Complicating Factors: Issues Relating to Romance and Reproduction During Space Missions

Kira Bacal, MD, PhD, MPH

Disclosures

January 02, 2009

Issues Involved With Pregnancy

The risk of pregnancy exemplifies how sexual relations and their sequelae can affect a mission's logistical requirements. Conditions, such as preeclampsia, gestational diabetes, or Rh incompatibility, will likely be difficult to treat in such a remote location. Based on astronaut demographics, it is also likely that a pregnant crew member will be older than average,[13] therefore the pregnancy may be classified as high-risk on that basis alone. The overall spontaneous abortion rate has also been high (40%) among US astronauts following spaceflight.[13] What will these findings mean to the mission as a whole?

Antarctica is considered an analogue environment for space, due to its remote location, hostile environment, small teams, and evacuation difficulty. Antarctic expedition medical personnel acknowledge that pregnancy among female team members creates risks to the individual, the fetus, and to the success of the expedition.[60] As one Antarctic physician said, "No one wants to become pregnant down there [in Antarctica], no one wishes a baby to be born down there. I think it would just put that much bigger burden on the station and the station medical officer."[60] In the same way, the sequelae of sexual relations on orbit must be considered not only from the standpoint of the individuals involved, but also from the standpoint of the mission, program, and agency.

For example, the need for contraceptives raises questions not only of those regarding efficacy and side effects, but also of issues related to supplies, stowage, and (depending upon the type of contraceptives) discard of used materials.[37] The known physiological changes of spaceflight are also likely to have effects on the pharmacokinetics and pharmacodynamics of medications.[25,61] Likewise, there is also evidence to suggests that some drugs deteriorate more rapidly in space, perhaps due to the radiation environment, leading to additional issues for (re)supply and storage,[62] as well as the reliability of the contraceptive.

Pregnancy test kits are currently part of the standard medical kit flown in space, though their inclusion has historically been for the diagnostic work up of abdominal pain in a female crew member rather than any anticipated detection of a pregnancy. An onboard ultrasound can be of diagnostic assistance in documenting the existence and location of a pregnancy, but what other devices, pharmaceuticals, and training will be required?

The terrestrial rate of ectopic pregnancy is 19.7 cases per 1,000 pregnancies in North America,[63] but it is unclear whether extraterrestrial rates will be higher or lower. Under these conditions, should the medical system include nonsurgical treatments, such as methotrexate, for the termination of ectopic pregnancies?[58] Similarly, what are the ethics involved in offering elective termination with mifepristone, as well as pregnancy support options to an expectant mother who is concerned about the teratogenic effects of the space environment?[37,44] Given these concerns, should the medical system include capabilities for amniocentesis and other pre-natal testing?

And of course, if we are talking about the possibility of an in-flight pregnancy, the corollary question also rises: what about in-flight terminations? Should mifepristone be in the medical kit? Given the real concerns about the teratogenic effects of the space environment,[10,22] what are the ethics involved in (not) offering termination?

One immediate question if a member becomes pregnant is whether to abort a mission, thus expanding the criteria for mission termination to include pregnancy of a crew member. Pregnancy is a disqualifying factor even for many aspects of ground-based NASA mission training, including extra-vehicular activity (spacewalk) training in the Neutral Buoyancy Laboratory, altitude chamber training, T-38 training, parabolic flights, and shuttle emergency egress training.[37,58] If an astronaut assigned to a mission becomes pregnant prior to the launch date, she is immediately replaced.[13,58]

But what should be done in the case of a pregnancy that occurs during a mission? Repatriation is recommended for women who become pregnant during an Antarctic expedition.[60] In the US military, pregnancy is grounds for medical disqualification from certain activities, such as flying status or worldwide deployment status.[64] In the event that a service member becomes pregnant while deployed, only she is withdrawn from her duties; the rest of her unit continues with the mission. That is not the case on many space missions, however, where evacuation capabilities may be designed for either the entire crew or no one.

