1Department of Obstetrics & Gynaecology, Indian Naval Hospital Ship Asvini, Mumbai, India; 2Department of Clinical Microbiology & Infectious Diseases, Army College of Medical Sciences & Base Hospital, New Delhi, India *Corresponding Author’s e-mail: titan_afmc@yahoo.com نتائج التوليد والوالدة عند احلجاج احلوامل من اهلند خربة ثالث سنوات يف بعثة احلج اهلندية الطبية �شازيا خان و اإنعام داني�ص خان abstract: Objectives: The Hajj, an annual mass gathering of Muslim pilgrims, is known for its high morbidity and mortality rates. However, pregnant women sometimes participate in this pilgrimage, despite guidelines that discourage such an undertaking due to potential fetomaternal complications. This study aimed to evaluate fetomat- ernal outcomes among pregnant Indian Hajj pilgrims. Methods: This prospective cross-sectional study was conducted at two Indian Hajj Medical Mission (IHMM)-affiliated secondary care hospitals in Saudi Arabia during the Hajj periods of August–October 2015 and 2016 and July–September 2017. All female Indian pilgrims of reproductive age who underwent pregnancy screening at secondary care IHMM hospitals during this period were included in the study. Definitive obstetric care was provided at the Makkah Maternity & Child Hospital. Data regarding the pilgrims’ obstetric characteristics, antenatal complications, management and fetomaternal outcomes were evaluated. Results: A total of 114 pregnant Indian pilgrims were identified during the study period. The most common antenatal complications were respiratory tract infections (51.75%), followed by iron deficiency anaemia (17.54%), hyperemesis gravidarum (14.04%), hypothyroidism (9.65%) and gestational diabetes mellitus (5.26%). There were 20 vaginal deliveries (17.54%), two Caesarean sections (1.75%) and 32 abortions (28.07%). The cumulative three-year birth rate was 24.60 per 1,000 females. Conclusion: During Hajj, pregnant pilgrims have a high risk of abortion, respiratory tract infections and various antenatal, perinatal and neonatal complications which may go unreported or untreated. Women should therefore be educated regarding the risk of adverse fetomaternal outcomes which may occur while undertaking a Hajj pilgrimage during pregnancy. Keywords: Travel Medicine; Muslims; Pregnancy Outcomes; Miscarriage; Respiratory Infections; Saudi Arabia. امللخ�ص: الهدف: احلج، وهو جتمع جماعي �شنوي للحجاج امل�شلمني، ومعروف مبعدلت مرا�شة ووفيات عالية. ومع ذلك، ت�شارك الن�شاء احلوامل اأحيانا يف هذا املو�شم على الرغم من املبادئ التوجيهية التي تثبط مثل هذه امل�شاركات ب�شبب امل�شاعفات الأمومية اجلنينية. تهدف هذه الدرا�شة اإىل تقييم النتائج الأمومية اجلنينية بني احلجاج احلوامل من الهند. الطريقة: اأجريت هذه الدرا�شة الإ�شتباقية امل�شتعر�شة يف اأثنني من م�شت�شفيات رعاية ثانوية للحّج الطبي يف اململكة العربية ال�شعودية خالل فرتات احلج من اأغ�شط�ص-اأكتوبر 2015 و 2016 ويوليو-�شبتمرب 2017. �شملت هذة الدرا�شة جميع احلجاج الن�شاء من الهند يف �شن الأجناب والالآتي خ�شعن لفح�ص احلمل يف م�شت�شفيات الرعاية الثانوية التابعة لبعثة احلج الهندية. مت توفري الرعاية التوليدية النهائية يف م�شت�شفى مكة للولدة والأطفال. مت تقييم املعطيات من 114 حتديد مت النتائج: اجلنينية. الأمومية والنتائج والإدارة للولدة ال�شابقة وامل�شاعفات التوليدية احلجاج بخ�شائ�ص املتعلقة احلجاج الهنود احلوامل خالل فرتة الدرا�شة. كانت اأكرث م�شاعفات ما قبل الولدة �شيوعا هي التهابات اجلهاز التنف�شي )%51.75( يليها فقر الدم ب�شبب نق�ص احلديد )%17.54(، تقيء احلمل املفرط )%14.04(، ق�شور الغدة الدرقية )%9.65( و�شكري احلمل )%5.26(. كان هناك 20 حالة ولدة مهبلية )%17.54(، وحالتان لولدة قي�شريية )%1.75( و 32 حالة اإجها�ص )%28.07(. وبلغ معدل الولدة الرتاكمي ملدة ثالث �شنوات 24.60 لكل 1,000 امراأة. اخلال�صة: اأثناء احلج، يكون احلجاج احلوامل اأكرث عر�شة لالإجها�ص، والتهابات اجلهاز التنف�شي وم�شاعفات ما قبل الولدة والفرتة املحيطة بالولدة وم�شاعفات التوليد والتي قد ل يتم الإبالغ عنها اأو