute limitation may be too
restrictive for a woman used to vigorous exercise and advocate the following:
• Pregnant women should tailor exercise to their needs and abilities. For a sed-
entary person who has never exercised vigorously, low intensity workouts that
involve walking, stationary cycling, and swimming are best.
• Exercise should be done within a comfort zone. Special caution should be taken
when exercising in a hot, humid climate. (It usually takes about two weeks for
the body to become heat-acclimated.) Hyperthermia should be avoided, espe-
cially during the first trimester when the nervous system is developing.
• If the woman is healthy and accustomed to very vigorous exercise, there’s prob-
ably no reason she can’t exceed the ACOG guidelines as long as she does not
become hyperthermic, hypoglycemic, or significantly dehydrated.
• The possible effect of low caloric intake of high endurance athletes also warrants
caution—this may represent more of a risk than the actual exercise itself.
• Water skiing is not advised because of the possibility of hydrostatic injury to the
vagina, cervix, or uterus. Downhill skiing and horseback rising after the first
trimester should be avoided. Cross-country skiing or hiking on uneven terrain
should be avoided in the third trimester because of the increased risk of falls.
• Pregnant women should not scuba dive. The fetus is at risk for decompression
sickness. No safe depth/time profiles have been established for pregnancy.
Snorkeling is safe.

262 Travel & Pregnancy

• Relative contraindications to vigorous exercise (or stressful travel for that mat-
ter) include hypertension, anemia, thyroid disease, diabetes, cardiac arrhyth-
mia, history of precipitous labor, history of intrauterine growth retardation, any
bleeding during present pregnancy, breech presentation during the last trimes-
ter, excessive obesity, or leading an extremely sedentary lifestyle.
• Absolute contraindications against exercising include a history of the following
conditions: three or more spontaneous miscarriages, ruptured membranes,
premature labor, multifetal pregnancy, incompetent cervix, bleeding or a diag-
nosis of placenta previa, or a diagnosis of heart disease.

HIGH ALTITUDES, TREKKING, AND PREGNANCY

There is no known fetal risk if you go to high altitudes for a few days. Some au-
thorities, however, advise against trekking in remote areas above 8,000 feet. Not
only might you develop acute altitude sickness, but emergency medical and ob-
stetrical care will be far away.
Women who remain at high altitudes during their pregnancies have an altitude-
associated increase in fetal growth retardation, high blood pressure, and premature
delivery. You should consult with your doctor if you will be traveling to, or plan
to live at, altitudes greater than 6,000 feet.

COMMERCIAL FLYING
Domestic airlines ordinarily won’t allow travel after the 36th week of gestation;
the cutoff for foreign airlines is 35 weeks.
After 24 weeks—You should get a letter from your doctor specifying details
of your pregnancy and giving you permission to travel. This letter is mandatory
for travel after week 35. You should call the particular airline you will be using to
verify specific requirements.
Unless you have severe anemia (hemoglobin less than 8.5 gm%) or sickle cell
disease/trait, the reduced cabin oxygen pressure will not cause harm to you or your
fetus. If your blood count is reduced more than 25% to 30%, however, you may
require pretravel treatment of the anemia and/or supplemental oxygen en route.
Cosmic radiation is increased at the flight altitudes of commercial jets. Studies
suggest that an exposure of 50 millirems of radiation per month (about 80 hours
of flight time) will not harm a fetus. This is the permissible monthly exposure
allowed pregnant flight attendants.
NOTE: Airport metal detectors will not harm the fetus.
Varicose veins and leg edema can be a problem, especially during the third tri-
mester. You should request an aisle seat so that you can get up and walk around
every 20 to 30 minutes. If you are in the third trimester, request a bulkhead seat
so that you can extend and elevate your legs. These measures will increase com-
fort, help relieve swelling, and reduce the risk of deep vein thrombosis.

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 FOOD AND WATER
You should drink only water that has been boiled, bottled (especially carbonated),
or chemically treated to remove bacteria, parasites, and viruses. This is especially
important if you are traveling in geographic areas where sanitation is poor,
hepatitis E is most prevalent (southern and western China, Nepal, northern India,
Indonesia, Myanmar, Pakistan, Algeria, Kenya, Sudan, Ethiopia, and Mexico).
The hepatitis E fatality rate can be as high as 25% during the second and third
trimesters of pregnancy. If necessary, you can use iodine tablets on a short term
basis (2–3 weeks) to treat water of questionable purity. Don’t use a water filter
alone—it won’t remove viruses. Use a water purifier instead. Water purifiers
contain an iodine-resin matrix that will eliminate hepatitis E and other viruses.
NOTE: It is also recommended that an iodine-resin purifier should not be used as
the sole source of drinking water for longer than 3 weeks in any 6-month period
due to high levels of residual iodine in the treated water (see Chapter 3).
All foods should be well cooked and served hot to avoid a variety of infectious
illnesses.

