Dr. Rose Recommends for Healthy & Safe Travel
Health Guide Chapter 20
Travel and Pregnancy
- Pregnant women should not travel to areas where adequate health care is not readily available.
- Travel to areas of the world with malaria is not advised. If travel is necessary, you must avoid evening and nighttime mosquito bites and consult with your doctor about the safety of anti-malarial medication.
- The Zika Virus is a threat to the fetus, especially in the 1st trimester. Avoid travel to Zika virus endemic areas, if possible. There is no vaccine against this virus, so protection against daytime-biting mosquitoes is essential. The Zika Virus & Malaria Prevention Kit can prevent >99% of bites if properly used.
- Travel after the 28th week should be limited to a 100-mile radius.
- Pregnant travelers should be fully immunized, with the exception of live virus vaccines, excluding yellow fever.
- Drugs commonly used for travelers’ diarrhea can be safely used during pregnancy.
If you are a healthy woman with an uncomplicated pregnancy, you do not necessarily need to curtail reasonable travel. According to the American College of Obstetricians and Gynecologists, the best time for travel is during the second trimester 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 lower. After the sixth month, the risks 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 as limited access to medical care. If you will be far away from expert medical and obstetric care, and/or have increased exposure 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 beyond a 100-mile radius after the 28th week. Problems after this time include increased 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.
A careful assessment of your medical and obstetric history, and your current state of health, is mandatory before departure. It should include the following:
- Obstetric history—Have you had any of the following conditions?
- Spontaneous abortion (miscarriage)
- Ectopic pregnancy
- Pre-eclampsia or eclampsia
- Premature labor
- Incompetent cervix
- Prolonged labor
- Cesarean section
- Premature rupture of membranes
- Uterine or placental abnormalities
- Pelvic inflammatory disease
- Phlebitis or pulmonary embolism
- D (Rho) negative blood group
- Severe morning sickness
- Twin births
- Medical history—Do you
- Have diabetes? Take insulin?
- Take medication for any other illness?
- Have symptomatic congenital or acquired heart disease?
- Have anemia, asthma, epilepsy, phlebitis, or any other significant medical illnesses?
- Get severe motion sickness?
- Have significant allergies?
- The current pregnancy—Do you have any immediate obstetric complications (e.g., mild pre-eclampsia)?
- 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 obstetric care in the countries on your itinerary—Is it available and adequate?
Medical Clearance for Travel—After reviewing the above checklists, your doctor will be able to discuss with you the relative safety of your travel plans and offer appropriate advice.
You should have your first prenatal appointment at 10 weeks’ gestation. 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 4 weeks until week 30, then every 2 weeks until week 36, then weekly until delivery. Travel plans should not interfere with these important checkups.
Pelvic Ultrasound—Before leaving, discuss with your obstetrician the advisability of having an ultrasound examination to check for tubal pregnancy, multi-fetal 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 obstetric 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 physicians and can give you 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 Travelers) at 519-836-0102. The list is free but a membership donation to this tax-free foundation is encouraged.
Travel Insurance—Travelers going to a less developed country should purchase 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 consultation 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 policies of the following companies cover complications of pregnancy through the third trimester:
International SOS Assistance, Inc.
3600 Horizon Boulevard, Suite 300
Trevose, PA 19053
800-523-8930 or 1-215-942 8000
Worldwide Assistance Services, Inc.
1133 15th Street, N.W., Suite 400 Washington, DC 20005 800-821-2828 or 1-202-331-1609 www.worldwideassistance.com
Calling Home—Travelers should always carry their doctor’s telephone number 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 physician who knows her best. In addition, providing the personal physician’s telephone number to overseas physicians may be extremely helpful during an emergency.
