Although travelling while pregnant is generally safe, steps should be taken to minimise risks by providing a comprehensive risk assessment before travel
Pregnant women may face additional risks when travelling overseas, which must be considered with assessment and travel health advice before they decide to travel. A careful risk assessment should be completed to identify the key risks and strategies for staying safe while travelling.
Citation: Tucker R (2014) Advising pregnant women on miminising travel risks. Nursing Times; 110: 14, 19-21.
Author: Rosemary Tucker is an independent travel health nurse adviser.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF, including any tables and figures
Pregnant women should be given comprehensive advice on the risks they may face if they choose to travel overseas so they can make an informed decision on whether or not to do so. To provide this advice, practitioners advising travellers should have access to reliable and up-to-date resources (Box 1).
Box 1. Travel and health advice resources
- National Travel Health Network and Centre
www.nathnac.org Advice line for health professionals: 0845 602 6712
- Public Health England, Malaria Reference Laboratory
www.malaria-reference.co.uk Provides a fax service for advice on malaria prophylaxis
www.travax.nhs.uk Travel health advice for health professionals. Subscription needed outside Scotland and Wales
- UK Civil Aviation Authority
www.caa.co.uk Produces guidelines on fitness to fly
- Royal College of Obstetricians and Gynaecologists
www.rcog.org.uk Has published a useful document on air travel and pregnancy (tinyurl.com/ RCOG-Air-Travel-Pregnancy)
Individual risk assessment
Health professionals should complete a careful risk assessment with pregnant travellers before they leave the country. This should take into account the woman’s medical and obstetric history as well as:
- Season of travel;
- Duration of stay;
- Any planned activities.
It is also important to establish the reason for travel. Illness in family members abroad, for example, may result in pregnant women travelling at short notice with little time for preparation.
It is also important to consider the medical facilities available at the destination, as gynaecological, obstetric and neonatal care may be limited, and invasive treatments may pose a risk of blood-borne viruses. Language barriers and cultural differences can also make consultations difficult.
Women with a complex obstetric history, such as placental abnormalities or a history of premature labour, may be advised against any travel during pregnancy (Field et al, 2010). For others, certain geographical destinations may be unsuitable, such as areas where malaria exists or remote areas with limited access to medical care. If travel is essential, women should be advised to discuss their travel plans with their obstetrician.
The second trimester is considered the safest time to travel - at this point the risk of miscarriage has decreased and the risk of complications such as pre-eclampsia and pre-term labour are low (Field et al, 2010). An early pregnancy scan should ideally be performed before departure to give a reliable due date and to confirm the pregnancy is normal. Pregnant women should be advised to carry a copy of their prenatal records.
Women are not always adequately prepared in terms of insurance (Kingman and Economides, 2003), but comprehensive travel health insurance is essential. This should cover repatriation and care for pregnancy complications such as premature delivery and neonatal intensive care.
Infectious disease risks
Pregnant women have an altered immune response making them more susceptible to infection and a more severe outcome. Food-borne illnesses of particular concern include toxoplasmosis and listeriosis, which may cause spontaneous abortion or stillbirth. For this reason, unpasteurised dairy products, soft cheeses and undercooked meat should be avoided. Hepatitis E infection is a cause of high fatality rates during pregnancy, so care should be taken with food, water and personal hygiene to reduce the risk of this and other gastrointestinal infections.
Pregnant women can be more vulnerable to dehydration caused by travellers’ diarrhoea or other food-borne illnesses. Oral rehydration is essential but they should be informed of suitable medications to use during pregnancy before travelling.
Respiratory infections, such as influenza, can cause complications in pregnancy and women should consider receiving the flu vaccination before travelling (Department of Health, 2013).
Avoiding bites in the first place is an important part of preventing both tick- and mosquito-borne diseases such as malaria, yellow fever, Japanese encephalitis and dengue fever; women should be advised of appropriate bite-avoidance measures before travel.
Guidance on malaria prevention was updated recently (Chiodini et al, 2013). This includes revised recommendations for malaria chemoprophylaxis (malaria tablets) in pregnant women.
The cornerstone to malaria prevention can be summarised using the “ABCD of malaria prevention” (Chiodini et al, 2013):
- Awareness of risk of malaria;
- Bite avoidance;
- Prompt diagnosis and treatment.
Awareness of risk
Pregnant women should be advised against travelling to malarious areas, particularly where chloroquine-resistant Plasmodium falciparum (P falciparum) is present. If travel is unavoidable, women need to be aware that if they do contract malaria, the disease is likely to be more severe and they are at higher risk of fatality than non-pregnant women (Chiodini et al, 2013). Complications from the disease can also lead to miscarriage, stillbirth and premature labour (Royal College of Obstetricians and Gynaecologists, 2010).
Pregnant women are particularly attractive to mosquitoes, making it essential to avoid bites. The insect repellent N,N-diethyl-meta-toluamide, more commonly known as DEET, has a good safety record in pregnancy (Fradin and Day, 2002) and is recommended to be used in concentrations of up to 50% (Chiodini et al, 2013).
For areas where malaria tablets are recommended, the choice of antimalarial drug will depend on the species of parasite at the destination, whether there is drug resistance, and what trimester of pregnancy the woman is in (Box 2). It should be remembered that no antimalarial drugs are 100% effective. Contraindications, adverse events and drug interactions must be considered carefully for each individual.
