Agent Detail

AIR TRAVEL

Agent Number 2280
CAS Number NONE
Last Updated 02/06/2024

Agent Summary

Quick take: Air travel increases the risk of dehydration and deep vein thrombosis in pregnant women. Other risks have not been established.

Air travel entails prolonged immobilization, exposure to reduced atmospheric pressure, to very dry air, and to an increase in cosmic radiations. Of these, exposure to ionizing radiation #1221 may not involve sufficiently large radiation dose levels (6). Some commentators were not convinced that air travel does not pose a radiation risk for pregnancy (7,8). Flying through solar particle events can entail exposure to additional radiation (25). It was estimated that the dose to the fetus would exceed a recommended fetal dose limit of 1 mSv after 10 round trips on commercial flights between Toronto and Frankfurt (17). For details on how individual patients can estimate their radiation exposure during air travel, see ref 13. The Federal Aviation Administration offers a calculator for estimating radiation doses for specific flights (26) and a discussion of workplans for pregnant crew members (31).

Human pregnancy

The cabin pressure in commercial jets is the equivalent of an altitude of 5000-8000 feet. Symptoms of hypoxia #3068 are seen at altitudes above 10,000 feet. Pregnant women can avoid flying above 10,000 feet in an unpressurized aircraft. Most airlines allow pregnant women to fly up to 36 weeks of gestation (30). For international travel, the cutoff can be 35 weeks gestation (9,30), but some airlines have no restrictions on pregnant travelers and no trained personnel to help with obstetric emergencies (15). Women with an increased risk of preterm delivery, placental abnormalities, pregnancy induced hypertension, poorly controlled diabetes, or sickle cell trait are discouraged from traveling by air at any time during pregnancy (9,18,20).

The dryness of the air coupled with the usual increase in minute ventilation associated with pregnancy will predispose pregnant women to dehydration; therefore, increased fluid intake during air travel is recommended. Prolonged immobilization can exacerbate the thrombotic tendencies of pregnancy (4,24). Preventative measures include the use of support stockings and periodic movement of the lower extremities (9,19,32).

Whether reduced atmospheric pressure is associated with decreased oxygen delivery to the fetus has been addressed by a study in which continuous fetal heart rate monitoring was used during air transport of women with obstetric complications. No late decelerations were seen, leading the authors to conclude that fetal hypoxia was not present (1). Another study of ten healthy pregnant women in the third trimester found no abnormalities of fetal heart rate tracings during air travel in spite of decreases in maternal transcutaneous pO2 (2). Two 2012 reviews of long-distance air travel in the second and third trimesters of pregnancy found no adverse maternal or fetal effects (22,23). Alterations in fetal oxygenation would not be expected under these conditions in view of the shift of the fetal oxyhemoglobin dissociation curve to the left of the adult curve. This shift promotes maximal fetal hemoglobin saturation unless maternal pO2 becomes lower than about 60 torr. Some commentators concluded in 1998 that any developmental risk associated with the hypobaria of air travel is small but worthy of additional investigation (11,12).

Occupation as a flight attendant was associated with an increase in miscarriage when compared to other women but not when compared to other employed women (10). Miscarriage prevalence was not increased among flight attendants compared to schoolteachers (21). Among 145 former flight attendants there was an increased prevalence of miscarriage, 26%, compared with a general population value, 17.1%, and 5 of 97 women reported births with congenital defects (29). The authors did not address possible selection or recall bias, and comparison to a non-concurrent general population rate may not be informative.

Among 546 women who traveled at least once during pregnancy and a control group of 447 women who did not travel by air, there was an increase in preterm birth and lower birth weight in travelers (14). There were no thromboembolic events complicating any pregnancies. Among 222 women who had flown at least once during pregnancy and delivered after 20 weeks gestation, air travel was not associated with reduced gestational age or low birth weight (16). Birth weight and gestational age were not altered in a cohort of 41,000 women who traveled by air during pregnancy (33).

In Western Australia, women at immediate risk of preterm delivery have been transferred hundreds of miles by air to a perinatal center in Perth (22). The record of 500 such pregnancies collected over 30 years showed that no women went into labor during the flight. Ambient altitude of greater than 14,000 feet or cabin altitude above sea level were associated with a delay in time from landing to delivery in women not in spontaneous preterm labor. US and international regulations regarding pregnant military aviators were discussed in a 2010 review (20). This review included discussion of removal from active flight status based on concerns about gravitational forces, hypobaric hypoxia, cosmic radiation, and ejection seats.