Review with your doctor those signs and symptoms that indicate a possible obstetric emergency and seek immediate, qualified obstetric care if you have any of the following:
- Vaginal bleeding
- Passing of tissue or blood clots
- Abdominal pain, cramps, or contractions
- Gush of watery fluid from the vagina
- Headaches, blurred vision, upper abdominal pain, nausea, and vomiting may be symptoms of severe pre-eclampsia
Other causes of illness should not be overlooked. Abdominal pain, for example, does not necessarily indicate that you have an obstetric emergency. You could have appendicitis, a urinary tract infection, or merely simple indigestion. Diagnosing the cause of abdominal pain is usually more difficult during pregnancy. Readily available, high- quality medical care is essential if you develop worrisome symptoms.
Symptoms that may be no cause for concern (but if persistent should be evaluated) include the following:
- Increased urination
- Fatigue, insomnia
- Slight increase in vaginal discharge
- Sore, bleeding gums
- Leg cramps
- Occasional mild dizziness
- Mild swelling around the ankles
Trauma During Pregnancy
Motor Vehicle Accidents—Accidents are the leading cause of death in travelers younger than age 55, and motor vehicle accidents are responsible for most cases of blunt trauma to pregnant women. Maternal mortality is increased sixfold and fetal mortality fivefold when the woman is ejected from the vehicle. Consequently, the use of seat belts is recommended to decrease maternal and fetal trauma. Use of a lap belt alone, however, has been implicated in placental injury and fetal injury. 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.
Falls—Women in their third trimester tend to have more falls. Eighty percent of these falls occur after the 32nd week and are mostly caused by fatigue, a fainting spell, a protuberant abdomen, a loss of balance and coordination, and increased joint mobility, especially looseness of the pelvic joints. Most of these third trimester 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 include abdominal pain and vaginal bleeding; severe pain without bleeding can also occur.
Fetal Monitoring—Early detection and treatment of abruptio placentae are critical to prevent fetal death and preserve the mother’s health. Fetal monitoring as early as the 20th week of pregnancy can be diagnostic. Studies show that there is frequent uterine activity—more than eight uterine contractions per hour—during the first few hours of monitoring after trauma in virtually all patients in whom abruption eventually occurs. Monitoring is advised, however, only after the stage of fetal viability (approximately 24 weeks) because no therapy exists for the treatment of fetal distress before this developmental stage. Concern for maternal health is the only indication for hospitalization before the stage of fetal viability.
Ultrasound—Ultrasound may be unreliable for the diagnosis of abruption. Fetal monitoring (cardiotocographic monitoring) is superior. Ultrasound is useful to (1) determine fetal well being if monitoring is equivocal; (2) measure fetal heart rate and verify lack of fetal cardiac activity if fetal death is suspected; and (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 continuous 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 bleeding, leak of fluid from the vagina, decrease in or lack of fetal motion, severe abdominal pain around the uterus, rhythmic contractions, dizziness, or fainting.
Vaccinations During Pregnancy
If you are pregnant (or think you may 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 benefit of the vaccine against the risk of contracting a serious, possibly life-threatening 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: The CDC now states that the flu vaccine is safe in all three trimesters and during breastfeeding. Therefore, all pregnant women should be immunized (using the injectable vaccine, not the live virus FluMist vaccine). Unfortunately, some physicians won’t vaccinate during the first trimester, fearing that some women who have a miscarriage will “blame” the vaccine, despite the fact that there is no evidence that flu vaccine causes miscarriages. Be aware that the flu season in the Southern Hemisphere is during our summer.
- Tetanus-Diphtheria (Td): This vaccine is routinely indicated for susceptible pregnant women.
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 are 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 very low. This vaccine is recommended if you are not immune to hepatitis A and plan to travel to a developing country.
- Hepatitis B: Hepatitis B vaccine is considered safe and may be administered during pregnancy.
- Japanese encephalitis: Significant side effects are possible, including fever, angioedema, and hypotension. There are 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.
- Meningococcal: This vaccine may be given during pregnancy if you have a substantial risk of exposure.
