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Selected Antenatal and Pregnancy Factsheets.
Travelling while Pregnant
(Christina Dorell, Madeline Sutton)
Since as many as 50% of pregnancies are unplanned, women of reproductive age should consider maintaining current
immunizations during routine check-ups in case an unplanned pregnancy coincides with a need to travel. Because they
decrease risk to the unborn child, preconceptional immunizations are preferred to vaccination during pregnancy. A
woman should defer pregnancy for at least 28 days after receiving live vaccines (e.g., MMR, yellow fever), because of
theoretical risk of transmission to the foetus. However, small studies of women who received these vaccines
unintentionally during pregnancy have not found a definitive link between these vaccines and poor pregnancy outcomes.
Therefore, pregnancy termination is not recommended after an inadvertent exposure.
According to the American College of Obstetrics and Gynecology, the safest time for a pregnant woman to travel is during
the second trimester (18–24 weeks), when she usually feels best and is in least danger of spontaneous abortion or
premature labor. A woman in the third trimester should be advised to defer overseas travel because of concerns about
access to medical care in case of problems such as hypertension, phlebitis, or premature labor. Pregnant women should
be advised to consult with their health-care providers before making any travel decisions. Collaboration between travel
health experts and obstetricians is helpful in weighing benefits and risks based on destination and recommended
preventive and treatment measures. Table 8-4 lists relative contraindications to international travel during pregnancy. In
general, pregnant women with serious underlying illnesses should be advised not to travel to developing countries.
Preparation for Travel during Pregnancy
Once a pregnant woman has decided to travel, a number of issues need to be considered before her departure.
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An intrauterine pregnancy should be confirmed by a clinician and ectopic pregnancy excluded before beginning
any travel.
General health insurance policies may or may not provide coverage while abroad and during pregnancy.
Pregnant travellers should inquire about what their health insurance policies cover, and if needed, obtain a
supplemental policy for their trip. Many supplemental travel insurance policies and a prepaid medical evacuation
insurance policies do not cover pregnancy-related problems, so this issue should be clarified before obtaining a
policy.
Check medical facilities at the destination. For a woman in the last trimester, medical facilities should be able to
manage complications of pregnancy, toxaemia, caesarean sections, and premature or ill neonates.
Determine beforehand whether prenatal care will be required while abroad and who will provide it. The pregnant
traveller should make sure she does not miss prenatal visits requiring specific timing.
Determine beforehand whether blood is routinely screened for HIV and hepatitis B and hepatitis C at the
destination. Pregnant travellers should consider the safety of blood transfusions if needed when making plans for
international travel. The pregnant traveller should also be advised to know her blood type, and Rh-negative
pregnant women should receive anti-D immune globulin (a plasma-derived product) prophylactically at about 28
weeks’ gestation. The immune globulin dose should be repeated after delivery if the infant is Rh positive.
Determine when influenza season begins and ends in the destination region and administer influenza vaccine
accordingly.
Determine whether the destination region has high prevalence of tuberculosis and whether the planned itinerary
will put the traveller at risk for TB. If exposure to TB is determined to be a risk (see the Tuberculosis section in
Chapter 5), the pregnant traveller should receive skin testing before and after travel.
General Recommendations for Travel during Pregnancy
A pregnant woman should be advised to travel with at least one companion; she should also be advised that, during her
pregnancy, her level of comfort may be adversely affected by travelling. Table 8-5 lists the greatest risks that pregnant
women face during international travel.
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Typical problems of pregnant travellers are the same as those experienced by any pregnant woman: fatigue,
heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased frequency of urination, and
haemorrhoids.
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Selected Antenatal and Pregnancy Factsheets.
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During travel, pregnant women can take preventive measures, including avoidance of gas-producing food or
drinks before scheduled flights (entrapped gases can expand at higher altitudes) and periodic movement of the
legs (to decrease venous stasis).
Pregnant women should always use seatbelts while seated, as air turbulence is not predictable and may cause
significant trauma.
Signs and symptoms that indicate the need for immediate medical attention are vaginal bleeding, passing tissue or clots,
abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual
problems.
Air Travel during Pregnancy
Commercial air travel poses no special risks to a healthy pregnant woman or her foetus. The American College of
Obstetricians and Gynaecologists (ACOG) states that women with healthy, single pregnancies can fly safely up to 36
weeks’ gestation.