Pregnant women may be at higher risk than nonpregnant individuals for venous thromboembolism (VTE) with air travel; air travel presents an increased risk for thromboembolism in travelers whether pregnant or not (27,34). Pregnant women were considered to have a 5- to 10-fold increased risk of thromboembolism when compared to nonpregnant women and a risk increased 20- to 80-fold during the postpartum period (27,32). The prevalence of venous thromboembolism during pregnancy with or without air travel was less than 0.0004% (34).

There is a case report of placental separation in a woman at 14 weeks gestation attributed to turbulence, despite the use of a seat belt #4139 (28). The American College of Obstetricians and Gynecologists recommended in 2009 that pregnant women wear seat belts on airplanes with the belt low across the hips between the abdomen and pelvis (18,30).

Female reproduction

Menstrual dysfunction, including menorrhagia, dysmenorrhea, and prolonged follicular phase of the menstrual cycle were reported in flight crew members (5). Whether these effects are due to stress #1989 from the physical exertion, time zone changes, or an actual environmental effect of air travel is not known.

Male reproduction

In male mink, there was impairment of sperm quality and a delay in sexual maturation in young animals transported in utero from America to Finland (3). While the air travel might have adversely affected intrauterine development of these mink, other factors may have been operative. For example, rearing by mothers that had been subjected to the handling and other rigors of the transport might have caused alterations in neonatal development.

Lactation

We have not located studies on possible lactation effects of air travel.

Selected References

  1. Elliot JP, Trujillo R: Fetal monitoring during emergency obstetric transport. Am J Obstet Gynecol 157:245-7, 1987.

  2. Huch R et al: Physiologic changes in pregnant women and their fetuses during jet air travel. Am J Obstet Gynecol 154:996-1000, 1986.

  3. Sundqvist C et al: Reproductive capacity in male mink after long distance transportation in pregnant females. Andrologia 17:575-8, 1985.

  4. Cruikshank JM, Gorlin R, Jennett B: Air travel and thrombotic episodes: the economy class syndrome. Lancet 2:498, 1988.

  5. Preston FS: The health of female air cabin crews. J Occupat Med 20:597, 1978.

  6. Friedberg W, Faulkner DN, Snyder L, Darden EB Jr., O'Brien K: Galactic cosmic radiation exposure and associated health risks for air carrier crewmembers. Aviat Space Environ Med 1989;60:1104-8.

  7. Geeze DS: Pregnancy and in-flight cosmic radiation. Aviat Space Environ Med 1998;69:1061-4.

  8. Bagshaw M: Pregnancy and in-flight cosmic radiation (letter). Aviat Space Environ Med 1999;70:533.

  9. Committee opinion: number 264, December 2001. Air travel during pregnancy. Obstet Gynecol 2001;98:1187-8.

  10. Daniell WE, Vaughan TL, Millies BA: Pregnancy outcomes among female flight attendants. Aviat Space Environ Med 1990;61:840-84.

  11. Platt MP, Fleming PJ, Blair PS, Leach CE, Golding J, Smith I: Hypoxic responses in infants. Danger to babies from air travel must be small. BMJ 1998;317:676.

  12. James PB: Hypoxic responses in infants. Risks associated with hypoxia during flights need to be investigated. BMJ 1998;317:677.

  13. Barish RJ: In-flight radiation exposure during pregnancy. Obstet Gynecol 103:1326-30, 2004.

  14. Chibber R, Al-Sibai MH, Qahtani N: Adverse outcome of pregnancy following air travel: A myth or a concern? Aust N Z J Obstet Gynaecol 2006;46:24-8.

  15. Breathnach F, Geoghegan T, Daly S, Turner MJ: Air travel in pregnancy: the 'air-born' study. Ir Med J 2004;97:167-8.

  16. Freeman M, Ghidini A, Spong CY et al: Does air travel affect pregnancy outcome? Arch Gynecol Obstet 2004;269:274-7.

  17. Chen J, Mares V. Estimate of doses to the fetus during commercial flights. Health Phys. 2008 Oct;95(4):407-12. PubMed PMID: 18784513.

  18. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 443: Air travel during pregnancy. Obstet Gynecol. 2009 Oct;114(4):954-5. PubMed PMID:19888065.

  19. Brenner B. Prophylaxis of travel-related thrombosis in women. Thromb Res. 2009;123 Suppl 3:S26-9. Review. PubMed PMID: 19203643.

