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Does Bed Rest for Preeclampsia Improve Neonatal Outcomes?

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Does Bed Rest for Preeclampsia Improve Neonatal Outcomes? From the CLINICAL INQUIRIES Family Physicians Inquiries Network Maria Linda Cabrera, MD, Todd McDiarmid, MD Does bed rest for preeclampsia Moses Cone Family Medicine Residency Program, Greensboro, NC improve neonatal outcomes? Leslie Mackler, MLS Greensboro AHEC Librarian, Moses Cone Hospital, Evidence-based answer Greensboro, NC No. Strict bed rest in the hospital for intensive care unit (NICU) admissions pregnant women with preeclampsia does (strength of recommendation: B, not appear to lower rates of perinatal based on 2 randomized controlled trials mortality, neonatal mortality, or neonatal [RCT] and extrapolations from 2 RCTs morbidity, including preterm birth, of pregnant patients with nonproteinuric endotracheal intubations, or neonatal hypertension). Clinical commentary Changing long-standing practices challenge for us, even though we is always a challenge consider the relationship we have with our We’ve said goodbye to magnesium for obstetrical nurses and physicians to be a preterm labor, and now it looks like bed good one. rest for preeclampsia is not far behind. Our plan to introduce these FAST TRACK Changing long-standing practices in modifications will follow previous Strict bed rest response to stronger evidence-based successful plans; the member of our group information is always a challenge, with the most “capital” in Obstetrics can for women with especially when we’ve been relying bring others on board. preeclampsia does on long-standing expert opinion or anecdotal evidence. Following these Ronald Januchowski, MD not lower rates Spartanburg Regional Medical Center, of preterm birth recommendations will be another Spartanburg, SC or NICU admission z Evidence summary to either strict bed rest with bathroom Ten percent of preeclampsia occurs in privileges in the hospital until delivery, pregnancies at less than 34 weeks of or to bed rest with the ability to move gestation. Traditionally, physicians of- freely around the hospital. Outcome as- ten recommended bed rest to preterm, sessors were not blinded to patient treat- preeclamptic patients in the belief that ment allocation. There was no statisti- it would improve neonatal outcomes. cal difference between the 2 groups in perinatal or neonatal mortality, or in the RCTs find no difference between neonatal morbidities of preterm births, bed rest and ad lib movement endotracheal intubations, or NICU A single-center RCT investigated bed admissions.1 rest treatment for 105 patients with pre- Similarly, a small, unblinded RCT of eclampsia and gestational ages between 40 preeclamptic patients treated in the 26 to 38 weeks. Patients were assigned hospital with strict bed confinement or 938 VOL 56, NO 11 / NOVEMBER 2007 THE JOURNAL OF FAMILY PRACTICE Bed rest for preeclampsia without restrictions found no significant tivity in fetal or neonatal outcomes.4 difference in fetal or perinatal mortality.2 No power calculations were reported Recommendations from others for detecting differences in neonatal out- An American College of Obstetrics and come rates in either of these studies. Gynecology practice bulletin on diag- nosis and management of preeclamp- Studies in nonproteinuric sia and eclampsia does not mention hypertension were no different bed rest.5 The Canadian Hypertension In addition to the studies in patients with Society Consensus Conference in 1997 preeclampsia, 2 RCTs measured neona- stated that a “policy of hospital admis- tal outcomes with bed rest compared sion and strict bed rest is not advised with normal activity in pregnancies com- for gestational hypertension with or plicated by nonproteinuric hypertension. without proteinuria.”6 n These studies also found that bed rest did not improve neonatal outcomes. References The first trial was a multicenter RCT 1. Meher S, Abalos E, Carroli G. Bed rest with or involving 218 patients between 28 to 38 without hospitalisation for hypertension during pregnancy. Cochrane Database Syst Rev 2005; (4): weeks gestation with nonproteinuric hy- CD003514. pertension (blood pressure >140/90 mm 2. Matthews DD, Agarwal V, Shuttleworth TP. A ran- Hg). The patients were randomized to 2 domized controlled trial of complete bed rest ver- sus ambulation in the management of proteinuric groups: bed rest in the hospital but al- hypertension during pregnancy. Br J Obstet Gyne- lowed to move around the ward, and col 1982; 89:128–131. normal activity at home without restric- 3. Crowther CA, Bouwmeester AM, Ashurst HM. tions. The outcomes were measured by Does admission to hospital for bed rest prevent disease progression or improve fetal outcome in masked assessors. There were no statis- pregnancy complicated by non-proteinuric hyper- tical differences in perinatal or neonatal tension? Br J Obstet Gynecol 1992; 99:13–17. mortality, or in the neonatal morbidities 4. Matthews DD. A randomized controlled trial of bed rest and sedation or normal activity and non-se- of preterm birth, newborns small for dation in the management of non-albuminuric hy- their gestational age, or NICU admis- pertension in late pregnancy. Br J Obstet Gynecol sions between the 2 groups.3 1977; 84:108–114. A second RCT of 135 nonprotein- 5. Diagnosis and management of preeclampsia and eclampsia. American College of Obstetrics and uric but hypertensive pregnant patients Gynecology (ACOG) Practice Bulletin, No. 33. Ob- with diastolic blood pressures between stet Gynecol 2002; 99:159–67. 90 and 109 mm Hg also demonstrated 6. Report of the Canadian Hypertension Society Con- sensus Conference: Nonpharmacologic manage- no difference between patients treated ment and prevention of hypertensive disorders in with bed rest and sedation or normal ac- pregnancy. Can Med Assoc J 1997; 157:907–919..
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