Travel medicine and pregnancy Dr Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FACRRM Deputy Director and Associate Professor Anton Breinl Centre for Public

Travel medicine andTravel medicine andpregnancypregnancy

Dr Peter A. LeggatDr Peter A. LeggatMD, PhD, DrPH, FAFPHM, FACTM, FACRRMMD, PhD, DrPH, FAFPHM, FACTM, FACRRM

Deputy Director and Associate ProfessorDeputy Director and Associate Professor

Anton Breinl Centre for Public Health and Tropical MedicineAnton Breinl Centre for Public Health and Tropical Medicine

James Cook University, AustraliaJames Cook University, Australia

About the authorAbout the author

Dr Peter Leggat has co-ordinated the Australian Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel medicine since postgraduate course in travel medicine since 1993. He has also been on the faculty of the 1993. He has also been on the faculty of the South African travel medicine course, South African travel medicine course, conducted since 2000, and the Worldwise New conducted since 2000, and the Worldwise New Zealand Travel Health update programs since Zealand Travel Health update programs since 1998. Dr Leggat has assisted in the 1998. Dr Leggat has assisted in the development of travel medicine programs in development of travel medicine programs in several countries and also the Certificate of several countries and also the Certificate of Knowledge examination for the International Knowledge examination for the International Society of Travel Medicine.Society of Travel Medicine.

ObjectivesObjectives

In this sessionIn this session Examine travel medicine and briefly list some Examine travel medicine and briefly list some

of components that are needed in order to of components that are needed in order to give correct health advice in the context of the give correct health advice in the context of the pregnant travelerpregnant traveler

Focus on some of the important issues in Focus on some of the important issues in travel medicine and pregnancytravel medicine and pregnancy

Air travelAir travelTravel insuranceTravel insuranceMalariaMalariaImmunizationsImmunizations

The Continuum of Travel MedicineThe Continuum of Travel Medicine

During TravelDuring Travel

Preventive Medicine

Contingency Planning

Treatment & Rehabilitation

VisitorsVisitors

Post-TravelPost-Travel

Pre-TravelPre-Travel

(Leggat et al., 2005)

General Approach to the General Approach to the TravellerTraveller

Risk assessment, Risk assessment, determining the risks of the determining the risks of the destination, mode of travel destination, mode of travel and the special conditions and the special conditions of the travelerof the traveler Vaccinate when possible Vaccinate when possible and indicated; and indicated; Provide the traveler with Provide the traveler with appropriate empirical self-appropriate empirical self-treatmenttreatmentConsider chemoprophylaxisConsider chemoprophylaxis

Consider any concerns Consider any concerns regarding underlying regarding underlying conditions and possible conditions and possible drug interactionsdrug interactionsConsult experts in travel Consult experts in travel medicine or specialty medicine or specialty areas as necessaryareas as necessaryEducate the traveler Educate the traveler Remind the traveler that Remind the traveler that these precautions are not these precautions are not 100% protective100% protective

(Ericsson, 2003)(Ericsson, 2003)

What do we advise pregnant What do we advise pregnant travelers?travelers?

Travel medicine and PregnancyTravel medicine and Pregnancy

Mezger N et al. Travelling when pregnant. Rev Med Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: 1263-1266. (in French)Suisse. 2005; 11: 1263-1266. (in French) Travel during the 2nd trimesterTravel during the 2nd trimester Favor comfortable type of travel, without long air or Favor comfortable type of travel, without long air or

road transportationroad transportation Avoid traveling if at risk pregnancyAvoid traveling if at risk pregnancy Check for adequate insurance coverageCheck for adequate insurance coverage Choose destination where good health services existChoose destination where good health services exist Avoid region of high malaria endemicityAvoid region of high malaria endemicity For any vaccination or medication risks and benefits For any vaccination or medication risks and benefits

should be carefully weighed, pregnant women are should be carefully weighed, pregnant women are more vulnerable and at higher risk of complications more vulnerable and at higher risk of complications

When is the best time When is the best time to travel during pregnancy?to travel during pregnancy?

Air travel during pregnancyAir travel during pregnancy

ACOG committee opinion. Air travel during pregnancy. ACOG committee opinion. Air travel during pregnancy. Int Int J Gyn Obst 2002;76:338-339.J Gyn Obst 2002;76:338-339. ““In the absence of obstetric or medical In the absence of obstetric or medical

complications, pregnant women can observe complications, pregnant women can observe the same general precautions for air travel the same general precautions for air travel as the general population and can fly safely as the general population and can fly safely up to 36 weeks of gestation.”up to 36 weeks of gestation.”