  20. Magann EF, Chauhan SP, Dahlke JD, McKelvey SS, Watson EM, Morrison JC. Air travel and pregnancy outcomes: a review of pregnancy regulations and outcomes for passengers, flight attendants, and aviators. Obstet Gynecol Surv. 2010 Jun;65(6):396-402. Review. PubMed PMID: 20633306.

  21. Grajewski B, Whelan EA, Lawson CC, Hein MJ, Waters MA, Anderson JL, MacDonald LA, Mertens CJ, Tseng CY, Cassinelli RT 2nd, Luo L. Miscarriage among flight attendants. Epidemiology. 2015 Mar;26(2):192-203. doi:10.1097/EDE.0000000000000225. PubMed PMID: 25563432; PubMed Central PMCID:PMC4510952.

  22. Akl N, Coghlan EA, Nathan EA, Langford SA, Newnham JP. Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: why are there no births in flight? Aust N Z J Obstet Gynaecol. 2012 Aug;52(4):327-33.doi: 10.1111/j.1479-828X.2012.01426.x. PMID: 22494047.

  23. Tchirikov M, Oshovskyy V, Steetskamp J, Thale V. Neonatal outcome following long-distance air travel for fetoscopic laser coagulation treatment of twin-to-twin transfusion syndrome. Int J Gynaecol Obstet. 2012 Jun;117(3):260-3. doi: 10.1016/j.ijgo.2012.01.016. PMID: 22445425.

  24. Izadi M, Alemzadeh-Ansari MJ, Kazemisaleh D, Moshkani-Farahani M, Shafiee A. Do pregnant women have a higher risk for venous thromboembolism following air travel? Adv Biomed Res. 2015 Feb 23;4:60. doi: 10.4103/2277-9175.151879. eCollection 2015. Review. PMID: 25802829; PMCID: PMC4361953.

  25. Anderson JL, Mertens CJ, Grajewski B, Luo L, Tseng CY, Cassinelli RT 2nd. Flight attendant radiation dose from solar particle events. Aviat Space Environ Med. 2014 Aug;85(8):828-32. doi: 10.3357/ASEM.3989.2014. PMID: 25199125.

  26. FAA. CARI-6: Radiobiology Research Team. 2017. https://www.faa.gov/data_research/research/med_humanfacs/aeromedical/radiobiology/cari6/

  27. Izadi M, Alemzadeh-Ansari MJ, Kazemisaleh D, Moshkani-Farahani M, Shafiee A. 2015. Do pregnant women have a higher risk for venous thromboembolism following air travel? Adv Biomed Res 4:60. doi: 10.4103/2277-9175.151879. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4361953/

  28. Fletcher HM, Wharle GH, Mitchell SY. 2003. Placental separation from a seat belt injury due to severe turbulence during aeroplane travel. J Obstet Gynecol 23(1) 73-74.

  29. Heidecker B, Spencer RM, Hayes V, Hall S, Parikh N, Stock EO, Redberg R. High prevalence and clinical/sociodemographic correlates of miscarriages among flight attendants. Am J Med. 2017 Dec;130(12):1397-1401. doi:10.1016/j.amjmed.2017.05.032. Epub 2017 Jun 15. PubMed PMID: 28624541.

  30. ACOG Committee Opinion No. 746: Air Travel During Pregnancy. Obstet Gynecol. 2018 Aug;132(2):e64-e66. doi: 10.1097/AOG.0000000000002757. PubMed PMID: 30045212.

  31. Office of Aerospace Medicine, Federal Aviation Administration. What aircrews should know about their occupational exposure to ionizing radiation. Washington, DC: FAA; 2003. Available at: https://apps.dtic.mil/sti/tr/pdf/ADA423589.pdf

  32. EBCOG Position Statement - Travelling when pregnant. Euro Journal Obstet Gynecol Reprod Biology 2019; 233:158-159.

  33. Shalev Ram H, Ram S, Miller N, Rosental YS, Chodick G. Air travel during pregnancy and the risk of adverse pregnancy outcomes as gestational age and weight at birth: A retrospective study among 284,069 women in Israel between the years 2000 to 2016. PLoS One. 2020;15(2):e0228639. Published 2020 Feb 6. doi:10.1371/journal.pone.0228639 https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/32027691/

  34. Ram S, Shalev-Ram H, Neuhof B, Shlezinger R, Shalev-Rosental Y, Chodick G, Yogev Y. 2023. Air travel during pregnancy and the risk of venous thrombosis. Am J Obstet Gynecol MFM. 5(1): 100751. PMID: 36115570. https://doi.org/10.1016/j.ajogmf.2022.100751

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