International traveling during pregnancy

1. International Travel andInternational Travel and
pregnancypregnancy
Ayman ShehataAyman Shehata
By

2. ObjectivesObjectives
In this sessionIn this session

General Approach to the TravellerGeneral Approach to the Traveller

Counseling prior to travelCounseling prior to travel

VaccinationsVaccinations

Obstetrical risks of travelObstetrical risks of travel

Contraindications to travelContraindications to travel

Airline travelAirline travel

Reaching destinationReaching destination

4. General Approach to theGeneral Approach to the
TravellerTraveller
Risk assessment,Risk assessment, determining the risks of the destination,determining the risks of the destination,
mode of travel and the special conditions of the travelermode of travel and the special conditions of the traveler
Many maternal risks are increased by travel, but many canMany maternal risks are increased by travel, but many can
be managed.be managed.
–– Prevention and early intervention is the keyPrevention and early intervention is the key
–– If mother stays healthy, fetus stays healthy.If mother stays healthy, fetus stays healthy.
Every situation is different: recommendations should beEvery situation is different: recommendations should be
individualized:individualized:
–– Type, reason, destination of travel.Type, reason, destination of travel.
–– Medical and obstetrical history.Medical and obstetrical history.
Remind the traveler that these precautions are not 100%Remind the traveler that these precautions are not 100%
protectiveprotective
(Ericsson, 2003)(Ericsson, 2003)

5. When is the best timeWhen is the best time
to travel during pregnancy?to travel during pregnancy?

6. Risks are generally lowest during
the second trimester (12-28weeks).
Many advocate 18-24 weeks as
most recommended screening is
complete.
 Personal comfort also at its
lowest in the 1st and 3rd
trimesters.

7.  Miscarriage
 Nausea, vomiting, fatigue,
poor appetite.
 Ectopic pregnancy
 Congenital infections
 Cystitis, pyelonephritis.
 Missed screening or
ultrasound opportunities.
Teratogenesis.

8.  FewestFewest..
 Miscarriage is rarerMiscarriage is rarer..
 Rarely premature labourRarely premature labour
 Complications of placenta previaComplications of placenta previa..
 Placental abruptionPlacental abruption
 IUGRIUGR
 Cystitis, pyelonephritisCystitis, pyelonephritis

9.  Preterm labour
 Premature rupture of
membranes
 Pre-ecclampsia/eclampsia
 HELLP
 Gestational diabetes
 Complications of delivery
 General discomfort
 Cystitis, Pyelonephritis

10. Congenital infectionsCongenital infections
ToxoplasmosisToxoplasmosis
CytomegalovirusCytomegalovirus
RubellaRubella
HIV, Syphilis, Hepatitis BHIV, Syphilis, Hepatitis B
VaricellaVaricella--Zoster VirusZoster Virus
Parvovirus B19Parvovirus B19
Malaria, Yellow FeverMalaria, Yellow Fever
Lieshmaniasis, filiriasis, TrypanosomiasisLieshmaniasis, filiriasis, Trypanosomiasis
Typhoid, TBTyphoid, TB

11. Pregnant travelerPregnant traveler
counselingcounseling

12. Pregnant traveler counselingPregnant traveler counseling
Counseling should identify those at high risk ofCounseling should identify those at high risk of
complications.complications.
Pregnant women should be evaluated for potentialPregnant women should be evaluated for potential
contraindication to travel before departure.contraindication to travel before departure.
Always teach pregnant women about the more commonAlways teach pregnant women about the more common
complications and how to recognize them .complications and how to recognize them .
Rh-negative pregnant women should receiveRh-negative pregnant women should receive
prophylactic anti-D immune globulin at about 28 weeks’prophylactic anti-D immune globulin at about 28 weeks’
gestation.gestation.
Pregnant woman should know warning signs:Pregnant woman should know warning signs:

BleedingBleeding

Abdominal pain or crampsAbdominal pain or cramps

Rupture of membranesRupture of membranes

Headache or visual changesHeadache or visual changes
Pregnant women should carry their records..Pregnant women should carry their records..

13. Important Documents forImportant Documents for
pregnant Travelerpregnant Traveler
Documentation concerning EDD and normality ofDocumentation concerning EDD and normality of
pregnancy (Within 7days).pregnancy (Within 7days).
Copy of antenatal record.Copy of antenatal record.
Blood group and Rh type.Blood group and Rh type.
Location of emergency services at their destination .Location of emergency services at their destination .
Immunization card.Immunization card.
Letter containing allowed medications.Letter containing allowed medications.
Proof of marriage.Proof of marriage.
Letter of permission from spouse.Letter of permission from spouse.
Insurance documents.Insurance documents.