- Pneumococcal (polysaccharide or conjugated): If you are a candidate for this vaccine, usually 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 before 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 because 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. Yellow fever vaccine may be given after the sixth month of pregnancy if there is substantial risk of exposure according to the World Health Organization. Get a waiver letter from your physician 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 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 is the most important insect-transmitted disease you need to avoid, especially 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 syndrome, shock, and coma. Maternal mortality rates of up to 10% can occur. Obstetric complications of malaria include spontaneous miscarriage, premature delivery, stillbirth, and neonatal deaths. Vivax malaria is associated with greater anemia and lower birth weight, but not with 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, it is imperative to (1) prevent mosquito bites and (2) take an effective prophylactic drug.
Mosquito Bites—Protection against insect bites is important in the tropics. Malaria, dengue fever, Lyme disease, and other insect-transmitted diseases can seriously 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% DEET to exposed skin and treat your clothing with permethrin. This combination is 99% to 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 impregnated 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.
Drug Prophylaxis—Chloroquine is the drug of choice when traveling to areas endemic for Vivax malaria and chloroquine-sensitive falciparum malaria. Mefloquine (Lariam) is the drug of choice for travel to areas with chloroquine-resistant falciparum malaria. Atovaquone/proguanil (Malarone), doxycycline, and primaquine are not safe to take during pregnancy.
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. Mefloquine is only 50% effective against Plasmodium falciparum along the borders of Thailand with Cambodia and Myanmar, and travel to these border areas should be avoided.
Doxycycline should not be used to prevent malaria during pregnancy, but doxycycline can be used during pregnancy to treat serious or life-threatening infections such as chloroquine-resistant falciparum malaria and ehrlichiosis when there are no other options.
Treatment of Malaria
Uncomplicated chloroquine-sensitive Plasmodium vivax and chloroquine-sensitive P. falciparum should be treated with a 3-day course of chloroquine. Uncomplicated 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 an increased risk of fetal death. In the Amazon Basin and Southeast Asia, P/S may not be effective. 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 Category 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 circumstances will dictate what regimen is best in a given situation. When possible, malaria in pregnancy is best treated by an expert in this area.
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 Plasmodium ovale malaria, you should continue chloroquine prophylaxis until after delivery when you can be treated with primaquine.
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 management of illnesses at home, you should employ nondrug remedies when possible. 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.
- Acetaminophen with codeine—Safe
- Aspirin—Avoid, especially in the last trimester. May increase incidence of bleeding, especially maternal and neonatal blood loss following delivery. Aspirin is a potent prostaglandin synthetase inhibitor, and it has been associated with premature closure of the ductus arteriosus.
- Low-dose aspirin—60 to 100 mg daily reduces incidence of pregnancy-induced hypertension; may be indicated for women at risk of developing pre-eclampsia. Should be used only on the recommendation of your obstetrician.
- Nonsteroidal anti-inflammatoy drugs (NSAIDs, e.g., ibuprofen)—Avoid NSAIDs do not appear to increase the risk of adverse birth outcomes but are strongly associated with miscarriage. NSAIDs may also increase bleeding potential. Theoretically, any NSAID can cause premature ductal closure.
- 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 Escherichia 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, Vibrio cholerae). Furazolidone is 80% effective against Giardia lamblia. There are 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 because it is carcinogenic in rodents and mutagenic in certain bacteria, a recent analysis of seven studies suggested that there is no increase in birth defects among infants exposed to metronidazole during the first trimester.
- Paromomycin—This is an oral aminoglycoside that is non-absorbed 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 reported 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 antibiotics should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.” Quinolone antibiotics should not be withheld 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 the first trimester. Acetazolamide is associated with limb abnormalities in animals. This is a sulfa analog.
- Calcium channel blockers (e.g., nifedipine)—No increased risk of fetal anomalies, but decrease in fetal blood flow is possible.
- Dexamethasone (Decadron)—Considered safe. No association with congenital anomalies has been reported.
Sleeping Pills and Tranquilizers
- Alcohol—Teratogenic; avoid, even in small amounts.
- Benzodiazepines—Avoid. One study associated diazepam with cleft lip.
- Drugs for Motion Sickness, Coughs, and 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 guaifenesin and dextromethorphan are acceptable.