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The lowered cabin pressure (kept at the equivalent of 1,524–2,438 m [5,000–8,000 ft]) has minimal effect on
foetal oxygenation because of the favourable foetal haemoglobin-oxygen dynamics.
If supplemental oxygen is going to be required during flight due to pre-existing medical conditions, arrangements
for oxygen need to be made in advance.
Severe anaemia, sickle-cell disease or trait, or history of thrombophlebitis are relative contraindications to flying.
Pregnant women with placental abnormalities or risks for premature labor should avoid air travel.
Airline Policies and Airport Security
Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline when booking
reservations, because some will require medical forms to be completed. Domestic travel is usually permitted until the
pregnant traveller is in week 36 of gestation, and international travel may be permitted until weeks 32–35, depending on
the airline. A pregnant woman should be advised to carry documentation stating the expected day of delivery, contact
information for her obstetric provider, and her blood type.
For pregnant flight attendants and pilots, working air travel is restricted by most airlines by 20 weeks’ gestation.
Airport security radiation exposure is minimal for pregnant women and has not been linked to an increase in adverse
outcomes for unborn children to date. However, because of early reports of a possible association of radiation exposure
during pregnancy and subsequent increased risk of childhood leukaemia and cancer, a pregnant passenger may request
a hand or wand search rather than being exposed to the radiation of the airport security machines.
General Tips
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An aisle seat at the bulkhead will provide the most space and comfort, but a seat over the wing in the midplane
region will give the smoothest ride.
A pregnant woman should be advised to walk every half hour during a smooth flight and flex and extend her
ankles frequently to prevent phlebitis.
Dehydration can lead to decreased placental blood flow and hem concentration, increasing risk of thrombosis.
Thus, pregnant women should drink plenty of fluids during flights.
Travel to High Altitudes during Pregnancy
There have been no documented reports of adverse pregnancy outcomes related to high-altitude exposure during
pregnancy. High-altitude destinations, however, often are remote from medical care in an emergency, and any decision to
trek or climb to high altitude while pregnant should take into account the uncertainties of being in a remote environment
while pregnant and the unknown possible effects of high altitude on the foetus. Conservative advice for pregnant women
is to avoid altitudes above 3,658 m (12,000 ft).
Food and Waterborne Illness during Pregnancy
Pregnant women should be advised of the following:
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Selected Antenatal and Pregnancy Factsheets.
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Adhere strictly to food and water precautions in developing countries because the consequences may be more
severe than diarrhoea and may have serious sequelae (e.g., toxoplasmosis, listeriosis).
Boil suspect drinking water to avoid long-term use of iodine-containing purification systems. Iodine tablets can
probably be used for travel up to several weeks, but congenital goiters have been reported in association with
administration of iodine-containing drugs during pregnancy.
Oral rehydration is the mainstay of therapy for travellers’ diarrhoea (i.e., boiled water, bottled carbonated
beverages).
Bismuth subsalicylate compounds are contraindicated because of the theoretical risks of foetal bleeding from
salicylates and teratogenicity from the bismuth.
The combination of kaolin and pectin may be used, and loperamide should be used only when necessary.
The antibiotic treatment of travellers’ diarrhoea during pregnancy can be complicated. Azithromycin or an oral
third-generation cephalosporin may be the best options for treatment if an antibiotic is needed.
Malaria during Pregnancy
Advise pregnant women to avoid travel to malaria-endemic areas if possible. Women who do choose to go to
malarious areas can reduce their risk of acquiring malaria by taking appropriate malaria chemoprophylaxis and following
insect precautions presented in the Malaria section and the Protection Against Mosquitoes, Ticks, and Other Insects and
Arthropods section in Chapter 2.
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Use insect repellents as recommended for adults, sparingly, but as needed.
Pyrethrum-containing house sprays may also be used indoors if insects are a problem.
Antimalarial Medications
For pregnant women who travel to areas with chloroquine-sensitive Plasmodium falciparum malaria, chloroquine has
been used for malaria chemoprophylaxis for decades with no documented increase in birth defects. For pregnant women
who travel to areas with chloroquine-resistant P. falciparum, mefloquine should be recommended for chemoprophylaxis.
Evidence suggests that mefloquine prophylaxis causes no significant increase in spontaneous abortions or congenital
malformations when taken during the first trimester.
Because there is no evidence that chloroquine and mefloquine are associated with congenital defects when used for
prophylaxis, CDC does not recommend that women planning pregnancy need to wait a specific period of time after their
use before becoming pregnant. However, if women or their health-care providers wish to decrease the amount of
antimalarial drug in the body before conception, Table 8-6 provides information on the half-lives of selected antimalarial
drugs. After two, four, and six half-lives, approximately 25%, 6%, and 2%, respectively, of the drug remain in the body.
