New Thinking on Risky Pregnancies

Bed rest may not be the answer for risky pregnancies
Source: The Wall Street Journal. Your health.
July 15th, 2013Studies show bed rest doesn’t alleviate complications, and could cause other problemsDoctors increasingly are recommending pregnant women limit their activities if they are at risk for complications, rather than resorting to the traditional approach of resting in bed.

Remaining in bed for extended periods has long been prescribed for women who are at risk for preterm delivery labor or have high blood pressure, bleeding or other complications. But studies have failed to turn up evidence that bed rest improves these conditions. And some research has shown that being confined to bed can cause health risks of its own, including blood clots and a temporary loss of bone-mineral content.

Bed rest is “not healthy, it’s not helpful and it’s potentially detrimental,” said Michael Katz, chief of obstetrics at California Pacific Medical Center in San Francisco. “It’s something I’m staying away from more and more.”

So why do many doctors continue to recommend bed rest? As many as 20% of women in the U.S. are placed on bed rest in the latter half of pregnancy, according to some estimates. Experts say some practitioners fear liability if a complication arises and the doctor didn’t take action. And some mothers want to feel they are minimizing risks to their unborn babies.

Dr. Adam Wolfberg says bed rest can help some women overcome fears.

“I think that bed rest is something women can do that makes them feel better in the incredibly powerless situation they find themselves in when facing a loss or preterm delivery,” said Adam Wolfberg, a specialist at Boston Maternal-Fetal Medicine. Dr. Wolfberg said he agrees there isn’t evidence that bed rest is beneficial, but he believes it can make a woman feel better and that it is unlikely to hurt.

Some doctors say they will only recommend full bed rest in extreme circumstances, such as advanced cervical dilation to the point when other measures haven’t helped, or the premature rupture of a membrane.

The controversy underlying bed rest was highlighted in May with the publication in the journal Obstetrics & Gynecology of a study and editorials that cast doubt on or criticized the practice. The study found that restrictions on activity by women who had a short cervix—which increases the risk of preterm birth—didn’t result in fewer preterm births than those who had no restrictions. The study, supported by the National Institute of Child Health and Human Development, part of the National Institutes of Health, analyzed data from a previous trial of about 650 women. About 252 of the women said they had been placed on activity restriction or bed rest.

The American Congress of Obstetricians and Gynecologists issued a bulletin to members last year on preterm labor, which affects about 12% of births and is defined as birth before 37 weeks. “Although bed rest and hydration have been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended,” read the bulletin.

Other studies have found detrimental effects to bed rest. A 2010 study in the American Journal of Obstetrics & Gynecology that reviewed previous research said that women placed on bed rest had a 19-fold increased chance of getting deep-vein thrombosis, or a blood clot in a deep vein, usually in the lower part of the body, said Anne Lyerly, associate director of the Center for Bioethics at the University of North Carolina, Chapel Hill.

Dr. Lyerly, who co-wrote one of the editorials in the May issue of Obstetrics & Gynecology, called the practice of prescribing bed rest unethical. In her editorial, she cited a 2011 review of previous research that said bed rest can also result in bone demineralization and muscle atrophy, and cause psychological effects, such as depression and increased stress levels. The review, published in the journal Expert Review of Obstetrics & Gynecology, cited earlier studies including one that found pregnant women on bed rest had a bone loss of 4.6% compared with 1.5% for those who weren’t.

Some doctors say they are increasingly recommending at-risk patients limit their activity rather than go on bed rest. They may tell patients to rest more or avoid strenuous exercise or long walks. “The modern woman is going to say, ‘Can I go to yoga? Can I go to the gym? Can I still work 60 hours a week?,'” said Adam Romoff, associate chairman of obstetrics and gynecology at Lenox Hill Hospital in Manhattan. “We still should be careful about whether these patients should be going to the gym or taking long walks. I think we should negotiate 20, 30 or 40% off the top as far as physical activity goes.”

Taking a Load Off


Nearly 1 in 5 women are put on bed rest at some point during pregnancy to safeguard against complications, some experts estimate. Bed-rest regimens can vary, depending on the degree of pregnancy risk.

  • On modified bed rest, a woman might need to limit her activities for a period of time. It might be OK to move around the house, and even continue working. But heavy tasks, such as housework and lifting children, should be avoided.
  • Strict bed rest might require remaining in a sitting or reclining position most of the time. Getting out of bed might be permitted only to shower or use the bathroom.
  • With total bed rest, typically recommended for the riskiest pregnancies, women might need to lie on their side at all times, even when eating. Personal hygiene is often limited to sponge baths and a bedpan. Some women require hospitalization.

Source Mayo Clinic

Connie Fong, a patient of Dr. Katz at California Pacific Medical Center, was put on strict bed rest in the hospital during her first pregnancy in 2011 after losing a baby the previous year. For 10 weeks, she was restricted to a bed and was wheeled outside on a gurney to get fresh air for one hour a day.

“It became a physical and mental challenge,” recalled the 35-year-old resident of Menlo Park, Calif.

Still, she felt the bed rest was warranted given that she was showing signs of preterm labor. In the end, Ms. Fong didn’t deliver the child early, and her son is now 23 months old.

Ms. Fong currently is expecting her second child in a couple of months. She is on modified bed rest, working from home three days a week to avoid the commute to her job in San Francisco. She can’t lift anything more than 10 pounds and tries to lie horizontal as much as possible. Still, she says the restrictions are far easier, both psychologically and physically, than her last pregnancy.

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