Box 2. Recommendations for malaria chemoprophylaxis in pregnancy
- Chloroquine + proguanil – Taken safely during pregnancy for many years, but may not be effective in many areas due to presence of drug-resistant P falciparum. Folic acid supplements (5mg daily) advised if proguanil is used
- Mefloquine – Data on use of mefloquine for prophylaxis in pregnant women is generally reassuring. It can be offered to pregnant women during the second and third trimesters and can also be justified in the first trimester if travelling to high-risk areas where P falciparum is present
- Atovaquone/proguanil – There is a lack of evidence on its safety in pregnancy and its use for chemoprophylaxis in pregnancy is not advised. However, if there are no other suitable options, atovaquone/proguanil can be considered in the second and third trimesters
- Doxycycline – Contraindicated in pregnancy. However, doxycycline can be used under special circumstances if required before 15 weeks’ gestation and if other options are not suitable. The full course, including the four weeks after travel, must be completed before 15 weeks’ gestation.
Source: Chiodini et al (2013)
Diagnosis and treatment
When malaria is contracted prompt diagnosis and treatment are crucial when it becomes symptomatic. Travellers should be made aware of the signs and symptoms of malaria (fever or flu-like illness) and be reminded that malaria can occur even up to a year after returning from a risk area (Chiodini et al, 2013).
Immunisation in pregnancy
There is no evidence of risk from vaccinating pregnant women with inactivated viral or bacterial vaccines or toxoids (Plotkin and Orenstein, 2013). Inactivated vaccines do not replicate and do not cause infection in either the mother or the foetus (DH, 2013). The decision be to vaccinated must be made by the woman after a thorough risk assessment, taking into account how severe the illness is likely to be during pregnancy. Health professionals should refer to the “Green Book” (DH, 2013) and individual Summary of Product Characteristics when advising about vaccination.
Live vaccines are generally contraindicated in pregnancy due to theoretical concerns that they may infect the foetus. For this reason, pregnant women should be advised against travel to areas where yellow fever is endemic. If this is unavoidable, yellow fever vaccine can be considered if the risk of disease outweighs those associated with the vaccine (Field et al, 2010). The measles, mumps and rubella vaccine, as well as the BCG and varicella vaccines are contraindicated in pregnancy.
Women may prefer to leave an interval between receiving a live vaccine or taking malaria tablets and becoming pregnant. Advice on the periods considered adequate for different medications and vaccines are outlined in Box 3.
Box 3. Pre-conception advice for vaccines and malaria tablets
Live vaccines – Delay conception for at least 28 days after receiving due to theoretical risk of transmission to the foetus (Field et al, 2010)
Antimalarial tablets – The ACMP recommends leaving the following time intervals between completing
a course of malaria tablets and trying to conceive:
- Mefloquine – three months
- Atovaquone/proguanil – two weeks
- Doxycycline – one week
Source: Chiodini et al (2013)
Commercial air travel is considered safe for women with an uncomplicated pregnancy. Those with a complex obstetric history or underlying medical conditions should seek specialist advice (see case study, Box 4).
Airlines’ main concern in accepting pregnant women as passengers is the risk of in-flight labour, and many do not allow women to fly after 36 weeks’ gestation. If there are significant risk factors for pre-term labour (such as multiple pregnancy), women should not fly after 32 weeks (RCOG, 2013). After 28 weeks of pregnancy many airlines and some cruise and ferry operators will ask for a medical letter confirming there are no anticipated complications.
The risk of travel-related venous thromboembolism (VTE) in flights lasting longer than four hours is estimated to be one in 6,000 in healthy individuals (World Health Organization, 2007). However, pregnancy increases this risk and an individual risk assessment for thrombosis is needed for all pregnant women who intend to fly. For flights lasting longer than four hours, they are advised to wear properly fitted graduated compression stockings (Kahn et al, 2012).
There is no information to suggest that pregnant women should avoid security scans (RCOG, 2013).
The safety of travelling to high altitude during pregnancy has not been thoroughly studied. Short exposures without exercise appear to be well tolerated by healthy pregnant women for altitudes up to 2,500m (Jean et al, 2008) However, potential complications, such as low foetal heart rate or premature labour, can occur at higher altitudes so pregnant women should be advised not to travel higher than 3,500m (Field et al, 2010).
Pregnant women can safely travel overseas provided they are given appropriate advice on the risks associated with travel and take steps to minimise these risks as far as possible. They should know how to manage minor illnesses and when to seek medical help.
- All travellers should undertake an individual risk assessment, but this is especially important if they are pregnant
- An ultrasound should be performed before travel to determine the baby’s due date and rule out any complications
- It is essential to take out comprehensive travel health insurance
- Pregnant women are more susceptible to infectious diseases and these may be more severe in pregnancy
- Malarial areas should be avoided by pregnant travellers
Chiodini PL et al (2013) Guidelines for Malaria Prevention in Travellers from the United Kingdom.
Department of Health (2013) Immunisation Against Infectious Disease.
Field VF et al (2010) Health Information for Overseas Travel. London: National Travel Health Network and Centre.
Fradin MS, Day JF (2002) Comparative efficacy of insect repellents against mosquito bites. New England Journal of Medicine; 347: 13-18.
Jean D et al (2008) Women Going to Altitude. Consensus Statement of the UIAA Medical Commission, volume 12.
Kahn SR et al (2012) Prevention of VTE in nonsurgical patients. Chest; 141 (Supplement): 195-226.
Kingman CE, Economides DL (2003) Travel in pregnancy: pregnant women’s experiences and knowledge of health issues. Journal of Travel Medicine; 10: 6, 330-333.
Plotkin SA, Orenstein WA (2013) Vaccines. Philadelphia, PA: WB Saunders.
Royal College of Obstetricians and Gynaecologists (2013) Air Travel and Pregnancy. Scientific Impact Paper No. 1.
Royal College of Obstetricians and Gynaecologists (2010) The Prevention of Malaria
in Pregnancy. Green-top guideline No 54A.
World Health Organization (2007) WHO Research into Global Hazards of Travel (WRIGHT) project: Final Report of Phase 1. tinyurl.com/WHO-WRIGHT