Doxycycline and primaquine are contraindicated for malaria prophylaxis during pregnancy, because both may cause
adverse effects on the foetus. Atovoquone/proguanil is currently not recommended for use by pregnant women to prevent
malaria because of the lack of safety studies during pregnancy.
Treatment and Management
Malaria must be treated as a medical emergency in any pregnant traveller. A woman who has travelled to an area
that has chloroquine-resistant strains of P. falciparum should be treated as if she has illness caused by chloroquineresistant organisms. The management of malaria in a pregnant woman should include frequent blood glucose
determinations and careful fluid monitoring (being careful not to give too much intravenous fluid).
Immunizations for Pregnant Travellers
Risk to a developing foetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists of
risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. The benefits of vaccinating
pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would
pose a risk to the mother or foetus, and when the vaccine is unlikely to cause harm.
The following table is intended for women who may require immunizations during pregnancy (Table 8-7). Pregnant
travellers may visit areas of the world where diseases eliminated by routine vaccination in the United States are still
endemic and therefore may require immunizations before travel.
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Selected Antenatal and Pregnancy Factsheets.
Table 8-4. Potential contraindications to international travel during pregnancy
Obstetrical Risk Factors
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History of miscarriage
Incompetent cervix
History of ectopic pregnancy
(ectopic with current pregnancy
should be ruled out before travel)
History of premature labor or
premature rupture of membranes
History of/or existing placental
abnormalities
Threatened abortion or vaginal
bleeding during current
pregnancy
Multiple gestation in current
pregnancy
Foetal growth abnormalities
History of toxaemia,
hypertension, or diabetes with
any pregnancy
Primigravida at 35 years of age
and older, or 15 years of age and
younger
Travel to
Potentially
Hazardous
Destinations
General Medical Risk
Factors
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History of thromboembolic
disease
Pulmonary hypertension
Severe asthma or other chronic
lung disease
Valvular heart disease (if NYHA
class III or IV heart failure)
Cardiomyopathy
Hypertension
Diabetes
Renal insufficiency
Severe anaemia or
haemoglobinopathy
Chronic organ system
dysfunction requiring frequent
medical interventions
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High altitudes
Areas endemic for or with
ongoing outbreaks of lifethreatening food- or insectborne infections
Areas where chloroquineresistant Plasmodium
falciparum malaria is
endemic
Areas where live virus
vaccines are required and
recommended
Table 8-05. Greatest risks for pregnant travellers
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Motor Vehicle
Accidents
Hepatitis E
Scuba Diving
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Safety belts should be worn whenever possible.
Fasten seatbelts at the pelvic area, not across the lower abdomen. Lap and shoulder
restraints are best.
In most accidents, the foetus recovers quickly from the safety belt pressure. However, consult
a physician even for mild trauma.
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Hepatitis E is not vaccine preventable and is especially dangerous in pregnant women.
Pregnant women should be advised that the best preventive measures are to avoid
potentially contaminated water and food, as with other enteric infections.
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Scuba diving should be avoided in pregnancy because of the risk of decompression
syndrome in the foetus.
Table 8-06. Half-lives of selected antimalarial drugs
Drug
Atovaquone
Chloroquine
Doxycycline
Mefloquine
Primaquine
Proguanil
Half Life
2–3 days
Can extend from 6 to 60 days
12–24 hours
2–3 weeks
4–7 hours
14–21 hours
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Selected Antenatal and Pregnancy Factsheets.
Drug
Half Life
Pyrimethamine 3–4 days
Sulfadoxine
6–9 days
The Travel Health Kit during Pregnancy
Additions and substitutions to the usual travel health kit (see the Travel Health Kits section in Chapter 2) need to be made
during pregnancy. Talcum powder, a thermometer, oral rehydration salt packets, prenatal vitamins, a topical antifungal
agent for vaginal yeast, acetaminophen, and a sunscreen with a high SPF should be carried. Women in the third trimester
may be advised to carry a blood-pressure cuff and urine dipsticks and have their providers train them to use them so they
can check for hypertension, proteinuria and glucosuria, any of which would require prompt medical attention. Antimalarial
and antidiarrheal self-treatment medications should be evaluated individually, depending on the traveller’s itinerary and
her health history. Most medications should be avoided, if possible.