عدم عالجها. لذلك يجب اأن يتم تعليم الن�شاء فيما يتعلق بخطر النتائج املعاك�شة الأمومية اجلنينية والتي قد حتدث للحوامل اأثناء اأداء فري�شة احلج. الكلمات املفتاحية: طب ال�شفر؛ امل�شلمني؛ نتائج احلمل؛ اإجها�ص؛ التهابات اجلهاز التنف�شي؛ اململكة العربية ال�شعودية. Obstetric and Neonatal Outcomes of Pregnant Indian Pilgrims A three-year experience at the Indian Hajj Medical Mission Shazia Khan1 and *Inam D. Khan2 clinical & basic research Sultan Qaboos University Med J, August 2018, Vol. 18, Iss. 3, pp. e355–361, Epub. 19 Dec 18 Submitted 21 Jan 18 Revisions Req. 18 Feb & 18 Mar 18; Revisions Recd. 28 Feb & 19 Mar 18 Accepted 12 Apr 18 doi: 10.18295/squmj.2018.18.03.015 Advances in Knowledge - This prospective study is the first of its kind to evaluate fetomaternal outcomes among pregnant Indian Hajj pilgrims. - The cumulative three-year birth rate was 24.60 per 1,000 women. - The most common antenatal complications were respiratory infections, followed by iron deficiency anaemia. There was also a high incidence of abortions and other adverse pregnancy and neonatal outcomes. Application to Patient Care - Mass gatherings increase the transmissibility of respiratory pathogens. In addition, local healthcare systems may not be able to detect antenatal complications during Hajj or may experience transport difficulties due to crowded conditions, potentially leading to neonatal morbidity and mortality. Pregnant women considering undertaking Hajj pilgrimage should be educated regarding such risks. Obstetric and Neonatal Outcomes of Pregnant Indian Pilgrims A three-year experience at the Indian Hajj Medical Mission e356 | SQU Medical Journal, August 2018, Volume 18, Issue 3 The Hajj is an annual Muslim pilgrimage of more than 2.3 million people from all over the world.1 Hajj forms one of the five pillars of Islam and is obligatory for all able-bodied men and women of requisite means.2 Muslims consider Hajj to be the most important pilgrimage for spiritual enlight- enment during their lifetime. However, the pilgrimage involves physically demanding rituals which take place over approximately 45 days in the desert climate of Saudi Arabia, sometimes without adequate nourishment, hyd- ration or sufficient rest.2 Furthermore, Hajj is associated with high rates of morbidity and mortality due to various factors, including old age, chronic diseases, infectious disease outbreaks, accidents and disasters, all of which require appropriate surveillance and emergency response systems.3–5 Mass gathering medicine is challenging due to the increased transmission of communicable diseases, lim- ited healthcare accessibility, the often overwhelming number of patients and difficulties in evacuating patients during emergencies. Healthcare during Hajj is also affected by pilgrim diversity and vulnerability, despite yearly efforts to augment resources and enhance prep- aredness.6–8 While the Holy Quran does not prohibit performing Hajj during pregnancy and air travel during this time is considered safe, the governments of several countries actively discourage women from undertaking Hajj while pregnant.9–12 Nevertheless, pregnant women regularly undertake this arduous journey, sometimes in the belief that giving birth in the holy cities of Makkah or Medina will confer spiritual benefit. Such pregnancies are often not declared and remain largely undetected prior to departure for Hajj.10 The Indian Hajj Medical Mission (IHMM) caters to pregnant Indian women during their pilgrimage before transferring them to Saudi Arabian state-sponsored hosp- itals for appropriate fetomaternal care.7,8 The IHMM comprises a multi-tier network of medical outreach teams, mobile medical task forces, primary care clinics, tent clinics and two secondary care hospitals with 30–40 beds each. In addition, the IHMM has referral