14. Pregnant traveler counselingPregnant traveler counseling

Plan to travel with a companion at all times.Plan to travel with a companion at all times.

Travel during the 2nd trimester.Travel during the 2nd trimester.

Favor comfortable type of travel, without long airFavor comfortable type of travel, without long air
or road transportation.or road transportation.

Check for adequate insurance coverageCheck for adequate insurance coverage thatthat
covers pregnancy, complications and birth.covers pregnancy, complications and birth.

Choose destination where good health servicesChoose destination where good health services
exist.exist.

Avoid region of high malaria endemicity.Avoid region of high malaria endemicity.

Vaccinations prior departure according toVaccinations prior departure according to
destination endemic diseasesdestination endemic diseases
Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: 1263-1266. (in French)Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: 1263-1266. (in French)

15. Pregnancy travel kit
We add to the items listed in the general international travelWe add to the items listed in the general international travel
health kitthe following :health kitthe following :
o Talc powdero Talc powder
o Thermometero Thermometer
o Oral rehydration salt packetso Oral rehydration salt packets
o Prenatal vitaminso Prenatal vitamins
o Topical antifungal agent for vaginal yeasto Topical antifungal agent for vaginal yeast
o Acetaminopheno Acetaminophen
O Antemetic (cyclizine)O Antemetic (cyclizine)
o Sunscreeno Sunscreen
Women who must travel in their third trimester should carry:Women who must travel in their third trimester should carry:

Blood pressure cuffBlood pressure cuff

Urine dipsticks.Urine dipsticks.

16. IMMUNIZATIONS FORIMMUNIZATIONS FOR
PREGNANT TRAVELERSPREGNANT TRAVELERS

17. Types of VaccinesTypes of Vaccines
•• Toxoid vaccinesToxoid vaccines as Tetanus Diphtheria .as Tetanus Diphtheria .
•• Live attenuated vaccinesLive attenuated vaccines areare
contraindicated in pregnancy e.g: MMR,contraindicated in pregnancy e.g: MMR,
Varicella vaccine, Influenza vaccine ,OralVaricella vaccine, Influenza vaccine ,Oral
typhoid ,BCG and Yellow fever vaccinetyphoid ,BCG and Yellow fever vaccine..
•• Inactivated vaccinesInactivated vaccines influenza, polio,influenza, polio,
rabies, and hepatitis A, typhoid, cholerarabies, and hepatitis A, typhoid, cholera

18. Types of vaccinesTypes of vaccines
Polysaccharide vaccinesPolysaccharide vaccines asas
pneumococcal, meningococcalpneumococcal, meningococcal vaccinesvaccines
Conjugate vaccinesConjugate vaccines as Haemophilusas Haemophilus
influenzae type b (Hib).influenzae type b (Hib).
Recombinant vaccinesRecombinant vaccines Hepatitis BHepatitis B
vaccines, Human papillomavirus vaccinesvaccines, Human papillomavirus vaccines

19. Pregnancy and vaccinationPregnancy and vaccination
WHO, 2005.
Op Cit

20. Safe vaccines in pregnancySafe vaccines in pregnancy
Hepatitis BHepatitis B
Influenza (inactivated )Influenza (inactivated )
Tetanus-diphtheria (Td)Tetanus-diphtheria (Td)
Tetanus-diphtheria-pertussis (Tdap)Tetanus-diphtheria-pertussis (Tdap)
Hepatitis AHepatitis A

21. No data are available on safety inNo data are available on safety in
pregnancypregnancy
Japanese encephalitisJapanese encephalitis
Meningococcal meningitisMeningococcal meningitis
PneumococcalPneumococcal
Polio,inactivatedPolio,inactivated
RabiesRabies
Typhoid (ViPSA)Typhoid (ViPSA)

22. Contraindicated VaccinesContraindicated Vaccines
Tuberculosis (BCG)Tuberculosis (BCG)
Measles-mumps-rubellaMeasles-mumps-rubella
Human papillomavirusHuman papillomavirus
VaricellaVaricella
Yellow feverYellow fever
Typhoid (Ty21a) Live bacterialTyphoid (Ty21a) Live bacterial
Influenza (live attenuated)Influenza (live attenuated)