““Safest time is during the second trimester” Safest time is during the second trimester” (18-24 weeks)(18-24 weeks)


AsMA. Medical Guidelines for airline travel. 2AsMA. Medical Guidelines for airline travel. 2ndnd Ed. 2003. http://www.asma.orgEd. 2003. http://www.asma.org ““Pregnant women can normally travel Pregnant women can normally travel

safely by air, however most airlines restrict safely by air, however most airlines restrict travel in late pregnancy”travel in late pregnancy”

After 28After 28thth week, doctor’s/midwife’s letter week, doctor’s/midwife’s letter confirming EDDconfirming EDD Single pregnancies-flying permitted to end Single pregnancies-flying permitted to end

3636thth weeks weeks Multiple pregnancies-flying permitted to Multiple pregnancies-flying permitted to

end of the 32end of the 32ndnd week week

What do airlines actually What do airlines actually recommend?recommend?

Some clues given in “Air-Some clues given in “Air-born” studyborn” study

Air travel during pregnancyAir travel during pregnancyBreathnach F et al. Air travel in pregnancy: the 'air-born' study. Breathnach F et al. Air travel in pregnancy: the 'air-born' study. Ir Med J. 2004; 97: 167-168. (25% response)Ir Med J. 2004; 97: 167-168. (25% response) Three of seventeen (17.5%) airlines applied no Three of seventeen (17.5%) airlines applied no

restrictions at all to pregnant passengers; the restrictions at all to pregnant passengers; the remainder applied restrictions to air travel with remainder applied restrictions to air travel with varying gestations (28 to 36 weeks). varying gestations (28 to 36 weeks).

A full delivery kit was carried by 5/17 airlines A full delivery kit was carried by 5/17 airlines (29%), and some form of training in the (29%), and some form of training in the management of a delivery was provided to the management of a delivery was provided to the cabin crew in 12/17 airlines (70%). cabin crew in 12/17 airlines (70%).

Experience of in-flight obstetric emergencies Experience of in-flight obstetric emergencies was reported by 11/17 airlines (65%). was reported by 11/17 airlines (65%).


ACOG (2002) gives further adviceACOG (2002) gives further advice In-craft environmental conditions, such as low In-craft environmental conditions, such as low

cabin humidity and changes in cabin pressure, cabin humidity and changes in cabin pressure, coupled with the physiologic changes of coupled with the physiologic changes of pregnancy, do result in maternal adaptations, pregnancy, do result in maternal adaptations, which could have transient effects on the fetus. which could have transient effects on the fetus.

Pregnant air travelers with medical problems that Pregnant air travelers with medical problems that may be exacerbated by a hypoxic environment, but may be exacerbated by a hypoxic environment, but who must travel by air, should be prescribed who must travel by air, should be prescribed supplemental oxygen during air travel. supplemental oxygen during air travel.

Pregnant women at significant risk for pre-term Pregnant women at significant risk for pre-term labor or with placental abnormalities should avoid labor or with placental abnormalities should avoid air travel. air travel.


ACOG, 2002ACOG, 2002 Because air turbulence cannot be predicted and the Because air turbulence cannot be predicted and the

risk for trauma is significant, pregnant women risk for trauma is significant, pregnant women should be instructed to continuously use their seat should be instructed to continuously use their seat belts while seated, as should all air travelers. belts while seated, as should all air travelers.

Pregnant air travelers may take precautions to ease Pregnant air travelers may take precautions to ease in-flight discomfort, and although no hard evidence in-flight discomfort, and although no hard evidence exists, preventive measures can be employed to exists, preventive measures can be employed to minimize risks. minimize risks.

Anderson (2001) describes a possible riskAnderson (2001) describes a possible risk Pregnancy predisposes to a risk of superficial and Pregnancy predisposes to a risk of superficial and

deep venous thrombosis due to alterations in deep venous thrombosis due to alterations in clotting factors and pressure of expanding uterus.clotting factors and pressure of expanding uterus.


