Overview 

Traveller’s diarrhoea (TD) is a widespread digestive issue. It can affect both short-term and long-term travellers, and there is generally no immunity against future occurrences. This condition is more prevalent in warmer climates, particularly in areas with poor sanitation and inadequate refrigeration. Additionally, the lack of safe drinking water and improper food preparation practices significantly increase the risk. In regions where food handling education is provided, the rates of traveller’s diarrhoea tend to be lower. Given the physiological shifts to a woman's immune system during pregnancy, these women remain at increased risk of infection.

Diarrhoea can lead to dehydration, which can create even more serious health challenges. Pregnant women who experience travellers' diarrhoea may be more susceptible to dehydration than non-pregnant travellers. The severity of dehydration and malnutrition due to diarrhoea is detrimental to both mother and child.¹

Causes and risk factors

The primary cause of traveller's diarrhoea is mainly the consumption of contaminated food or drinks, which leads to infections from pathogens.⁴ The most common causes include:

Bacterial infections

• Enterotoxigenic E. coli (ETEC) is the primary reason for traveller’s diarrhoea
• Salmonella can lead to severe gastrointestinal and systemic infections
• Shigella causes dysentery with bloody diarrhoea
• Campylobacter jejuni can lead to severe diarrhoea with abdominal pain

Viral infections

• Norovirus easily spreads and is rampant in cruise ships and other hotels
• Rotavirus is a leading cause of diarrhoea in the world, especially among children

Parasitic infections

• Giardia lamblia brings about chronic diarrhoea and a lack of nutrient absorption
• Entamoeba histolytica, the primary cause of amebiasis, causes severe dysentery
• Cryptosporidium spp is responsible for chronic diarrhoea in immunocompromised hosts

Pregnant women carry additional challenges and risk factors such as:

• Infection due to altered immune function
• Increased risk of sensitivity to dehydration
• Hormonal fluctuations cause changes in gastrointestinal motility
• Limited access to medical care while travelling or being in remote areas

Symptoms of traveller’s diarrhoea

During pregnancy, women tend to experience traveller’s diarrhoea symptoms due to a variety of factors. Many of these factors can be concerning because they have the risk of complications.

They include: 

• Increased frequency of loose watery stools (3 to more times a day)
• Abdominal cramping with bloating
• Nausea with vomiting
• Fever
• Dehydration resulting in dizziness and less urine

In extreme conditions, excretion of blood or mucus through the stool. 

Potential complications while pregnant: Mother and child care are essential during pregnancy. Traveller's diarrhoea can cause issues to the child's health or development. Some of these complications are: Severe dehydration can cause an imbalance of electrolytes, low levels of Amniotic fluid, and an increase towards premature labor. 

Malnutrition.

Complicated diarrhoea that lasts for an extended period can reduce the capability to absorb nutrients and cause a lack of important vitamins and minerals that are crucial for the growth of the fetus.

Management and treatment

The focus for treatment of traveller's diarrhoea for expectant mothers is based on rehydrating, eating appropriate foods, and using medication when needed.⁵

Rehydration therapy

Oral Rehydration Solution (ORS): The World Health Organisation (WHO) recommends ORS for effectively restoring lost fluids and electrolytes. 

Increased Fluid Intake: Consuming fruit juices, coconut water, and clean water can be beneficial.

IV Fluids: In severe cases of dehydration, intravenous fluids may be necessary.

Emergency Rehydration Solution: If commercial products are unavailable, you can create your rehydrating solution by mixing:

• 3/4 teaspoon of table salt
• 2 tablespoons of sugar
• 1 quart of uncontaminated bottled or boiled water

You may also add a sugar-free flavour powder, such as Crystal Light, if desired.

Dietary recommendations

BRAT Diet (Bananas, Rice, Applesauce, Toast): Preventing aggravation to the stomach from the use of a diet soothes the stomach.

Avoid Dairy and Fatty Foods: These foods can worsen the issue of diarrhoea.