23. Human Normal IGHuman Normal IG
Immunoglobulins, specific globulinImmunoglobulins, specific globulin
preparations If indicated for pre- orpreparations If indicated for pre- or
postexposure use.postexposure use.
No known risk to fetusNo known risk to fetus

24. Yellow fever vaccine is live attenuated andYellow fever vaccine is live attenuated and
generally contraindicated.generally contraindicated.
Fetal infection can occur.Fetal infection can occur.
Natural infection is many times more likely to leadNatural infection is many times more likely to lead
to maternal and fetal morbidity and mortality.to maternal and fetal morbidity and mortality.
Non-immune pregnant women should be stronglyNon-immune pregnant women should be strongly
discouraged from traveling to endemic areas.discouraged from traveling to endemic areas.

25. Pregnancy and malariaPregnancy and malaria
Personal Protective MeasuresPersonal Protective Measures

Avoidance (Avoidance (Remain indoors between dusk andRemain indoors between dusk and
dawn)dawn)

Clothing (Clothing (wear light-coloured clothing, long sleeves,wear light-coloured clothing, long sleeves,
long pants, and shoes and stocks)long pants, and shoes and stocks)

Housing with air-conditioning and/or screens;Housing with air-conditioning and/or screens;

Use permethrin-impregnated bed netsUse permethrin-impregnated bed nets

Insecticides and mosquito repellents (DEET)Insecticides and mosquito repellents (DEET)
ChemoprophylaxisChemoprophylaxis

26. Malaria ChemoprophylaxisMalaria Chemoprophylaxis
Chloroquine (Chlorquin) – category DChloroquine (Chlorquin) – category D
Small risk of neurological damage to the foetus during pregnancy.Small risk of neurological damage to the foetus during pregnancy.
Taken weekly. Commence 1 week before departure and continueTaken weekly. Commence 1 week before departure and continue
for 4 weeks after leaving malarial area.for 4 weeks after leaving malarial area.
Mefloquine (Lariam) – category BMefloquine (Lariam) – category B
Not recommended in 1st trimester, otherwise safe. Taken weekly.Not recommended in 1st trimester, otherwise safe. Taken weekly.
Commence 1-2 weeks before travelling and continue for 4 weeksCommence 1-2 weeks before travelling and continue for 4 weeks
after leaving malarial area.after leaving malarial area.
Proguanil (Paludrine) – category BProguanil (Paludrine) – category B
Safe during pregnancy. Use only in combination with chloroquine.Safe during pregnancy. Use only in combination with chloroquine.
Folate supplementation required. Two tablets daily.Folate supplementation required. Two tablets daily.
Atovaquone-proguanil combination (Malarone) – category BAtovaquone-proguanil combination (Malarone) – category B
Folate supplementation required. Safety in pregnancy has not beenFolate supplementation required. Safety in pregnancy has not been
established. 1 tablet daily 1-2 days before entering malarial areaestablished. 1 tablet daily 1-2 days before entering malarial area
and continuing for seven days after leaving.and continuing for seven days after leaving.

27. Contraindications for travelingContraindications for traveling
during Pregnancyduring Pregnancy

Medical risk factorsMedical risk factors

Obstetric risk factorsObstetric risk factors

Hazardous destinationHazardous destination

28. Obstetrical risk factorsObstetrical risk factors
History of miscarriageHistory of miscarriage
Incompetent cervixIncompetent cervix
History of ectopic pregnancy (ectopic with currentHistory of ectopic pregnancy (ectopic with current
pregnancy should be ruled out before travel)pregnancy should be ruled out before travel)
History of preterm labor or premature rupture ofHistory of preterm labor or premature rupture of
membranesmembranes
History of or existing placental abnormalitiesHistory of or existing placental abnormalities
Threatened abortion or vaginal bleeding during currentThreatened abortion or vaginal bleeding during current
pregnancypregnancy
Multiple gestation in current pregnancyMultiple gestation in current pregnancy
History of toxemia, hypertension, or diabetes with anyHistory of toxemia, hypertension, or diabetes with any
pregnancypregnancy
Primigravida at 35 years of age and older, or 15 years ofPrimigravida at 35 years of age and older, or 15 years of
age and youngerage and younger

