Clinical Practice Guidelines Antenatal Care — Module II
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- Risks associated with travel in pregnancy
- Discussing travel during pregnancy
- Overseas travel
- Long-distance air travel
- Vaccinations
- Travel insurance
- Travel to malaria-endemic areas
- Practice summary: travel
5.10TravelDiscussing the risks associated with travel during pregnancy enables women to make informed decisions and take measures to improve their safety. BackgroundStudies have identified limited knowledge among women of factors associated with travel during pregnancy, including the correct use of seat belts and risks associated with overseas travel. Risks associated with travel in pregnancyCar travel: Severe and non-severe injuries from motor vehicle accidents are associated with adverse maternal and fetal outcomes (Schiff & Holt 2005; El Kady et al 2006; Hitosugi et al 2006; Wahabi et al 2007; Aboutanos et al 2008; Klinich et al 2008; Kvarnstrand et al 2008; Schiff et al 2008; Weiss et al 2008; Cheng et al 2012), with a higher risk of adverse outcomes if the birth takes place during an admission for a motor vehicle accident (Vivian-Taylor et al 2012). Adverse maternal and fetal outcomes are more likely following a motor vehicle accident if a seat belt is not worn (Hyde 2003; Klinich et al 2008; Motozawa et al 2010). Airbag deployment does not appear to adversely affect maternal or fetal outcomes (Metz & Abbott 2006; Schiff et al 2010). Long-distance air travel: Commercial flights are normally safe for pregnant women (Freeman et al 2004; RCOG 2008; ACOG 2009) and frequent air travel during pregnancy (eg by flight crew members) does not appear to increase the risk of adverse outcomes (Irgens et al 2003; dos Santos Silva et al 2009). However, air travel at 34–37 weeks gestation has been associated with an increased risk of preterm birth (Chibber et al 2006; Magann et al 2010). Venous thrombosis, which is associated with long-distance air travel in the general population (Belcaro et al 2001), is more likely in pregnancy. Overseas travel: Exposure to infection is increased with travel to certain regions. Pregnant women are more likely than non-pregnant women to become infected with malaria (Coll et al 2008). Malaria during pregnancy is associated with spontaneous miscarriage, preterm birth, low birth weight, stillbirth, congenital infection and maternal death (Lagerberg 2008). Discussing travel during pregnancyWhile the available evidence on travel in pregnancy is from low level studies and is heterogeneous, this evidence largely supports the NICE recommendations. Car travelHigh-level evidence from general populations supports the use of seat belts (Glassbrenner & Starnes 2009). However, studies examining pregnant women’s knowledge and compliance of seat belt use and health professionals’ counselling on the use of seat belts in pregnancy have found a lack of knowledge, compliance and advice given (McGwin et al 2004a; McGwin et al 2004b; Beck et al 2005; Jamjute et al 2005; Taylor et al 2005; Sirin et al 2007). Information provided to pregnant women can promote correct use of seat belts (McGwin et al 2004b). The Confidential Enquiry into Maternal Deaths in the United Kingdom provides the following advice on the correct use of seatbelts in pregnancy (Lewis & Drife 2001): straps should be placed above and below the ‘bump’, not over it; use three-point seatbelts with the lap strap placed as low as possible beneath the ‘bump’, lying across the thighs with the diagonal shoulder strap above the bump lying between the breasts; and adjust the fit to be as snug as comfortably possible. Recommendation 8 Grade B Inform pregnant women about the correct use of seat belts — that is, three-point seat belts ‘above and below the bump, not over it’.
A survey of women’s knowledge of air travel risks in pregnancy reported that only one-third of respondents sought travel advice and one-quarter were unaware of the risk of venous thrombosis (Kingman & Economides 2003). Advice on venous thrombosis provided by health professionals also varies (ranging from simple preventive measures to use of aspirin or heparin) (Voss et al 2004). Preventive measures to minimise the risk of venous thrombosis include (ACOG 2009; Brenner 2009): using support stockings and periodic movement of the lower extremities; avoiding restrictive clothing; undertaking occasional ambulation; and maintaining hydration (eg drinking plenty of water, avoiding caffeine and not drinking alcohol). Recommendation 9 Grade C Inform pregnant women that long-distance air travel is associated with an increased risk of venous thrombosis, although it is unclear whether or not there is additional risk during pregnancy.
in general, killed or inactivated vaccines, toxoids and polysaccharides can be given during pregnancy, as can oral polio vaccine; live vaccines are generally contraindicated because of largely theoretical risks to the baby; and measles, mumps, rubella, BCG and yellow fever vaccines should be avoided in pregnancy. The risks and benefits of specific vaccines should be examined for each woman and the advice of a travel medicine doctor sought. Recommendations on vaccinations during pregnancy are included in the Australian Immunisation Handbook and the World Health Organization provides interactive maps on areas where the risk of specific infections is medium to high (see Section 5.11).
Pregnant women should be advised to discuss considerations such as air travel, vaccinations and travel insurance with their midwife or doctor if they are planning to travel overseas. Travel to malaria-endemic areasDue to the risks associated with maternal malaria and potential adverse effects associated with preventive medications, the safest option is for women to avoid travel to malaria-endemic areas during pregnancy. When travel cannot be deferred, women should be advised about preventive measures and any risks associated with them. Taking precautions against mosquito bites is an important preventive measure. Insecticide-treated bed nets have been shown to reduce malarial levels in the general population (Jacquerioz & Croft 2009) and adverse outcomes among pregnant women (Gamble et al 2006). Other barrier measures include: wearing clothes that have been pretreated with insecticide; wearing long-sleeved treated clothing when outdoors in the evening and at night; and applying insect repellent regularly to exposed skin. Barrier measures have the additional advantage of protecting against other mosquito-transmitted infections, such as dengue fever, Japanese encephalitis and yellow fever. Recommendation 10 Grade B If pregnant women cannot defer travel to malaria-endemic areas, advise them to use insecticide-treated bed nets. Medications to prevent malaria infection reduce antenatal parasite prevalence and placental malaria among pregnant women, regardless of number of previous pregnancies (Garner & Gülmezoglu 2006). Among women having their first or second baby, they also have positive effects on birth weight and may reduce the risk of perinatal death (Garner & Gülmezoglu 2006). The use of preventive medicine depends on the level of risk (eg travel destination, season, length of stay). The Therapeutic Goods Administration (TGA) advises that the use of preventive medicines is justified in high-risk situations (TGA 2013). Practice point k Beyond the first trimester, mefloquine is approved for use to prevent malaria. Neither malarone nor doxycycline are recommended for prophylaxis any time during pregnancy. Chloroquine (or hydroxychloroquine) plus proguanil is safe but less effective so seldom used. For areas where only vivax is endemic, chloroquine or hydroxychloroquine alone is appropriate. Current information on specific medicines in pregnancy is available from the TGA and information on areas where there is a risk of transmission of malaria is available from the WHO and the Centers for Disease Control and Prevention (CDC) (see Section 5.11). The risks and benefits of specific anti-malarial medications should be examined for each woman and the advice of an expert in travel medicine sought. Practice summary: travel
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