Freeman M et al. Does air travel affect pregnancy Freeman M et al. Does air travel affect pregnancy outcome? Arch Gynecol Obstet 2004;269:274-277. outcome? Arch Gynecol Obstet 2004;269:274-277. (small cohort study 222 pregnant women)(small cohort study 222 pregnant women)

Findings suggest that air travel is not Findings suggest that air travel is not associated with increased risk of associated with increased risk of complications for pregnancies that complications for pregnancies that reach 20 weeks' gestation. reach 20 weeks' gestation.

But there are some relative But there are some relative contraindications to travelcontraindications to travel

Air travel during PregnancyAir travel during Pregnancy

Anderson (2001) citing CDC Anderson (2001) citing CDC summarizes relative contraindications summarizes relative contraindications for travel during pregnancyfor travel during pregnancy Medical risk factorsMedical risk factors Obstetric risk factorsObstetric risk factors Travel to destination that may be Travel to destination that may be

hazardoushazardous

Pregnancy and insurancePregnancy and insurance

Travel insurance is an important safety net Travel insurance is an important safety net for travelersfor travelers Covers emergency medical and dental care Covers emergency medical and dental care

abroad (may also underwrite the treatment)abroad (may also underwrite the treatment) Provides emergency assistance hotline or Provides emergency assistance hotline or

telephone numbertelephone number Usually can arrange for aeromedical Usually can arrange for aeromedical

evacuation where requiredevacuation where requiredLeggat et al., 1999Leggat et al., 1999

What do we know about What do we know about pregnancy and travel pregnancy and travel insurance?insurance?


Kingman CE et al. Travel in pregnancy:pregnant women's Kingman CE et al. Travel in pregnancy:pregnant women's experiences and knowledge of health issues. experiences and knowledge of health issues. J Travel Med J Travel Med 2003; 10: 330-3332003; 10: 330-333. (138 pregnant women). (138 pregnant women) Long-distance travel is common in Long-distance travel is common in

pregnancy, and women are not always pregnancy, and women are not always adequately prepared in terms of adequately prepared in terms of insurance and travel advice insurance and travel advice

Half had traveled abroad in this pregnancyHalf had traveled abroad in this pregnancy> 1/3 of the women traveled without > 1/3 of the women traveled without sufficient insurancesufficient insuranceOnly 1/3 sought advice prior to travel Only 1/3 sought advice prior to travel


Carroll D et al. The pregnant wilderness traveller. Travel Carroll D et al. The pregnant wilderness traveller. Travel Med Inf Dis (in press)Med Inf Dis (in press) ““Many travel insurance policies specifically Many travel insurance policies specifically

exclude pregnancy”. exclude pregnancy”. ““Finding coverage is usually expensive.”Finding coverage is usually expensive.”

Jothivijayarani A. Travel considerations during pregnancy. Jothivijayarani A. Travel considerations during pregnancy. Prim Care Update Ob/Gyns 2002; 9: 36-40.Prim Care Update Ob/Gyns 2002; 9: 36-40. ““Many insurance plans do not cover Many insurance plans do not cover

pregnant women overseas and many plans pregnant women overseas and many plans have gestational cutoff dates for travel, have gestational cutoff dates for travel, beyond which they will not cover delivery out beyond which they will not cover delivery out of the area”.of the area”.


Leggat PA et al. Emergency assistance provided abroad Leggat PA et al. Emergency assistance provided abroad to insured travellers from Australia. to insured travellers from Australia. Travel Med Inf Dis.Travel Med Inf Dis.

2005;3:9-17 (>2000 claims)2005;3:9-17 (>2000 claims) 2.8 % of travel insurance claims 2.8 % of travel insurance claims

involving provision of emergency involving provision of emergency assistance were for obstetric assistance were for obstetric problemsproblems

What do we advise regarding What do we advise regarding insurance?insurance?

Take out travel insurance (that covers Take out travel insurance (that covers pregnancy if possible)pregnancy if possible)

Regardless of insurance coverage, it is Regardless of insurance coverage, it is always best to check in advance always best to check in advance regarding obstetrical care at the regarding obstetrical care at the destination or medical evacuation destination or medical evacuation should it become necessary.should it become necessary.

