Miscarriage and questions of fitness to fly

MEDICAL MATTERS:THE ISSUE of when it is safe to travel by air when pregnant was brought into sharp focus last week when the authorities planned to deport a Nigerian asylum seeker who had recently suffered a miscarriage.

Olayinka Ijaware, who was eight weeks pregnant when she miscarried, was taken to the Rotunda Hospital from Dublin airport when she complained of vaginal bleeding. She was discharged with a letter stating “the above named patient is unfit for air travel if she is actively bleeding per vagina”, and subsequently returned to Dublin airport when, for reasons that remain unclear, the flight was cancelled.

Would the Garda National Immigration Bureau have been correct if it had gone ahead and flown her back to Nigeria while she actively bled in the weeks following a miscarriage? In general, travel in pregnancy is “low risk”. But the risks do vary with the stage of pregnancy. The second trimester is considered the safest in which to travel.

A doctor assessing the fitness of a pregnant woman to fly will pay specific attention to blood-pressure readings and ultrasound findings. He will look for any acute symptoms or signs, such as vaginal bleeding or abdominal pain.

Whether the woman is at increased risk of premature labour, pre-eclampsia (a potentially dangerous rise in blood pressure) or of having a pre-delivery haemorrhage must also be assessed.

Does the expectant mother have pre-existing medical conditions such as diabetes or asthma and if so are these likely to deteriorate during travel? And where is she travelling to? There is a big difference between arriving in a large western city with state-of-the-art obstetric facilities and medical expertise and heading into the bush or a jungle with nothing more than a first-aid box.

The risks of air travel during pregnancy include miscarriage, premature birth and deep-vein thrombosis. According to a review published in the British Medical Journal the miscarriage rate is 3-30 per cent for women who experience vaginal bleeding in the first trimester. There is no evidence to suggest air travel increases a woman’s risk of miscarriage; however, being airborne when a miscarriage occurs increases the difficulty of safely managing the situation. And there are studies showing female flight attendants have higher miscarriage rates than their peers.

In the latter stages of pregnancy, the main concern when flying is the risk of premature birth. It is often unpredictable, although women with a history of delivering prematurely and those expecting twins do have a statistically greater chance of premature labour. In recognition of this, most airlines will not permit a woman with a multiple pregnancy to fly after 32 weeks of gestation.

Deep-vein thrombosis is more common in pregnant women and is estimated to complicate about one in 1,000 pregnancies. Travel adds additional risk because of immobility, lower oxygen concentrations and low humidity, leading to more sluggish blood flow in veins.

While most exotic infectious diseases are uncommon, traveller’s diarrhoea is not: it affects up to 60 per cent of visitors to tropical and semi-tropical regions of the developing world. A bad dose can cause severe dehydration and may increase the risk of premature labour. And while oral hydration salts mixed with filtered water will settle the majority of cases, severe diarrhoea in a pregnant woman should hasten the use of intravenous fluids.

So where does that leave Olayinka Ijaware and the actions of the Garda? Probably the most important determinant of her fitness to fly was the nature, quantity and intensity of her vaginal bleeding. Bright red blood in copious amounts is a greater cause for concern than a trickle of older, brown-coloured blood. The decision of the Garda doctor who examined her and declared her fit to fly suggests she may have been experiencing a lighter form of bleeding, which may persist for weeks after miscarriage.