29. General medical risk factorsGeneral medical risk factors
History of thromboembolic diseaseHistory of thromboembolic disease
Pulmonary hypertensionPulmonary hypertension
Severe asthma or other chronic lung diseaseSevere asthma or other chronic lung disease
Valvular heart disease (if NYHA class III or IVValvular heart disease (if NYHA class III or IV
heart failure)heart failure)
CardiomyopathyCardiomyopathy
HypertensionHypertension
DiabetesDiabetes
Renal insufficiencyRenal insufficiency
Severe anemia or hemoglobinopathySevere anemia or hemoglobinopathy

30. Travel to potentially hazardousTravel to potentially hazardous
destinationsdestinations
High altitudesHigh altitudes
Areas endemic for or with ongoingAreas endemic for or with ongoing
outbreaks of life-threatening food- oroutbreaks of life-threatening food- or
insect-borne infectionsinsect-borne infections
Areas where chloroquine-resistantAreas where chloroquine-resistant
Plasmodium falciparum malaria isPlasmodium falciparum malaria is
endemicendemic
Areas where live virus vaccines areAreas where live virus vaccines are
required and recommendedrequired and recommended

33. Air travel during pregnancyAir travel during pregnancy
““Pregnant women canPregnant women can
normally travel safely bynormally travel safely by
air, however most airlinesair, however most airlines
restrict travel in laterestrict travel in late
pregnancy”pregnancy”

Single pregnancies-flyingSingle pregnancies-flying
permitted to end 36permitted to end 36thth
weeksweeks

Multiple pregnancies-flyingMultiple pregnancies-flying
permitted to end of the 32permitted to end of the 32ndnd
weekweek
Medical Guidelines for airline travel. 2Medical Guidelines for airline travel. 2ndnd
Ed. 2003.Ed. 2003.
http://www.asma.orghttp://www.asma.org

34. Air travel during pregnancyAir travel during pregnancy
Seat beltsSeat belts :: As the risk for trauma is significant, pregnant womenAs the risk for trauma is significant, pregnant women
should be instructed to continuously use seat belt passed between breastshould be instructed to continuously use seat belt passed between breast
and below pelvic bones.and below pelvic bones.
Aisle Seat :Aisle Seat : to allow free mobility.to allow free mobility.

35. Aisle SeatAisle Seat

36. Air travel during pregnancyAir travel during pregnancy

X-Ray security devices:X-Ray security devices:
Hand-held metal detectors and walk through metal detectorsHand-held metal detectors and walk through metal detectors dodo
not appear to pose a hazard to for pregnant women and theirnot appear to pose a hazard to for pregnant women and their
fetuses [5,6].fetuses [5,6].
Backscatter unitsBackscatter units create an image from very small amounts ofcreate an image from very small amounts of
x-ray that reflect off the person being screened. Accordingx-ray that reflect off the person being screened. According
to Rapiscan, the manufacturer of the backscatter units, theto Rapiscan, the manufacturer of the backscatter units, the
dose for one screening from a backscatter unit is 5dose for one screening from a backscatter unit is 5
microrems (5 millionths of a rem) which is about 1/2000thmicrorems (5 millionths of a rem) which is about 1/2000th
(0.05% ) the radiation dose received from one chest x ray , a(0.05% ) the radiation dose received from one chest x ray , a
negligible risk according to the International Commission onnegligible risk according to the International Commission on
Radiological ProtectionRadiological Protection
So Airport security radiation exposure is minimal, but a pregnant passengerSo Airport security radiation exposure is minimal, but a pregnant passenger
may request a hand or wand search.may request a hand or wand search.

37. X-ray Security deviceX-ray Security device

38. •HumidityHumidity :: low nearly 8% so dehydration may occur so liberallow nearly 8% so dehydration may occur so liberal
fluids should be advised.fluids should be advised.
•Altitude :Altitude : high altitude more than 8000 feet need pressurized airhigh altitude more than 8000 feet need pressurized air
to maintain O2 supply and prevent hazards of hypoxia otherwise oxygento maintain O2 supply and prevent hazards of hypoxia otherwise oxygen
supplementation is required.supplementation is required.
O2 deficiency may be harmful for pulmonary, cardiac pt. ,sickle cellO2 deficiency may be harmful for pulmonary, cardiac pt. ,sickle cell
anemia , thalasemia and sever anemia.anemia , thalasemia and sever anemia.
Multiple studies have shown that fetal circulation and perfusion are notMultiple studies have shown that fetal circulation and perfusion are not
compromised by lower altitude for the duration of flights due tocompromised by lower altitude for the duration of flights due to
Hyperventilation of pregnancy and fetal hemoglobin that assureHyperventilation of pregnancy and fetal hemoglobin that assure
adequate fetal oxygenation.adequate fetal oxygenation.
Chronic exposures (pilots/flight attendants) have been associated withChronic exposures (pilots/flight attendants) have been associated with
increased miscarriages due to chronic hypoxia, hemoconcentration andincreased miscarriages due to chronic hypoxia, hemoconcentration and
reduced uterine perfusion.reduced uterine perfusion.
Air travel during pregnancyAir travel during pregnancy