Table 8-07. Vaccination during pregnancy
Vaccine/Immunobiologic
Use
Immune globulins, Immune globulin or
pooled or
specific globulin
If indicated for pre- or postexposure use. No known risk to foetus
hyperimmune
preparations
Vaccination of pregnant women is recommended
Recombinant or
Hepatitis B
Recommended for women at risk of infection
plasma-derived
All women who are pregnant in the second and third trimesters during the flu
Inactivated whole
Influenza
season (October–March); and women at high risk for pulmonary
virus or subunit
complications regardless of trimester
DiphtheriaIf indicated, such as lack of primary series, or no booster within past 10
Toxoid
tetanus
years
Not contraindicated, but data on safety, immunogenicity and outcomes of
Diphtheriapregnancy are not available. ACIP recommends Td when tetanus and
Toxoid—acellular
tetanus-pertussis
diphtheria protection are required but Tdap to add protection against
pertussis in some situations. Second or third trimester is preferred.
Data on safety in pregnancy are not available. Because hepatitis A vaccine
is produced from inactivated hepatitis A virus, the theoretical risk of
Hepatitis A
Inactivated virus
vaccination should be weighed against the risk of disease. Consider immune
globulin rather than vaccine.
Pregnancy is a precaution, and under normal circumstances vaccination should be deferred; vaccine should
only be given when benefits outweigh risks
Data on safety in pregnancy are not available. Pregnant women who must
Japanese
Inactivated virus
travel to an area where the risk is high should be vaccinated when the
encephalitis
theoretical risks are outweighed by the risk of disease.
Meningococcal conjugate vaccine (MCV4) is preferred for adults; however,
there are no data on safety and immunogenicity in pregnant women.
Meningococcal
Polyvalent meningococcal meningitis vaccine (MPSV4) can be administered
Polysaccharide
meningitis
during pregnancy if hte woman is entering an epidemic area. Indications for
prophylaxis are not altered by pregnancy; vaccine recommended in unusual
outbreak situations.
The safety of pneumococcal (PPV23) vaccine during the first trimester of
pregnancy has not been evaluated, although no adverse events have been
Pneumococcal
Polysaccharide
reported after inadvertent vaccination during pregnancy. Women with chronic
diseases, smokers, and immunosuppressed women should consider
vaccination.
Indicated for susceptible pregnant women travelling in endemic areas or in
Polio, inactivated
Inactivated virus
other high-risk situations
Indications for postexposure prophylaxis not altered by pregnancy. If risk of
Rabies
Inactivated virus
exposure to rabies is substantial, pre-exposure prophylaxis may also be
indicated.
Typhoid (ViCPS)
Polysaccharide
If indicated for travel to endemic areas.
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Selected Antenatal and Pregnancy Factsheets.
Vaccine/Immunobiologic
Use
Data on safety in pregnancy are not available; theoretical risk because liveTyphoid (Ty21a)
Live bacterial
attenuated
The safety of yellow fever (YF) vaccination in pregnancy has not been
studied in a large prospective trial. Pregnant women who must travel to
areas where the risk of YF infection is high should be vaccinated and their
infants should be monitored after birth for evidence of congenital infection
Yellow fever
Live attenuated virus
and other possible adverse effects resulting from YF vaccination. Pregnancy
may interfere with the immune response to YF vaccine; therefore, serologic
testing to document a protective immune response to the vaccine can be
considered (see the Yellow Fever section in Chapter 2 for more details).
Pregnancy is a contraindication to vaccination; vaccine should not be administered to pregnant women
Contraindicated due to theoretical risk of disseminated disease. Skin testing
Attenuated
Tuberculosis (BCG)
for tuberculosis exposure before and after travel is preferable when the risk
mycobacterial
of possible exposure is high.
Contraindicated; vaccination of susceptible women should be part of
postpartum care. Unvaccinated women should delay travel to countries
Measles-mumpsLive attenuated virus where measles is endemic until after delivery. Unvaccinated pregnant
rubella
women with a documented exposure to measles should receive IG within 6
days to prevent illness.
Contraindicated. Currently, the vaccine has not been causally associated
Human
Recombinant
with adverse outcomes of pregnancy; however, additional information is
papillomavirus
quadrivalent
needed for further recommendations.
Contraindicated; vaccination of susceptible women should be considered
Varicella
Live attenuated virus postpartum. Unvaccinated pregnant women should consider postponing
travel until after delivery when the vaccine can be given safely.
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