Resources
Websites:
www.journeywoman.com

www.HERmail.net
www.pregnanttraveller.com


Discussion Topics
• Medical considerations
• Safety and Cultural issues
• Pregnancy and Travel


Medical - History
Pretravel History:
-When, why, how, how long
-characteristics of trip (type of travel, accommodations, solo or group)

-detailed itinerary, activities (?altitude, ?scuba)

-characteristics of woman (experience, knowledge, fears, etc.)

Medical - Immunizations
Routine- DT, MMR, Polio


Recommended

hepatitis A/B, typhoid
rabies, J.E.
influenza, varicella
pneumococcal


Required
yellow fever, meningitis

Medical – Female Specific
(1) Menstrual

(2) Contraception

(3) Infectious

(4) First Aid Kit

Medical – Menstrual

Considerations:

-irregular menses or amenorrhea common with travel

-supplies, environmental issues

-may be easiest to skip it altogether…..

The Keeper……

Medical - Contraception

Oral Contraceptives:

-safe to take continuously to delay menstruation (better with monophasic pill)

-drawbacks: may lose stability in hot/humid environments, compliance issues with time changes, etc.

Medical - Contraception
Birth Control Patch

-better compliance, changed weekly
-can delay menstruation as with OCP
-has been shown to maintain effectiveness in hot/humid weather
-drawbacks: not yet available in Canada

Medical - Contraception
Depo Provera
-will induce amenorrhea over time
-good compliance
-drawbacks:
-high incidence of BTB in the first 3-9 months
-If traveling longer than 3 months, will need to administer medication abroad

Medical - Contraception

Emergency

-within 72 hours

-Ovral, Plan B, consider including in medical kit

-website with information on EC and searchable by country:

http://ec.princeton.edu/worldwide/default.asp

Medical - Infections

STD'S

-discuss pretravel

-precautions: latex condoms, abstinence

-Post exposure prophylaxis?

-consider for traveler at high risk for unprotected sex, blood product exposure

-avoid tattooing, piercing, electrolysis

Medical - Infections
The common….

-vaginitis (candida)

-Urinary Tract Infection

The Uncommon….

-shistosomiasis

-intestinal nematodes
Medical - Hygiene
The Toilet Issue…
-LEARN TO SQUAT!!

Other Gadgets…

Medical kit

The Usuals +

-Diflucan 150 mg, or topical candidal medication

-Ciprofloxacin: for TD and UTI

-Contraception, emergency contraception

-Pregnancy test

-multivitamin

-Moist towlettes, antibacterial gel

Medical - Insurance

Travel Medical Insurance:

-make sure they have it

-read the fine print

-should include evacuation insurance

Safety

Read and plan ahead:

-safety issues, customs, culture, role of women in places visited

-what to expect and how to prepare

-traveling light reduces vulnerability and makes it easier to use public transport

-avoid arriving in a new destination after dark

-bring extra copies of all documents

-NEVER LOOK LOST!!

Safety

• Use alcohol with caution, especially if alone. Intoxication = vulnerability

-Safety
-Group/Adventure Tours
-does not eliminate risk
-research ahead; do leaders know first aid? Local language?
-ability/level of other group members
-respect personal capabilities, a foreign country is not always the best place to try something completely new.

Culture
• Be prepared, read ahead
• In male dominated cultures, may be considered inappropriate for women to be traveling alone
• Be prepared to be openly stared at, verbally harassed, touched, pinched
• Eye contact may be seen as an “invitation”
• In some areas may be beneficial to join up with other travelers

Culture - Dress
-appropriate dress shows cultural sensitivity, decreases harassment, and enhances safety and well as experience.
-appropriate dress especially important in religious sites
Pregnancy & Travel
General considerations:
-medical facilities and access to medical care at destination
-need for and safety of vaccinations
-health insurance, needs to include newborn coverage and evacuation
-weigh risks and postpone travel / modify itinerary as necessary
-generally safest during second trimester

Pregnancy & Travel
Relative Obstetrical contraindications
• Hx of miscarriage
• Incompetent cervix
• Hx of ectopic pregnancy
• Hx of premature labor/PROM
• Placental abnormalities
• Vaginal bleeding
• Multiple gestation
• Hx of Pregnancy induced hypertension, or gestational diabetes
• Age <15 or >35 years

Pregnancy & Travel
Relative medical contraindications:
-valvular heart disease
-history of thromboembolism
-severe anemia
-chronic organ system dysfunction requiring frequent medical intervention

Pregnancy & Travel
Relative destination contraindications:
-high altitudes
-areas endemic for or epidemic for life threatening food/insect borne infections
-areas where chloroquine resistant malaria is endemic
-areas where live vaccine are recommended

Tables taken from CDC website

Pregnancy & Travel

Vaccinations:
-need to weigh risks/benefit
-try to avoid in the first TM if possible, due to risk of febrile reaction

In general, live vaccines contraindicated
Vaccines in Pregnancy
Vaccines in Pregnancy
Pregnancy & Travel

Hepatitis E:
-no vaccine
-Most prevalent if Far East and Mexico
-transmission through contaminated food and water
-case fatality rate of 17-33% in pregnancy

Malaria in Pregnancy
• Significant morbidity and mortality for both mother and fetus
• No antimalarial is 100% effective, therefore
• consideration should be made to postpone travel to infected area
• Personal protective measures:

-Permethrin considered safe
-Deet considered safe

Malaria in Pregnancy

Medication safety:
- Chloroquine considered safe
- Mefloquine considered safe (officially
-preferable after first TM due to risk of fever)
- Doxycycline contraindicated
- Atovaquone/Proguanil has no studies in pregnancy, not recommended
- Primaquine contraindicated

NOTE: Antimalarials may decrease folic acid stores, therefore dosage of folic acid should be increased to 2 mg/day while taking antimalarials in pregnancy or pre conception.

Pregnancy & Travel

Travelers Diarrhea:
-vigilance with dietary precautions
-TD can lead to dehydration leading to
-decreased placental blood flow
-severe TD can induce labor
-well cooked meat and pasteurized
-dairy only
-avoid prolonged use of iodine for water
-purification (can lead to congenital goiter)

Pregnancy & Travel
Treatment of TD:
-oral rehydration, loperimide when necessary
-peptobismol is contraindicated

Antimicrobials:
-Azithromycin
-3 rd generation cephalosporin
-Ciprofloxacin single dose probably okay
-Flagyl is safe for treatment of giardia after first TM

Pregnancy & Travel
Air Travel:
-Regulations differ with airline, generally domestic travel restricted after 36 weeks, and international travel after 32 weeks
-Increased risk of phlebitis
-Relative contraindications: severe anemia, sickle cell disease/trait, history of thrombophlebitis, placental problems

Pregnancy & Travel
Altitude:
-No good studies looking at safety of high altitude travel and pregnancy
-Generally considered safe up to 12,000 ft
-Conflicting evidence on the safety of diamox in pregnancy

Diving:
-Not a good idea
-Definitely not below 32 ft
-High risk of decompression syndrome in mother and fetus

Pregnancy & Travel
Additions to the travel kit…
-prenatal vitamins
-BP cuff
-urine dipstick
-thermometer

In Conclusion…

Have fun, be safe………and explore!!