39. O2 supply in airplaneO2 supply in airplane

40. Air travel during PregnancyAir travel during Pregnancy
Risk of DVTRisk of DVT:: is higher in airplane traveler especially ifis higher in airplane traveler especially if
long journey more than 5 hours due to :long journey more than 5 hours due to :
PregnancyPregnancy
Seat immobilitySeat immobility
Leg compression against seat edgeLeg compression against seat edge
High humidity.High humidity.

41. Air travel during PregnancyAir travel during Pregnancy
Measures toMeasures to
minimize DVT:minimize DVT:
Aisle seatAisle seat
Frequent walks / 30 mFrequent walks / 30 m
Frequent flexion and extension ofFrequent flexion and extension of
kneesknees
Fluids liberal intakeFluids liberal intake
Regular deep breathsRegular deep breaths
Lower limb stockingLower limb stocking
Low molecular weight heparinLow molecular weight heparin
before departure in high risk pt. asbefore departure in high risk pt. as
SLE.SLE.

42. Travel motion sicknessTravel motion sickness
Common complaint and
can be avoided by mild
antihistaminic antemetic
as Vit.B6 (pyridoxine )
And cyclizine

43. Air travel during PregnancyAir travel during Pregnancy
Jet lag :Jet lag :
Due to difference in timingDue to difference in timing
between home andbetween home and
destination and can bedestination and can be
overlapped by mildoverlapped by mild
tranquilizer and gradualtranquilizer and gradual
adaptation.adaptation.

44. Sea travelSea travel

45. Car travelCar travel
Frequent stops is neededFrequent stops is needed
Driving not more than 6 hsDriving not more than 6 hs
Presence of companion .Presence of companion .
Seat belt is mandatorySeat belt is mandatory
Air bag instructions to be inAir bag instructions to be in
mind in case of accidents .mind in case of accidents .

46. Reaching destinationReaching destination

47. Food and Water SafetyFood and Water Safety
is caused by contaminated food or water, and dehydration fromis caused by contaminated food or water, and dehydration from
travelers’ diarrhea can be more of a problem for pregnant women.travelers’ diarrhea can be more of a problem for pregnant women.
Eat only food that is cooked and served hot.Eat only food that is cooked and served hot.
Do not eat cold food or food that has been sitting at roomDo not eat cold food or food that has been sitting at room
temperature .temperature .
Do not eat raw or undercooked meat or fish.Do not eat raw or undercooked meat or fish.
Eat fresh fruits and vegetables only if you can peel them or washEat fresh fruits and vegetables only if you can peel them or wash
them in clean water.them in clean water.
Do not eat unpasteurized dairy products.Do not eat unpasteurized dairy products.
Drink only water, sodas, or sports drinks that are bottled and sealed.Drink only water, sodas, or sports drinks that are bottled and sealed.
Do not drink anything with ice in it—ice may be made withDo not drink anything with ice in it—ice may be made with
contaminated water.contaminated water.
Vegetarian diet is mostly safe for pregnant woman.Vegetarian diet is mostly safe for pregnant woman.

48. FluidsFluids ::plenty of safe water may be IV fluidsplenty of safe water may be IV fluids
ORS :ORS : may be neededmay be needed
Antibiotics:Antibiotics: Azithromycin (of choice) orAzithromycin (of choice) or
metronidazolemetronidazole
Antidiadheals:Antidiadheals: LoperamideLoperamide ,, Kaopectate.Kaopectate.
Treatment of traveler diarrhea

49. Personal SafetyPersonal Safety
Insect- and animal-related illnessesInsect- and animal-related illnesses

Protection against insect bites.Protection against insect bites.

