Air Travel Answer

Suggested reading.

The NICE guideline guideline on antenatal care as revised in June 2008 deals with:

air travel on pages 101 and 102.

“travelling abroad” on pages 103 – 105.

The bit in between is about car travel and seat belts, which you should read too.

There was an article on air travel in TOG in 2002 which is still sufficiently up-to-date to be necessary reading.

There is another in 2005 on malaria, which you ought to read.

Malaria has not yet featured in the MRCOG essays and is likely to do so one day.

The Department of Health has a short section about travel & pregnancy.

The Foreign Office has information on its website.

The Centers for Disease Control has a good, short section on its website.

There are lots of sites giving advice about immunisation, malaria prophylaxis etc.

Facts you would want to include in your essay.

I would be inclined to imagine:

planning a flight

and going through all the stages

from booking the flight

to settling in at the destination.

This will help you to remember everything.

Risk and air travel usually deal with “long-haul” flights.

I don’t think there is universal agreement about what constitutes “long-haul”.

Some say > 3 hours, others > 4 hours.

Should the journey be made at all?

The Foreign Office has advice about places it deems too dangerous to visit.

Most authorities will also advise against travelling to areas where the health risks are high.

E.g. an area with drug-resistant falciparum malaria.

The DOH website mentions the use of mefloquine in pregnancy.

It particularly mentions its use for women who cannot be “dissuaded” from visiting areas with chloroquine-resistant malaria.

See section 15.2 of the website.

You would also need to think about the medical facilities.

If it is a “third-world” country the facilities for obstetrics, neonatal care, blood transfusion etc. may be basic and good grounds for not going.

The CDC website has a nice table of contraindications to travel.

Airline regulations & pregnancy.

Different airlines have different regulations.

Virgin Atlantic has no restrictions for normal pregnancies up to 28 weeks.

It needs a medical certificate from 28 to 34 weeks.

After that you need to bring a doctor or nurse!

British Airways is happy with normal pregnancies up to 28 weeks.

It needs a medical certificate after 28 weeks.

It has an absolute upper limit of 36 weeks, 32 for multiple pregnancy.

She needs to check.

If a seat with extra legroom can be booked, this may help with both comfort and leg exercises.

Health Insurance.

This is vital.

It has to cover pregnancy and neonatal problems.

A baby delivered at 28 weeks might spend months in intensive care and need a re-mortgage to pay for it.

For European Union travel, a "European Health Insurance Card" makes sense.

This replaced the old E111 form in 2006.

It entitles EEC citizens to free or reduced-cost treatment in EU countries.

Immunisations.

There are plenty of sites offering advice: typical example 1, typical example 2.

CDC provides comprehensive information for most possible destinations.

It lists 58 diseases with implications for travellers!

Some you might not think of.

For example, polio, for which immunisation is recommended for most of Africa as well as India and Pakistan .

Live vaccines are to be avoided unless the risks of the disease are thought to outweigh the risks of the vaccine.

CDC gives a detailed list.

See also MCQ12, question 3.

The WHO recommends tetanus toxoid for pregnant women.

It is effective in reducing the risk of maternal and neonatal tetanus.

It is not routine in the UK, as the risk of maternal and neonatal tetanus relates to poor hygiene at the time of delivery

A pregnant woman planning to travel to an underdeveloped country and deliver under such circumstances might have the toxoid.

But it would be better to persuade her to have the baby where facilities are better.

Planning basic hygiene.

Local water supplies may not be potable.

I use “potable” because I like the word and rarely get a chance to use it.

My Oxford English Dictionary just says “drinkable”.

So you may not be able to drink the local water or anything made from it: ice cubes, ice cream etc.

Nor should you use it for preparing food that is not to be cooked, e.g. salad vegetables.

Water can be made safe to drink by boiling or disinfection.

This is dealt with in detail on the CDC website.

Some of the disinfection processes use iodine.

Advice needs to be taken to see if the preparation used is safe in pregnancy.

There are reports of neonatal goitre attributed to excessive maternal iodine intake from treated water.

Dairy produce should be pasteurised

Diarrhoea is common in many tropical countries.

Using electrolyte additives is safe, so long as the added water is OK.

Avoiding insect bites

Disease prophylaxis is mainly about malaria.