The International Space Station, for example, has a single "life boat," the Soyuz, and protocol states that even if a single crew member is ill, the entire crew must abandon the station. Similarly, a Mars mission or a lunar base may have only a single means of evacuation. If it is used to evacuate a single crew member the rest of the team would have no way to abandon the platform should an emergency arise. Therefore, would it be appropriate to abandon the entire mission in order to bring home a pregnant woman?

If there is a higher than average risk of fetal malformations, and particularly if the risk is cumulative due to increased exposure to the environment, then it could be argued that there is an ethical obligation to return mother and fetus to Earth as quickly as possible, regardless of the astronaut's personal preferences, the cost of the mission, and the risk to the rest of the crew from implementing an emergency evacuation plan. This last risk is not inconsequential. Australia's Antarctic program dealt with a female expedition member who developed severe hyperemesis gravidarum during a crossing of the Southern Ocean. Serious consideration was given to the ship returning to Hobart, Australia, despite the risk to the entire vessel of spending more time in those extremely dangerous waters and the impact such a step would have had on the whole expedition.[60]

Even if plans are to immediately return a pregnant crew member to Earth, it can take days or months for her to arrive back on the planet, depending on the type of mission. Therefore, the medical system will need to afford some assistance and services during that time, regardless of the desired long-term outcome.

How would the mission be affected if the decision is made for the entire crew to continue the operation? Based on current standards, a pregnant woman would not be allowed to engage in extra-vehicular activities. So, for example, if the pregnant crew member was assigned to spacewalking duties, that role would need to be transferred to her backup, thereby compromising that person's other activities. Furthermore, if a swap of activities were to occur between the two crew members, additional training would be required for both of them, thus affecting mission timelines.

In addition, the pregnancy is likely to place additional, potentially unexpected demands upon the medical system. Supplies such as intravenous fluids and analgesics might need to be rationed or withheld in preparation for an obstetrical event, rather than being available for use during nominal mission activities or in the case of an emergency or another pregnancy.

As the pregnancy progresses, there could be additional issues involving human factors. For example, the Soyuz has a potential landing impact of up to 30G, which requires individualized, form-fitted seat liners to help attenuate the effects of landing forces on the crew. A heavily pregnant crew member is unlikely to fit in her seat liner, let alone be able to withstand those kinds of G forces. This could affect evacuation options and landing protocols when the crew arrives at their destination.

What if there were complications of pregnancy? At present, part of the rationale for pregnancy being a disqualification for even short duration spaceflight is concern for potential complications that could overwhelm the platform's medical capabilities, such as miscarriage, preterm labor, and ectopic pregnancy.[37] In addition, there are concerns about the impact of the environment on both the developing fetus and the mother's physiologic adaptation.[37]

If a normal pregnancy were carried to term in an off-Earth environment, how would childbirth take place? Should the mission's medical system be designed with such a possibility in mind? If delivery occurs in the microgravity environment, will labor be unduly prolonged? Ronca and Alberts found that pregnant rats that delivered on Earth after flying during gestation were in labor longer than control rats[65] although other changes of significance were relatively few.[59,65] This was presumably due to less effective uterine contractions,[65] which would be in accord with other observed changes to the neuromuscular system and may be rooted in gravity-related modifications to intracellular architecture.[23,30] What are the implications for a woman delivering while still in a low-G environment? Pain control may be an issue, especially if labor is prolonged as well as the potential for caesarean section, risk of damage to surrounding structures (e.g. bladder injury, fistula formation, etc), and hemorrhage. The issue of hygiene and risk to other crew members from exposure to blood and body fluids should also not be underestimated.[3]

What about care for the newborn? Would they need to stock neonatal resuscitation equipment, baby clothes, and diapers? If there are problems such as prematurity or birth defects, what resources should be available for the baby's care? How would this situation affect crew morale, and what would be the public reaction?

Given these manyserious considerations, one option might be to make pregnancy impossible on space missions. There are obvious ethical and practical issues to implementing such a requirement. However, the fact remains that for a long-term human presence in space, reproduction off-Earth will be needed, so these questions can only be deferred, not ignored.

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