Avoid contact with animals including dogs,Avoid contact with animals including dogs,
snakes, rodents, birds, and bats.snakes, rodents, birds, and bats.
Person-to-person infectionsPerson-to-person infections

Wash your hands .Wash your hands .

Protection against droplet infections.Protection against droplet infections.

Protect yourself from HIV/AIDS and otherProtect yourself from HIV/AIDS and other
sexually transmitted infections.sexually transmitted infections.

50. At destinationAt destination
Headache:Headache: is treated by Paracetamolis treated by Paracetamol
Worm infestations:Worm infestations: is treated after delivery asis treated after delivery as
Piperazine is not safe in pregnancy.Piperazine is not safe in pregnancy.
UTI:UTI: is treated by Penicillins or Erythromycinis treated by Penicillins or Erythromycin
Amoxicillin-clavulanate, cephalosporins, nitrofurtanoinAmoxicillin-clavulanate, cephalosporins, nitrofurtanoin
are safe choices.are safe choices.
Vaginitis:Vaginitis: Topical AntifungalsTopical Antifungals Nystatins orNystatins or
Clotimazole are safe in pregnancy.Clotimazole are safe in pregnancy.

51. •Listeriosis: is potentially deadly to mother and foetusis potentially deadly to mother and foetus
and may be present in many foods. Dairy, processedand may be present in many foods. Dairy, processed
foods.foods.
•Toxoplasmosis: is found in many types of meat (mainis found in many types of meat (main
source of infection) and infection may be devastating to thesource of infection) and infection may be devastating to the
foetus.foetus.
•Hepatitis E: is not vaccine preventable and is especiallyis not vaccine preventable and is especially
dangerous in pregnant women , as with other entericdangerous in pregnant women , as with other enteric
infections, pregnant women should be advised that theinfections, pregnant women should be advised that the
best preventive measures are to avoid potentiallybest preventive measures are to avoid potentially
contaminated water and food. Mortality is 15-33% incontaminated water and food. Mortality is 15-33% in
pregnant women.pregnant women.
•Influenza, TB: may also be more severe in pregnancy.may also be more severe in pregnancy.
At destination

52.  Central African RepublicCentral African Republic -- 81%81%
 TanzaniaTanzania -- 48%48%
 ZambiaZambia -- 23%23%
 ArgentinaArgentina -- 53-58%53-58%
 AustriaAustria -- 36%36%
 BelgiumBelgium -- 46%46%
 ChileChile -- 59%59%
 ColombiaColombia -- 60%60%
 EthiopiaEthiopia -- More than 75%More than 75%
 FranceFrance -- 52%52%
 GuatemalaGuatemala -- 46%46%

53. Can exacerbate conditions seen inCan exacerbate conditions seen in
pregnancy:pregnancy:
–– Vaginal yeast infectionsVaginal yeast infections
Dehydration can be dangerous to motherDehydration can be dangerous to mother
and foetus.and foetus.
Heat exhaustion/heat stroke/heat shockHeat exhaustion/heat stroke/heat shock
can trigger early labour or foetal distress.can trigger early labour or foetal distress.
Severe increases in body temperatureSevere increases in body temperature
during the first trimester can lead toduring the first trimester can lead to
teratogenesis (e.g. Neural tube defects).teratogenesis (e.g. Neural tube defects).
Recommendations include maintainingRecommendations include maintaining
hydration, avoiding excessive activity andhydration, avoiding excessive activity and
exposure during hottest hours.exposure during hottest hours.

54. At destinationAt destination
Swimming :Swimming : Avoid fresh water (Bilh.) Chlorinated orAvoid fresh water (Bilh.) Chlorinated or
sea water are safesea water are safe
Diving:Diving: is contraindicated (why)is contraindicated (why)

55. At Destination: TraumaAt Destination: Trauma
 Trauma is the most common travel-Trauma is the most common travel-
related complication pregnantrelated complication pregnant
women will encounter.women will encounter.
 Balance is compromised andBalance is compromised and
centre of gravity altered. Cautioncentre of gravity altered. Caution
with hiking, cycling, motorcycles,with hiking, cycling, motorcycles,
ships.ships.
 Pregnant women should alwaysPregnant women should always
wear seatbelts in moving vehicles.wear seatbelts in moving vehicles.
 Activities requiring fine balanceActivities requiring fine balance
(eg. skiing, water skiing, technical(eg. skiing, water skiing, technical
climbing...) are not recommended.climbing...) are not recommended.