Carroll et al. op citCarroll et al. op cit


Take records Take records (Carroll et al. op cit)(Carroll et al. op cit) Documentation concerning EDD and normality of Documentation concerning EDD and normality of

pregnancypregnancy Copy of perinatal recordCopy of perinatal record Other documentation as needed for travelOther documentation as needed for travel

Know warning signs Know warning signs (Anderson, 2001)(Anderson, 2001) Bleeding, passing tissues or clotsBleeding, passing tissues or clots Abdominal pain or crampsAbdominal pain or cramps Rupture of membranesRupture of membranes Headache or visual changesHeadache or visual changes

Pregnancy and travel kitPregnancy and travel kit

Carroll et al (in press) op citCarroll et al (in press) op cit

Take a traveler’s medical kit to Take a traveler’s medical kit to manage common conditionsmanage common conditions

Pregnancy and antimicrobials*Pregnancy and antimicrobials*

RecommendedRecommended PenicillinsPenicillins AminoglycosidesAminoglycosides CephalosporinsCephalosporins MacolidesMacolides AntifungalsAntifungals MetronidazoleMetronidazole Praziquantel and other Praziquantel and other

antiparasitics are antiparasitics are probably safeprobably safe

Not recommendedNot recommended KanamycinKanamycin StreptomycinStreptomycin TetracyclinesTetracyclines GriseofulvinGriseofulvin Quinolones (?safely)Quinolones (?safely)

WHO, 2005 op cit

*antimalarials to be discussed separately

Pregnancy and insurance: Pregnancy and insurance: Last word-contingency plansLast word-contingency plans

There are several agencies that may offer There are several agencies that may offer emergency assistance/assist with emergency assistance/assist with evacuation of pregnant women traveling evacuation of pregnant women traveling abroad (examples)abroad (examples) IAMAT (IAMAT (http://www.iamat.orghttp://www.iamat.org)) ISTM (ISTM (http://www.istm.orghttp://www.istm.org) ) International SOSInternational SOS

WWW resourcesWWW resources http://www.obgyn.net/country/country.asphttp://www.obgyn.net/country/country.asp

provides country specific informationprovides country specific informationJothivijayarani, 2002 Op CitJothivijayarani, 2002 Op Cit

Pregnancy and malariaPregnancy and malaria

WHO. International Travel and Health. WHO. International Travel and Health. Geneva: WHO, 2005.Geneva: WHO, 2005.

““Travel to malaria-endemic Travel to malaria-endemic areas should be avoided areas should be avoided during pregnancy, if at all during pregnancy, if at all possible”possible”

“…“…or intend to get or intend to get pregnant”pregnant” (McGready et al, (McGready et al, 2004)2004)

Why?Why?


WHO. International Travel and Health. Geneva: WHO. International Travel and Health. Geneva: WHO, 2005.WHO, 2005.

Malaria increases risk of Malaria increases risk of maternal death, maternal death,

miscarriage, miscarriage,

stillbirth, and stillbirth, and

low birth weight with associated low birth weight with associated risk of neonatal deathrisk of neonatal death


WHO. International Travel and Health. Geneva: WHO. International Travel and Health. Geneva: WHO, 2005.WHO, 2005. ““Pregnant women with falciparum Pregnant women with falciparum

malariamalariaMay rapidly develop any of the clinical May rapidly develop any of the clinical symptoms of severe malariasymptoms of severe malariaAre particularly susceptible to Are particularly susceptible to hypoglycemia and pulmonary edemahypoglycemia and pulmonary edemaMay develop postpartum hemorrhage May develop postpartum hemorrhage and hyperpyrexia leading to fetal and hyperpyrexia leading to fetal distress”distress”


WHO. International Travel and Health. Geneva: WHO. International Travel and Health. Geneva: WHO, 2005.WHO, 2005.

Therefore, in relation to travelers, Therefore, in relation to travelers, WHO recommends WHO recommends “Any pregnant woman with “Any pregnant woman with severe falciparum malaria should severe falciparum malaria should be transferred to intensive care”be transferred to intensive care”

What do we advise if a What do we advise if a pregnant traveler must go to pregnant traveler must go to

a malarious area?a malarious area?