TRAVELERS’ DIARRHEA
The treatment of travelers’ diarrhea can be problematic. On the one hand, you
don’t want to risk causing a drug-related fetal injury (even though this may be
highly unlikely)—while on the other hand, not treating diarrhea may result in
symptoms ranging from extreme personal discomfort and inconvenience to
(rarely) life-threatening illness. Some authorities, worried primarily about the
safety of the fetus, focus on fluid replacement and shy away from recommending
practically any drug treatment. Others take a different view: they believe that the
severity of the symptoms and the circumstances of the particular illness should
dictate treatment—not arbitrary guidelines.
Basic treatment—Drink extra fluids to prevent dehydration. If you have mild/
moderate watery diarrhea, you can safely take loperamide (Imodium). This drug
is especially useful if toilet facilities are not close by and uncontrolled symptoms
would cause undue inconvenience, discomfort, or embarrassment.
Antibiotic treatment—Refer to Chapter 5 for antibiotic dosage recommenda-
tions. The use of an antibiotic depends upon severity of symptoms: volume and
frequency of stools, abdominal pain, general feelings of illness, and degree of in-
convenience. The HealthGuide believes that if you do use an antibiotic, the first
choice should be a quinolone, such as ciprofloxacin or levofloxacin. Quinolones
are the best drugs for treating infectious diarrhea, and if antibiotic treatment is
indicated, then the most effective agent should be used.
Alternative drugs, in order of preference, are azithromycin, cefixime, and furazoli-
done.
• Azithromycin (Zithromax) is emerging as an important drug for treating trav-
elers’ diarrhea. It is presumed safe in pregnancy. In one study performed in Thai-

264 Travel & Pregnancy

land, azithromycin was superior to ciprofloxacin in the treatment of
campylobacter enteritis. Other studies have demonstrated effectiveness against
multidrug-resistant shigella as well as salmonella, E. coli, and V. cholerae.
• Cefixime (Suprax), a cephalosporin, is effective against most pathogens caus-
ing infectious diarrhea and is considered safe in pregnancy. There are reports,
however, of its lack of effectiveness in the treatment of shigellosis.
• Furazolidone (Furoxone) has activity against a wide range of gastrointestinal
pathogens, including E. coli, salmonella, shigella, campylobacter, and the vibrio
species (which cause cholera). It is also effective against giardia.
Treating more severe diarrhea/dysentery—If you have severe or incapacitat-
ing diarrhea, diarrhea causing dehydration, or diarrhea with dysentery, start treat-
ment with a quinolone antibiotic. Institute aggressive fluid replacement therapy.
Seek medical consultation if you are not better in 24 hours. Although fluids are
very important, antibiotics are also essential in order to treat the cause of the ill-
ness, not just the symptoms. Often, only a few days of antibiotic treatment are
needed, and it is highly unlikely that there will be adverse fetal effects from the
medication. NOTE: Quinolones are Category C pregnancy drugs: Adverse effects
have been shown in some test animals but have not been demonstrated in hu-
mans.) The benefits of treatment with a quinolone will most likely far outweigh
any potential harm to the fetus. Remember, the nature and severity of your ill-
ness should determine the choice treatment, not fetal risk. Effective treatment of
your infection is the first priority, and keeping you healthy is also the best way to
ensure a healthy baby.

Khan LK, Li R, Gootnick D, et al. Thyroid abnormalities related to iodine excess from
water purification units. Lancet 1998; 352:1519.
Khan WA, Seas C, Dhar U, et al. Treatment of shigellosis: Comparison of azithromycin
and ciprofloxacin. A double-blind, randomized, controlled trial. Ann Int Med 1997
May 1; 126(9):697–703.
Koren G, Pastuszak A. Drugs in Pregnancy. N Engl J Med 1998; 338:1128–1137.
Nosten F, McReady R, Simpson JA, et al. Effects of plasmodium vivax malaria in
pregnancy. Lancet 1999; 354:546–549.
Rose, SR. Pregnancy and Travel. Emerg Med Clinics N America 1997;15:93–111.
Samuel BU, Barry M. The Pregnant Traveler. Infect Dis Clinics N Am 1998;12:325–354.

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