56. Pregnancy and malariaPregnancy and malaria
Malaria increases risk ofMalaria increases risk of
maternal death,maternal death,
miscarriage,miscarriage,
stillbirth, andstillbirth, and
low birth weight withlow birth weight with
associated risk of neonatalassociated risk of neonatal
deathdeath
WHO. International Travel and Health. Geneva: WHO, 2005.WHO. International Travel and Health. Geneva: WHO, 2005.

57. Pregnancy and malariaPregnancy and malaria

Pregnant women with P.falciparum malaria:Pregnant women with P.falciparum malaria:
May rapidly develop any of the clinicalMay rapidly develop any of the clinical
symptoms of severe malariasymptoms of severe malaria
Are particularly susceptible to pulmonaryAre particularly susceptible to pulmonary
edema and hypogycemia.edema and hypogycemia.
Severe malaria may need transfe to intensiveSevere malaria may need transfe to intensive
carecare
Hyperpyrexia may leads to fetal distressHyperpyrexia may leads to fetal distress
May develop postpartum hemorrhageMay develop postpartum hemorrhage
WHO. International Travel and Health. Geneva: WHO, 2005.WHO. International Travel and Health. Geneva: WHO, 2005.

58. What do we advise if aWhat do we advise if a
pregnant traveler must go topregnant traveler must go to
a malarious area?a malarious area?

59. Pregnancy and malariaPregnancy and malaria
Personal Protective MeasuresPersonal Protective Measures

Avoidance (Avoidance (Remain indoors between dusk andRemain indoors between dusk and
dawn)dawn)

Clothing (Clothing (wear light-coloured clothing, long sleeves,wear light-coloured clothing, long sleeves,
long pants, and shoes and stocks)long pants, and shoes and stocks)

Housing with air-conditioning and/or screens;Housing with air-conditioning and/or screens;

Use permethrin-impregnated bed netsUse permethrin-impregnated bed nets

Insecticides and mosquito repellents (DEET)Insecticides and mosquito repellents (DEET)
ChemoprophylaxisChemoprophylaxis

60. DEETDEET
Well accepted and no adverse effects in womenWell accepted and no adverse effects in women
No increase in congenital abnormalitiesNo increase in congenital abnormalities
DEET does cross placentaDEET does cross placenta
More information needed on safety of DEET in 1More information needed on safety of DEET in 1stst
trimestertrimester

61. Treatment of malaria inTreatment of malaria in
pregnant womanpregnant woman

Malaria must be treated as a medical emergencyMalaria must be treated as a medical emergency
in any pregnant traveler.in any pregnant traveler.

Take standby drugTake standby drug

Seek medical attention as soon as possibleSeek medical attention as soon as possible

Frequent blood glucose determinationsFrequent blood glucose determinations

Careful fluid monitoringCareful fluid monitoring

62. Pregnancy and malaria treatmentPregnancy and malaria treatment
RecommendedRecommended

ChloroquineChloroquine

Chloroquine plus proguanilChloroquine plus proguanil

Mefloquine (2Mefloquine (2ndnd
and 3and 3rdrd
trimester)trimester)

ArtemisininArtemisinin

QuinineQuinine

Sulfadoxine-pyrimethamineSulfadoxine-pyrimethamine
Non-recommendedNon-recommended

DoxycyclineDoxycycline

TetracyclineTetracycline

Artemether/lumfantrineArtemether/lumfantrine
(Coartem)(Coartem)

Atovaquone plusAtovaquone plus
proguanil (Malarone)proguanil (Malarone)

PrimaquinePrimaquine

TafenoquineTafenoquine
WHO, 2005. Op Cit

63. Pregnancy and malaria treatmentPregnancy and malaria treatment

Because of the risk of quinine inducedBecause of the risk of quinine induced
hyperinsulinemia and hypogycemia,hyperinsulinemia and hypogycemia,
artesunate and artemetherartesunate and artemether are the drugs ofare the drugs of
choice for treatment of severe malaria in thechoice for treatment of severe malaria in the
22ndnd
and 3and 3rdrd
trimester.trimester.

Data on the use ofData on the use of artemisinin derivativesartemisinin derivatives inin
the 1the 1stst
trimester are limited.trimester are limited.
WHO. International Travel and Health. Geneva: WHO, 2005.WHO. International Travel and Health. Geneva: WHO, 2005.