and evac- uation capabilities in Makkah, Medina and Jeddah.7,8 To the best of the authors’ knowledge, no data have yet been reported in the literature regarding pregnancy and neonatal outcomes during Hajj or in comparable mass gathering settings. This study therefore aimed to evaluate the obstetric and neonatal outcomes of pregnant Indian Hajj pilgrims over a three-year period from 2015–2017. Methods This prospective cross-sectional study was conducted at two IHMM-affiliated secondary care hospitals in Saudi Arabia during the Hajj seasons of August–October 2015 and 2016 and July–September 2017. All female Indian pilgrims between 15–45 years old with amenorr- hoea who were seen at secondary care IHMM hospitals during the study period underwent pregnancy screening under the supervision of obstetricians and gynaecol- ogists. All pregnant patients identified during Hajj as well as those who had registered their pregnancies in Indian hospitals prior to their arrival in Saudi Arabia were included in the study as part of a convenience inclusive sampling strategy. Patients who attended the hospitals for follow-up appointments for pre- and post- pregnancy events or those who had conditions unrelated to pregnancy were excluded. All pregnant patients either presented to the secondary care hospitals directly or after referral from IHMM-affiliated clinics or mobile task forces. Subseq- uently, a prenatal nursing assessment was performed to determine gravidity, parity and the number of prev- ious abortions or living offspring. At their first visit to the secondary care hospital, the pregnancy was registered under the supervision of an IHMM-affiliated obstetrician and gynaecologist. A basic work-up was performed to confirm the pregnancy, including height, weight and blood pressure measurements, a complete blood count and random blood glucose and urine pregnancy tests. All results were processed in the secondary care hospital laboratory under the supervision of a pathologist or microbiologist. For high-risk pregnancies, patients were referred to the Makkah Maternity & Children Hospital for an antenatal work-up that included blood grouping, Rhesus typing, a coagulation profile and screening for HIV, hepatitis B and C, syphilis, toxoplasmosis, rubella, cyto- megalovirus and herpes simplex virus (i.e. TORCH screening), followed by ultrasonography and routine follow-up. Potential exposure to pilgrims from developing or underprivileged countries mandates detailed screening for infectious diseases, including TORCH screening, which would otherwise not be routinely recommended.13 In addition, patients requiring fetal monitoring, perinatal care and neonatal intensive care, those in labour and obstetric emergency cases were also transferred to the Makkah Maternity & Children Hospital. However, all patients were followed up by IHMM-affiliated doctors throughout their entire stay in Saudi Arabia and, when necessary, were transferred to India under medical supervision. Data were analysed using Microsoft Excel, Version 2010 (Microsoft Inc., Redmond, Washington, USA). Various clinicodemographic characteristics, including diagnosis, management, the presence of antenatal compl- ications and fetomaternal outcomes, were compiled and compared with previous years for analysis. The results were expressed as descriptive statistics, including frequ- encies, percentages and 95% confidence intervals. Shazia Khan and Inam D. Khan Clinical and Basic Research | e357 Ethical approval for this study was provided by the IHMM. Written informed consent was obtained from all participants prior to their inclusion in the study. Results Overall, there were 450,000 Indian pilgrims seen at IHMM-affiliated secondary care hospitals between 2015–2017, including 89,400 female pilgrims of reprod- uctive age (19.87%). Of