But basic advice about avoiding insect bites applies to other diseases like yellow fever.

There are lots of sites providing this kind of advice.

Read the TOG article from 2005 to update on malaria.

Malaria is transmitted by the anopheles mosquito, which mainly bites between dusk and sunrise.

Insect repellents can be used, e.g. DEET.

Both the CDC and the authors of the TOG article say is safe to be applied to the skin in pregnancy.

Picardin is less well-known but in the same category as DEET.

Oil of lemon eucalyptus and oil of citronella are natural products with lovely names, so some will prefer them.

Clothing should cover the maximum skin area: more burkha than bikini.

Clothing can be impregnated with insecticides and insect repellents like permethrin.

Window & door screens can help to keep out mosquitoes.

Bed nets, often impregnated with insecticides, are commonplace.

Various devices exist to release insecticides and zap mosquitoes.

Air conditioning discourages mosquitoes.

Drug prophylaxis.

This is mainly about malaria.

Active prophylaxis means starting drug treatment before setting out and continuing it on return for a month or so.

The drugs recommended vary with region.

The DOH website website states that:

pregnant women are twice as likely as the non-pregnant to get bitten,

and that malaria is more severe in the pregnant.

It recommends the use of chloroquine + proguanil if P. falciparum is sensitive.

And mentions the need for folic acid 5mg. when proguanil is used.

It says that mefloquine can be used in the 2^nd. & 3^rd. trimesters.

Doxycycline is contra-indicated.

Airport security.

The radiation emitted by airport scanners is believed to be safe.

But pregnant women may prefer to have a manual search to avoid any dose of radiation.

Seat belts.

Once you are in your seat, the first thing you do is to fasten your seat belt.

This is dealt with in MCQ7, question 27.

The belt should be worn across the pelvic girdle, not the abdomen.

Venous thrombo-embolism.

There is no data about the risk of long car or bus journeys, but they have similarities to flying in relation to VTE.

NICE quotes estimated incidences of symptomatic VTE after a long-haul flight of between 1 in 400 and 1 in 10,000.

With non-symptomatic VTE being ten times more common.

It says that the incidence of VTE in pregnancy is between 0.13 and 1 per thousand.

And that that an increased risk from air travel in pregnancy is unproven.

It says that the main aetiological factor is immobility and quotes a small study of below-knee compression stockings being effective.

On a recent flight to the USA my wife and I were offered stockings which barely reached our ankles, so I doubt were of any use at all.

NICE mentions all the things you already know:

walking about during the flight,

doing iso-metric leg exercises,

using compression stockings,

avoiding dehydration and drinks with alcohol and caffeine.

The use of low-dose aspirin for low-risk individuals is contentious.

The BMA published a document on the medical aspects of flying in 2004.

It reckoned that 17,000 passengers would need to take aspirin to prevent 1 DVT.

It also worked out that about 1 person in 40 who takes aspirin gets some degree of side-effects.

These are mainly gastric irritation, but some get nasty haemorrhages and ulceration.

What the figures would be for low-dose aspirin is not clear as many of the studies involved higher doses.

Obviously, high-risk individuals need the basic measures + aspirin or low-dose heparin.

They would need the advice of their physician or haematologist.

Radiation.

Cosmic rays.

Sounds like the inspiration for a bad horror movie.

The amounts of radiation are small and not thought to be a significant risk.

Disinsection.

I have not mis-spelled the above!

It means removal of insects.

The WHO requires aircraft cabins to be sprayed with insecticide in certain parts of the world.

There is no evidence that this is harmful.

The insecticide clears within minutes, during which time it probably makes sense to close one’s eyes and not to inhale!

I doubt that the RCOG will include this in any marking system for an essay!

Hypoxia.

Commercial flights do involve a minor degree of hypoxia.

But this is regarded by most authorities as involving no risk to pregnant women or their babies.

Cabins are kept at a pressure equivalent to that experienced at altitudes of 5,000 to 8,000 feet.

Many towns and cities are at equivalent or grater altitudes.

The highest town is Wenzhuan, 16,730 feet above sea level.

The UK can’t boast anything so impressive, with Wanlockhead being the highest, but at a mere 1531 feet.

Fetal heart rate monitoring has been done in healthy women during normal commercial flights and no abnormality detected.