Personal Protective MeasuresPersonal Protective Measures AvoidanceAvoidance ClothingClothing InsecticidesInsecticides

DEETDEET


McGready R et al. Safety of insect repellent N,N-diethyl-M-McGready R et al. Safety of insect repellent N,N-diethyl-M-toluamide (DEET) in pregnancy. Am J Trop Med Hyg 2001; toluamide (DEET) in pregnancy. Am J Trop Med Hyg 2001; 65: 285-289. (20% solution of DEET applied by women 65: 285-289. (20% solution of DEET applied by women during 2during 2ndnd and 3 and 3rdrd trimester) trimester) Well accepted and no adverse effects in Well accepted and no adverse effects in

womenwomen No increase in LBW, prematurity or congenital No increase in LBW, prematurity or congenital

abnormalityabnormality DEET does cross placenta (8% of cord DEET does cross placenta (8% of cord

samples), although blood levels lowsamples), although blood levels low More information needed on safety of DEET in More information needed on safety of DEET in

11stst trimester trimester


McGready R et al. Malaria and the pregnant McGready R et al. Malaria and the pregnant traveller. Travel Med Inf Dis 2004;2:127-142.traveller. Travel Med Inf Dis 2004;2:127-142. ““Chemoprophylactic and treatment Chemoprophylactic and treatment

options for pregnant women (or those options for pregnant women (or those planning to conceive) are extremely planning to conceive) are extremely limited and lag behind what can limited and lag behind what can currently be offered to non-pregnant currently be offered to non-pregnant travellers”travellers”

ChemoprophylaxisRecommended options

for chloroquine resistant areas

Mefloquine250mg weekly

2nd/3rd trimester

Malarone250mg/100mg daily

(from 2000)

Doxycycline100mg daily

PregnancyPregnancy and malaria and malaria

Alternatives include:Alternatives include:− chloroquine 300mg weekly + proguanil 200mg dailychloroquine 300mg weekly + proguanil 200mg daily

− Sulfadoxine-PyrimethamineSulfadoxine-Pyrimethamine

The flip side….The flip side…. What if the woman is What if the woman is wanting to become wanting to become pregnant?pregnant?

Pregnancy and malariaPregnancy and malariaDrugDrug Half-lifeHalf-life Time to wait Time to wait

before conceivingbefore conceiving

MefloquineMefloquine 14-21 days14-21 days 3 months3 months

Doxycycline /Doxycycline /

tetracyclinetetracycline

12-24 hours12-24 hours 1 week1 week

Malarone /Malarone /

AtovaquoneAtovaquone

2-3 days2-3 days 2 weeks2 weeks

ProguanilProguanil 14-21 hours14-21 hours 1 week1 week

McGready et al., 2004. Op Cit; WHO, 2005 Op Cit

What if the pregnant woman What if the pregnant woman gets “malaria”?gets “malaria”?

WHO (2005)WHO (2005) Take standby drugTake standby drug Seek medical attention as soon as Seek medical attention as soon as

possiblepossible

Pregnancy and malaria treatmentPregnancy and malaria treatment

RecommendedRecommended ChloroquineChloroquine Chloroquine plus proguanilChloroquine plus proguanil Mefloquine (2Mefloquine (2ndnd and 3 and 3rdrd

trimester)trimester) ArtemisininArtemisinin Clindamycin (limited data)Clindamycin (limited data) QuinineQuinine Sulfadoxine-pyrimethamineSulfadoxine-pyrimethamine

Non-recommendedNon-recommended DoxycyclineDoxycycline TetracyclineTetracycline Artemether/lumfantrine Artemether/lumfantrine

(Coartem)(Coartem) Atovaquone plus Atovaquone plus

proguanil (Malarone)proguanil (Malarone) PrimaquinePrimaquine TafenoquineTafenoquine

WHO, 2005. Op Cit

Pregnancy and malaria treatmentPregnancy and malaria treatmentWHO. International Travel and Health. Geneva: WHO, 2005.WHO. International Travel and Health. Geneva: WHO, 2005. ““Because of the risk of quinine induced Because of the risk of quinine induced

hyperinsulinemia and hypogycemia, artesunate hyperinsulinemia and hypogycemia, artesunate and artemether are the drugs of choice for and artemether are the drugs of choice for treatment of severe malaria in the 2treatment of severe malaria in the 2ndnd and 3 and 3rdrd trimester. trimester.

Data on the use of artemisinin derivatives in the Data on the use of artemisinin derivatives in the 11stst trimester are limited. trimester are limited.

However, neither quinine nor artemisinin However, neither quinine nor artemisinin derivatives should be withheld in any trimester derivatives should be withheld in any trimester if they are considered life saving for the if they are considered life saving for the mother.”mother.”

What about vaccination during What about vaccination during pregnancy?pregnancy?

““Pregnancy should not deter a Pregnancy should not deter a women from receiving vaccines women from receiving vaccines that are safe and will protect her that are safe and will protect her

health and that of her child.”health and that of her child.”