these, 114 (0.13%) were pregnant. The pregnancy was identified by urine test for the first time in 22 women (19.3%). A total of 101 women (88.6%) had planned pregnancies, although these were not declared to the Hajj medical authorities prior to beginning the pilgrimage. Of these, nine women (8.91%) were unaware of their pregnancy prior to their arrival in Saudi Arabia. A total of 39 women (38.61%) had received routine antenatal care in India. Among 23 women (20.18%) who were in the early stages of pregnancy, nine (39.13%) had had an antenatal appointment in India after conception and 14 (60.87%) were unaware of the date of their last menstrual period. There were four patients (3.51%) with twin pregnancies. The cumulative three- year birth rate was 24.60 per 1,000 women [Table 1]. All of the women had received oral poliomyelitis, combined seasonal influenza and influenza A subtype H1N1 and meningococcal (serogroups A, C, Y and W-135) vaccines prior to their arrival in Saudi Arabia. Respiratory tract infections were the most common antenatal complication (51.75%), followed by iron def- iciency anaemia (17.54%), hyperemesis gravidarum (14.04%), hypothyroidism (9.65%) and gestational diabetes mellitus (GDM; 5.26%) [Table 2]. There were no reported cases of calf pain or deep vein thrombosis. All respiratory infections were treated empirically with antimicrobials as specific bacterial, fungal and viral cultures and immunological and molecular diagnostic procedures were unavailable. In addition, affected women were regularly monitored to avoid the trans- mission of suspected cases of H1N1 or Middle East respiratory syndrome (MERS). None of the women with respiratory infections required intensive care Table 1: Obstetric characteristics of pregnant Indian pilgrims undertaking Hajj pilgrimage between 2015–2017 (N = 114) Characteristic n (%) 95% CI* 2015 (n = 38) 2016 (n = 32) 2017 (n = 44) Total Gravidity Primigravidae 10 (26.32) 9 (28.13) 11 (25) 30 (26.32) 18.72–35.55 Multigravidae 28 (73.68) 23 (71.88) 33 (75) 84 (73.68) 64.45–81.28 Type of pregnancy Single 37 (97.37) 31 (96.88) 42 (95.45) 110 (96.49) 90.73–98.87 Twin 1 (2.63) 1 (3.13) 2 (4.55) 4 (3.51) 1.13–9.27 Birth rate per 1,000 females 42.85 13.60 18.75 24.60 - CI = confidence interval. *Of the cumulative percentage. Table 2: Antenatal complications of pregnant Indian pilgrims undertaking Hajj pilgrimage between 2015–2017 (N = 114) Complication* n (%) 95% CI† 2015 (n = 38) 2016 (n = 32) 2017 (n = 44) Total RTIs 19 (50) 18 (56.25) 22 (50) 59 (51.75) 42.24–61.14 Iron deficiency anaemia‡ 6 (15.79) 8 (25) 6 (13.64) 20 (17.54) 11.29–26.03 Hyperemesis gravidarum 4 (10.53) 5 (15.63) 7 (15.91) 16 (14.04) 8.49–22.09 Hypothyroidism 2 (5.26) 5 (15.63) 4 (9.09) 11 (9.65) 5.15–16.98 GDM 2 (5.26) 3 (9.38) 1 (2.27) 6 (5.26) 2.16–11.57 Oligohydramnios 1 (2.63) 0 (0) 1 (2.27) 2 (1.75) 0.30–6.81 Severe PE 0 (0) 0 (0) 1 (2.27) 1 (0.88) 0.05–5.51 CI = confidence interval; RTIs = respiratory tract infections; GDM = gestational diabetes mellitus; PE = pre-eclampsia. *Percentages do not add up to 100% as some women may have had more than one complication. †Of the cumulative percentage. ‡Defined as a haemoglobin level of <10.5 g/dL. Obstetric and Neonatal Outcomes of Pregnant Indian Pilgrims A three-year experience at the Indian Hajj Medical Mission e358 | SQU Medical Journal, August 2018, Volume 18, Issue 3 or mechanical ventilation. Cases of iron deficiency anaemia received haematinic supplements, while those with hyperemesis gravidarum were admitted to hospital for supportive care and received intravenous (IV) fluids and antiemetics. Patients with GDM were prescribed 500 mg of metformin three times daily to ensure good glycaemic control and those with hypo- thyroidism were treated with thyroxine. The most common adverse early pregnancy