- Decongestants—Pseudoephedrine (Sudafed) and oxymetazoline (Afrin) are considered safe.
Drugs for Malaria and Other Infections
- Atovaquone/proguanil (Malarone)—Do not use for prophylaxis; safety in pregnancy has not been established.
- Chloroquine—Considered to be safe.
- Clindamycin—No studies of adverse embryo-fetal effects. This drug is a good alternative to doxycycline for the treatment of falciparum malaria when used in combination with quinine or quinidine.
- Doxycycline—Avoid. This drug should be used only for the treatment of a life-threatening infection.
- Erythromycin—Considered safe. If used to treat maternal syphilis, however, adequate fetal blood levels may not be achieved because little drug passes the placenta.
- Halofantrine—Avoid. Halofantrine is embryotoxic.
- Mefloquine—Drug of choice to prevent chloroquine-resistant malaria.
- Nitrofurantoin—Selected by many obstetricians as the initial choice for most urinary tract infections. Congenital anomalies have not been reported.
- Penicillin, ampicillin, amoxicillin—Considered safe. This includes the newer penicillins such as piperacillin, as well as those combined with beta-lactamase inhibitors, clavulanic acid (Augmentin), 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 (three-tablet) presumptive 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 increase the 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 diseases (e.g., ehrlichiosis).
- Iodine tablets and iodine-resin water purifiers—Do not use for more than 3 weeks in any 6-month period as the 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 mechanism of choice for longer-term water purification. Note: Prolonged use (more than 2 years) of demand-release iodine-resin filters by Peace Corps workers in Africa resulted in a fourfold 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 the 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, more and more women are active and sports minded, and many obstetricians say that strenuous 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.
- Hyperthermia should be avoided. 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 sedentary 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 2 weeks for the body to become acclimated to heat.) Hyperthermia should be avoided, especially during the first trimester when the nervous system of the fetus is developing.
- If the woman is healthy and accustomed to very vigorous exercise, there’s probably 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 on 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 riding 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.
- Relative contraindications to vigorous exercise (or stressful travel for that matter) include hypertension, anemia, thyroid disease, diabetes, cardiac arrhythmia, history of precipitous labor, history of intrauterine growth retardation, any bleeding during current pregnancy, breech presentation during the last trimester, 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, multi-fetal pregnancy, incompetent cervix, bleeding or a diagnosis 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 authorities, however, advise against trekking in remote areas above 8,000 feet. Not only may you develop acute altitude sickness, but emergency medical and obstetric care will also be far away.
Women who remain at high altitudes during their pregnancies have altitude-associated increases in fetal growth retardation, high blood pressure, and premature delivery. You should consult your doctor if you will be traveling to, or plan to live at, altitudes greater than 6,000 feet.
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 of 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 pre-travel 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 trimester. 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 comfort, help relieve swelling, and reduce the risk of deep vein thrombosis.
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 to 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 because of high levels of residual iodine in the treated water (see Chapter 5). All foods should be well cooked and served hot to avoid a variety of infectious illnesses.
The treatment of travelers’ diarrhea can be problematic. You don’t want to risk causing a drug-related fetal injury (even though this may be highly unlikely), but 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 or 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 recommendations. The use of an antibiotic depends on the severity of symptoms: volume and frequency of stools, abdominal pain, general feelings of illness, and degree of inconvenience. The Health Guide 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 furazolidone.
- Azithromycin (Zithromax) is emerging as an important drug for treating travelers’ diarrhea. It is presumed safe in pregnancy. In one study performed in Thailand, azithromycin was superior to ciprofloxacin in the treatment of Campylobacter enteritis. Other studies have demonstrated effectiveness against multi-drug–resistant Shigella as well as Salmonella, E. coli, and V. cholerae.
- Cefixime (Suprax), a cephalosporin, is effective against most pathogens causing 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 incapacitating diarrhea, diarrhea causing dehydration, or diarrhea with dysentery, start treatment with a quinolone antibiotic or azithromycin. 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 to treat the cause of the illness, 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 humans. 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 illness should determine the choice of 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.