WHO, 2005 op cit

Pregnancy and vaccinationPregnancy and vaccination

WHO. International Travel and Health. Geneva: WHO. International Travel and Health. Geneva: WHO, 2005.WHO, 2005. Killed or inactivated vaccines, toxoids and Killed or inactivated vaccines, toxoids and

polysaccharides can generally be given during polysaccharides can generally be given during pregnancy, as can oral polio vaccinepregnancy, as can oral polio vaccine

Live vaccines are generally contraindicated Live vaccines are generally contraindicated because of largely theoretical risks to the babybecause of largely theoretical risks to the baby

However risk and benefits need to be examined in some However risk and benefits need to be examined in some individual casesindividual casesYellow fever vaccination may be considered after the 6Yellow fever vaccination may be considered after the 6 thth month of pregnancy, when the risk of exposure is deemed month of pregnancy, when the risk of exposure is deemed greater than the risk to the fetusgreater than the risk to the fetusPregnant women should be advised not to travel to areas Pregnant women should be advised not to travel to areas where there is a risk of exposure to yellow feverwhere there is a risk of exposure to yellow fever

Pregnancy and vaccinationPregnancy and vaccination

WHO, 2005.

Op Cit

In brief, examples of other In brief, examples of other conditions of concernconditions of concern

Anderson, 2001Anderson, 2001 MVA are a common cause of trauma and death MVA are a common cause of trauma and death

for all travelers for all travelers ““Hepatitis E virus acquired during pregnancy Hepatitis E virus acquired during pregnancy

has a particularly high case fatality rate (15-has a particularly high case fatality rate (15-30%). Transmission of the virus occurs through 30%). Transmission of the virus occurs through fecal-oral exposure.”fecal-oral exposure.”

WHO, 2005WHO, 2005 In infection with American trypanosomiasis, In infection with American trypanosomiasis,

“congenital infection is possible, due to “congenital infection is possible, due to parasites crossing the placenta during parasites crossing the placenta during pregnancy.”pregnancy.”

Travel medicine and PregnancyTravel medicine and Pregnancy

Mezger N et al. Travelling when pregnant. Rev Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: 1263-1266. (in French)Med Suisse. 2005; 11: 1263-1266. (in French) Travel during the 2nd trimesterTravel during the 2nd trimester Favor comfortable type of travel, without long air or Favor comfortable type of travel, without long air or

road transportationroad transportation Avoid traveling if at risk pregnancyAvoid traveling if at risk pregnancy Check for adequate insurance coverageCheck for adequate insurance coverage Choose destination where good health services existChoose destination where good health services exist Avoid region of high malaria endemicityAvoid region of high malaria endemicity For any vaccination or medication risks and benefits For any vaccination or medication risks and benefits

should be carefully weighed, pregnant women are should be carefully weighed, pregnant women are more vulnerable and at higher risk of complications more vulnerable and at higher risk of complications

Further ReadingFurther Reading

Anderson S. Women’s health and travel. In. Anderson S. Women’s health and travel. In. Zuckerman JN. Zuckerman JN. Principles and Practice of Travel Principles and Practice of Travel MedicineMedicine. John Wiley and Sons Ltd, 2001: 381-. John Wiley and Sons Ltd, 2001: 381-422.422.

World Health Organization. World Health Organization. International Travel International Travel and Healthand Health. Geneva: WHO, 2005. URL: . Geneva: WHO, 2005. URL: http://www.who.int/ith http://www.who.int/ith

Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Health Information for International Travel. URL: Health Information for International Travel. URL: http://www.cdc.gov/travelhttp://www.cdc.gov/travel