out- comes were missed (23.68%) or threatened (8.77%) abortions. There were 20 vaginal deliveries (17.54%) and two Caesarean deliveries (1.75%) [Table 3]. There were no instrumental deliveries. Four of the women with threatened abortions were admitted for progesterone support and bed rest, while the remaining six patients were managed conservatively. Of the 32 missed and Table 4: Neonatal outcomes of births among pregnant Indian pilgrims undertaking Hajj pilgrimage between 2015– 2017 (N = 22) Outcome* n (%) 95% CI† 2015 (n = 12) 2016 (n = 4) 2017 (n = 6) Total Alive and well 10 (83.33) 4 (100) 5 (83.33) 19 (86.36) 0.64–0.96 Low birth weight‡ 2 (16.67) 0 (0) 2 (33.33) 4 (18.18) 0.06–0.41 Low Apgar score§ 2 (16.67) 0 (0) 1 (16.67) 3 (13.64) 0.03–0.36 Neonatal resuscitation 2 (16.67) 0 (0) 1 (16.67) 3 (13.64) 0.03–0.36 Admission to NICU 2 (16.67) 0 (0) 1 (16.67) 3 (13.64) 0.03–0.36 Preterm¶ 2 (16.67)\\ 0 (0) 1 (16.67) 3 (13.64) 0.03–0.36 Fetal distress/birth asphyxia 2 (16.67) 0 (0) 1 (16.67) 3 (13.64) 0.03–0.36 RDS 1 (8.33) 0 (0) 0 (0) 1 (4.55) 0.24–0.25 Jaundice 1 (8.33) 0 (0) 0 (0) 1 (4.55) 0.24–0.25 Stillborn 0 (0) 0 (0) 1 (16.67) 1 (4.55) 0.24–0.25 CI = confidence interval; NICU = neonatal intensive care unit; RDS = respiratory distress syndrome. *Percentages do not add up to 100% as some neonates may have fallen into more than one category. †Of the cumulative percentage. ‡Defined as <2,500 g. §Defined as <5 at 10 minutes. ¶Defined as <37 gestational weeks. \\Two preterm babies were born as a result of preterm labour occurring in a twin pregnancy. Table 3: Pregnancy outcomes of pregnant Indian pilgrims undertaking Hajj pilgrimage between 2015–2017 (N = 114) Outcome* n (%) 95% CI† 2015 (n = 38) 2016 (n = 32) 2017 (n = 44) Total Early pregnancy Missed abortion 9 (23.68) 6 (18.75) 12 (27.27) 27 (23.68) 16.44–32.73 Threatened abortion 4 (10.53) 2 (6.25) 4 (9.09) 10 (8.77) 4.52–15.93 Inevitable abortion 2 (5.26) 0 (0) 3 (6.82) 5 (4.39) 1.63–10.44 Ectopic pregnancy 0 (0) 0 (0) 1 (2.27) 1 (0.88) 0.05–5.51 Single fetal demise 0 (0) 0 (0) 1 (2.27) 1 (0.88) 0.05–5.51 Term pregnancy Vaginal delivery 11 (28.95) 4 (12.5) 5 (11.36) 20 (17.54) 11.29–26.03 Caesarean delivery 1 (2.63) 0 (0) 1 (2.27) 2 (1.75) 0.3–6.81 Preterm birth 1 (2.63) 0 (0) 1 (2.27) 2 (1.75) 0.3–6.81 Premature labour 1 (2.63) 0 (0) 1 (2.27) 2 (1.75) 0.3–6.81 IUFD/stillbirth 0 (0) 0 (0) 1 (2.27) 1 (0.88) 0.05–5.51 CI = confidence interval; IUFD = intrauterine fetal demise. *Percentages do not add up to 100% as some women may have fallen into more than one category. †Of the cumulative percentage. Shazia Khan and Inam D. Khan Clinical and Basic Research | e359 inevitable abortions, the spontaneous expulsion of products of conception was confirmed by ultrasono- graphy in 28 cases (87.5%), whereas the remaining four patients (12.5%) underwent outpatient dilation and evacuation procedures. One patient with an ectopic pregnancy underwent a laparoscopic salpingectomy at the Makkah Maternity & Child Hospital. Among the four patients with twin pregnancies, one experienced the demise of a single fetus at 29 gestational weeks, although an examination four weeks earlier had indicated that both fetuses were viable. This patient was closely monitored for coagul- opathy disorders until she returned to India. Another pregnancy ended in intrauterine fetal demise at 29 gest- ational weeks due to ultrasonography-confirmed oligo- hydramnios, intrauterine growth restriction and skeletal and skull defects. This patient went into spontaneous premature labour and subsequently required postnatal inpatient care. There were a total of 22 births (19.3%) during the study period. The male-to-female ratio was 1.4:1. Neonatal outcomes were good in 19 cases (86.36%). However, there were three cases (13.64%) of birth asphyxia [Table 4]. In