Safe medications during pregnancy 

• Antibiotics: The following are the safest choices during pregnancy if a bacterial infection appears to be present:
• Azithromycin (Preferred choice)
• Amoxicillin or Cephalosporins (only in selected bacterial infections)
• Metronidazole (for parasitic infections when needed) 
• Antimotility Agents: These medicines, which include loperamide and drugs containing diphenoxylate, provide prompt but temporary relief by:

• Reducing muscle spasms in your gastrointestinal tract
• Slowing the transit time through your digestive system
• Allowing more time for absorption
• In acute and severe cases, Loperamide may be utilised, but it should not be used in cases of suspected bacterial dysentery

Prevention strategies:

As avoidance is better than a cure, especially when dealing with a sensitive case of traveller's diarrhoea in pregnant women, the following are some of the notable precautions:

Food and water safety

• Only drink bottled or purified water.
• Do not use ice cubes unless they are made from safe water.
• Avoid eating street food and instead, consume only well-cooked food.
• Peel or wash fruits and vegetables with clean water before consuming them.

Hand hygiene

Wash your hands often. Use bottled water and soap. Wash your hands before you eat or prepare food. Also, wash your hands after you use the bathroom. When you do not have access to soap, use alcohol-based hand sanitisers.

Vaccinations

Consider the cholera vaccine (Dukoral) as it provides ETEC and partial protection for high-risk travel.

Prophylactic measures

Probiotic³ supplements can help lessen the risk of infection.

Some of the most frequently studied and recommended probiotics include:

The Lactobacillus genus, including L. acidophilus, L. rhamnosus, L. casei and L. plantarum.

The Bifidobacterium genus includes Bifidobacterium longum and Bifidobacterium breve.

Pepto-Bismol should not be used during pregnancy due to possible dangers to the fetus.

Staying hydrated and resting

Staying hydrated and getting plenty of rest may help your body fight infections naturally. 

FAQ’s

Is traveller’s diarrhoea dangerous during pregnancy?

In the majority of cases, the condition is mild and self-resolving, but in some instances, diarrhoea may precipitate severe dehydration that can affect both mother and baby in some cases. Excessive dehydration can trigger premature labor and various electrolyte imbalances as well as additional complications.

Can traveller’s diarrhoea harm the baby?

Traveller's diarrhoea usually poses no significant danger when mild. Severe dehydration can disrupt placental blood flow, which reduces the delivery of oxygen and nutrients to the baby. Medical assistance should be obtained if symptoms persist or intensify.

How can pregnant women prevent travellers’ diarrhoea?

• Consume only bottled, boiled, or purified water 
•  Refrain from drinking beverages with ice unless they're from purified water 
• Opt for thoroughly cooked meals and steer clear of raw or undercooked meats and seafood
• Wash your hands regularly with soap and water
• Avoid eating food from street vendors as well as products sold by them

When should a pregnant woman seek medical help?

• For more than 48 hours, persistent diarrhoea 
• If there is any amount of blood present in the stool 
• If feeling extreme dehydration (too thirsty, feeling dizzy and having a dark colored urine) 
• If there is a significantly high temperature (> 101 Fahrenheit or 38.3 centigrade) 

How is traveller's diarrhoea diagnosed and treated?

Your healthcare provider will conduct an examination. If your symptoms persist for more than two weeks, a sample of your stool may be collected for testing to identify the germ causing your diarrhoea. A blood test may also be performed to check for the germ. Depending on the results, you might require medication to treat an infection caused by bacteria or a parasite. Additionally, you may need medication to help slow down or stop the diarrhoea.

Summary

When managing traveller's diarrhoea in pregnant women, it is essential to take careful precautions to avoid serious consequences such as dehydration, malnutrition, and other health issues that could impact the pregnancy. Critical considerations are about maintaining food and water sanitation standards, practising good hygiene habits, using medications responsibly and seeking professional medical advice when needed. Expectant mothers need to discuss travel plans with their doctor and establish a plan to handle diarrhoea before their trip. Travelling with young children presents particular difficulties during such incidents, yet implementing these strategies reduces travellers' diarrhoea risks. Following this procedure enables mothers and their children to experience a secure and pleasurable vacation.