ReferencesReferencesACOG committee opinion. Air travel during pregnancy. ACOG committee opinion. Air travel during pregnancy. Int J Gynaecol Obstet 2002 76: 338-339.Int J Gynaecol Obstet 2002 76: 338-339. AsMA. Medical Guidelines for airline travel. 2AsMA. Medical Guidelines for airline travel. 2ndnd Ed. 2003. http://www.asma.org Ed. 2003. http://www.asma.orgAnderson S. Women’s health and travel. In. Zuckerman JN. Principles and Practice of Travel Medicine. John Wiley and Anderson S. Women’s health and travel. In. Zuckerman JN. Principles and Practice of Travel Medicine. John Wiley and Sons Ltd, 2001: 381-422. Sons Ltd, 2001: 381-422. Breathnach F, Geoghegan T, Daly S, Turner MJ. Air travel in pregnancy: the 'air-born' study. Ir Med J. 2004; 97: 167-Breathnach F, Geoghegan T, Daly S, Turner MJ. Air travel in pregnancy: the 'air-born' study. Ir Med J. 2004; 97: 167-168. 168. Carroll D, Van Gompel. The pregnant wilderness traveller. Travel Medicine and Infectious Disease. (in press)Carroll D, Van Gompel. The pregnant wilderness traveller. Travel Medicine and Infectious Disease. (in press)Ericsson CD. Travellers with pre-existing medical conditions. Int J Antimicrob Agents. 2003; 21: 181-188.Ericsson CD. Travellers with pre-existing medical conditions. Int J Antimicrob Agents. 2003; 21: 181-188.Freeman M, Ghidini A, Spong CY, Tchabo N, Bannon PZ, Pezzullo JC. Does air travel affect pregnancy outcome? Arch Freeman M, Ghidini A, Spong CY, Tchabo N, Bannon PZ, Pezzullo JC. Does air travel affect pregnancy outcome? Arch Gynecol Obstet 2004;269:274-277.Gynecol Obstet 2004;269:274-277.Jothivijayarani A. Travel considerations during pregnancy. Primary Care Update Obstetrics and Gynecology. 2002; 9: Jothivijayarani A. Travel considerations during pregnancy. Primary Care Update Obstetrics and Gynecology. 2002; 9: 36-40.36-40.Kingman CE, Economides DL. Travel in pregnancy:pregnant women's experiences and knowledge of health issues. Kingman CE, Economides DL. Travel in pregnancy:pregnant women's experiences and knowledge of health issues. J J Travel Med 2003; 10: 330-333Travel Med 2003; 10: 330-333. . Leggat PA, Carne J, Kedjarune U. Travel insurance and health. J Travel Med 1999; 6: 243-248.Leggat PA, Carne J, Kedjarune U. Travel insurance and health. J Travel Med 1999; 6: 243-248. Leggat PA, Ross MH, Goldsmid JM. Introduction to travel medicine. In: Leggat PA, Goldsmid JM, editors. Primer of Leggat PA, Ross MH, Goldsmid JM. Introduction to travel medicine. In: Leggat PA, Goldsmid JM, editors. Primer of travel medicine, 3rd ed. rev. Brisbane: ACTM Publications; 2005: 3-21.travel medicine, 3rd ed. rev. Brisbane: ACTM Publications; 2005: 3-21.Leggat PA, Griffiths R, Leggat FW. Emergency assistance provided abroad to insured travellers from Australia. Leggat PA, Griffiths R, Leggat FW. Emergency assistance provided abroad to insured travellers from Australia. Travel Travel Medicine and Infectious Disease.Medicine and Infectious Disease. 2005; 3: 9-17. 2005; 3: 9-17. McGready R, Ashley EA, Nosten F. Malaria and the pregnant traveller. Travel Med Inf Dis 2004; 2: 127-142.McGready R, Ashley EA, Nosten F. Malaria and the pregnant traveller. Travel Med Inf Dis 2004; 2: 127-142.McGready R, Hamilton KA, Simpson JA et al. Safety of insect repellent N,N-diethyl-M-toluamide (DEET) in pregnancy. McGready R, Hamilton KA, Simpson JA et al. Safety of insect repellent N,N-diethyl-M-toluamide (DEET) in pregnancy. Am J Trop Med Hyg 2001; 65: 285-289.Am J Trop Med Hyg 2001; 65: 285-289.Mezger N, Chappuis F, Loutan L. Travelling when pregnant. Rev Med Suisse. 2005;11:1263-6.Mezger N, Chappuis F, Loutan L. Travelling when pregnant. Rev Med Suisse. 2005;11:1263-6. Steffen R, DuPont HL. Travel medicine: what’s that? J Travel Med 1994;1:1-3.Steffen R, DuPont HL. Travel medicine: what’s that? J Travel Med 1994;1:1-3.World Health Organization. International Travel and Health. Geneva: WHO, 2005. URL: http://www.who.int/ith World Health Organization. International Travel and Health. Geneva: WHO, 2005. URL: http://www.who.int/ith

Documents

Travel medicine and pregnancy Dr Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FACRRM Deputy Director and Associate Professor Anton Breinl Centre for Public