one of these cases, the mother was multigravida and presented with imminent eclampsia, high blood pressure (190/160 mmHg), albuminuria, headache, visual disturbances and epigastric discomfort. A magnesium sulphate infusion was administered, along with steroids. Subsequently, the patient was transferred to the Makkah Maternity & Child Hospital for an immediate Caesarean section at 34 gestational weeks. The preterm neonate had perinatal asphyxia and seizures, requiring a six-day stay in the neonatal intensive care unit and phenobarbital and ventilator support. He was later readmitted with neonatal sepsis and administered IV antimicrobials. Discussion The Saudi Arabian Ministry of Health has published succinct guidelines for pregnant pilgrims recommending that such women postpone pilgrimage due to the risk of infection, heat stroke and dehydration.14,15 The Hajj Committee of India has similarly prohibited Hajj pilgrimages for pregnant women over four gestational months, cautioning that pregnant pilgrims may potent- ially be deboarded from Hajj flights.11 However, many pregnant women are likely to covertly attempt Hajj pilgrimage, perhaps for religious or financial reasons. In Saudi Arabia, maternal and child healthcare is sponsored for foreign Hajj pilgrims, which may tempt those who reside in countries where adequate obstetric and neonatal care is not accessible or affordable. The overcrowding of people from diverse geo- graphical backgrounds in mass gathering settings—in which population density may reach up to 9 indiv- iduals/m2—can increase the transmissibility of certain respiratory pathogens, such as Ebola virus, MERS, H1N1, multidrug-resistant tuberculosis and poly- microbial infections, against which many people do not have pre-existing immunity.16 Moreover, if an out- break occurs during Hajj, there is high risk of the global spread of pathogens and continuing risk once affected individuals return to their countries of residence. Although most viral pathogens cause limited morbidity in healthy adults, they can pose significant risks to both mother and fetus during pregnancy.17,18 Cardio- respiratory compromise can adversely affect maternal haemodynamic stability, thereby affecting fetal nourish- ment.19 In addition, viruses which are transmitted trans- placentally can cause fetal viraemia, leading to multi- organ infections.20 This is particularly worrying as the detection of such infections is limited in mass gathering settings.21 Furthermore, the clinical presentation of certain respiratory infections may be non-specific, especially in cases of seasonal influenza and H1N1, thus increasing the burden of laboratory testing. During Hajj, the Saudi Arabian healthcare system has limited resources at its disposal, particularly when it comes to the sophisticated molecular tests required for the diagnosis and identif- ication of novel respiratory pathogens.21–23 While there are operational stringencies in place for the isolation of suspected cases of infection, there are no approved anti- viral drugs for treating novel respiratory pathogens—the teratogenic effects of which would need to be assessed in any case—nor available guidelines for their specific monitoring, prognosis or follow-up.21 Moreover, hospitalisation can further increase the transmission of respiratory pathogens.24 Unfortunately, sociolinguistic and ethnocultural differences are barriers to proposed measures aiming to help prevent the transmission of respiratory infections among Hajj pilgrims. It is possible that the adverse outcomes observed in the present study are attributable to the strenuous physical demands of Hajj. Pilgrims routinely perform physically demanding religious rituals including tawaf (circumambulating the Kaaba) and sa’i (a religious ritual involving walking for long distances) along with trips to Mina, Muzdalifah and Arafat, often without eating or drinking properly or getting sufficient rest. Pregnancy can negatively affect the physiological status of the mother due to the increasing demands of the growing fetus. Physical exhaustion can lead to contractions of the lower abdomen, backaches, physical injuries and physiological compromise.25 However, there is an incr- Obstetric and Neonatal Outcomes of Pregnant Indian Pilgrims A three-year experience at the Indian Hajj Medical Mission e360 | SQU Medical Journal, August 2018, Volume 18, Issue 3 easing body of evidence that women who participate in sustained and vigorous physical activity in the first and second trimester, such as high-performance sports and endurance training, have successful fetomaternal outcomes.25–27 Nevertheless, pregnant pilgrims run the risk of the spontaneous onset of labour during Hajj rituals, resulting in unattended delivery. Furthermore, other complications like anaemia, pre-eclampsia, GDM and hypothyroidism can have adverse fetomaternal outcomes. Such compl- ications require on-site antenatal management which may not be readily accessible; moreover, transportation to other facilities may not be possible due to overcrowding.7,8 Generally, pregnant women who travel for extended periods of time are likely to miss out on opportunities for breast feeding counselling, family planning, neonatal care and antenatal surveillance to detect gynaecological comorbidities. It is recommended that women with high-risk pregnancies, a history of preterm labour, recurrent pregn- ancy losses, GDM, chronic hypertension, pre-eclampsia, heart disease and those in the third trimester postpone Hajj pilgrimage. If determined to proceed, pregnant women should consult an obstetrician prior to embarking on Hajj and travel with sufficient medications for the entire pilgrimage. In addition, they should do their best to avoid crowds, wear comfortable clothes and shoes and maintain proper nutrition, hydration, rest and exercise.28 Adverse symptoms like bleeding, abdominal contractions, headaches and watery vaginal discharge should be immediately reported. Moreover, pregnant women should avoid excessive physical effort during Hajj rituals and take advantage of allowances, such as using a wheelchair during tawaf and sa’i. Patients should also declare known pregnancies or their intention to conceive during Hajj to the Saudi Arabian medical authorities, thereby enabling the adequate provision of antenatal care. Such efforts should be further prom- ulgated by medical missions in various countries. Conclusion Women who perform Hajj pilgrimages while pregnant have a high risk of abortion, respiratory infections and various antenatal and neonatal complications which may go untreated. Practitioners should therefore educate patients of these risks and advise them to postpone the pilgrimage until after the pregnancy. conflict of interest The authors declare no conflicts of interest. funding No funding was received for this study. References 1. General Authority for Statistics, Kingdom of Saudi Arabia. Num- ber of domestic and foreign pilgrims during Hajj. From: www. stats.gov.sa/en/28 Accessed: Mar 2018. 2. Gatrad AR, Sheikh A. Hajj: Journey of a lifetime. BMJ 2005; 330:133–7. doi: 10.1136/bmj.330.7483.133. 3. Al-Jasser FS, Kabbash IA, Almazroa MA, Memish ZA. Patterns of diseases and preventive measures among domestic hajjis from Central, Saudi Arabia. Saudi Med J 2012; 33:879–86. 4. Shafi S, Memish ZA, Gatrad AR, Sheikh A. Hajj 2006: Comm- unicable disease and other health risks and current official guid- ance for pilgrims. Euro Surveill 2005; 10:E051215.2. doi: 10.2807/ esw.10.50.02857-en. 5. Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. 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