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Bed Rest in Pregnancy MOUNT SINAI JOURNAL OF MEDICINE 78:291–302, 2011 291 SPECIAL FEATURE Bed Rest in Pregnancy Catherine Bigelow, BA, and Joanne Stone, MD Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, Mount Sinai School of Medicine, New York, NY OUTLINE obstetricians utilizing maternal activity restriction in some way in their practice. Bed rest is prescribed for EPIDEMIOLOGY OF THE a variety of complications of pregnancy, from threat- USE OF ANTEPARTUM BED REST ened abortion and multiple gestations to preeclamp- CLINICAL CONDITIONS FOR WHICH BED REST sia and preterm labor. Although the use of bed rest is pervasive, there is a paucity of data to support IS PRESCRIBED its use. Additionally, many well-documented adverse Threatened Abortion physical, psychological, familial, societal, and finan- Multiple Gestations cial effects have been discussed in the literature. Hypertensive Disease of Pregnancy: There have been no complications of pregnancy Gestational Hypertension and for which the literature consistently demonstrates Preeclampsia a benefit to antepartum bed rest. Given the well- Preterm Labor documented adverse effects of bed rest, disruption Embryo Transfer of social relationships, and financial implications Fetal Growth Restriction of this intervention, there is a real need for sci- Other Conditions entific investigation to establish whether this is an appropriate therapeutic modality. Well-designed ran- POTENTIAL COMPLICATIONS domized, controlled trials of bed rest versus nor- Maternal Effects mal activity for various complications of pregnancy Effects on the Family are required to lay this debate to rest once and Neonatal Effects for all. Mt Sinai J Med 78:291–302, 2011. 2011 DISCUSSION Mount Sinai School of Medicine ABSTRACT Key Words: antepartum activity restriction, bed rest, pregnancy. The use of bed rest in medicine dates back to Hippocrates, who first recommended bed rest as Hippocrates was the first physician to recommend a restorative measure for pain. With the formaliza- bed rest as a potential treatment for a medical ailment. tion of prenatal care in the early 1900s, maternal bed In this case, he prescribed it for the management of rest became a standard of care, especially toward the pain, but noted that ‘‘should a long period of inac- end of pregnancy. Antepartum bed rest is a com- tivity be followed by a sudden return to exercise, mon obstetric management tool, with up to 95% of there will be an obvious deterioration.’’1 Before the 19th century, patients were likely to refuse bed rest due to lack of income and fear that one would never Address Correspondence to: get up again. In the mid-1800s, Dr. John Hilton pub- lished his work ‘‘On Pain and Rest,’’ in which he Joanne Stone advocated bed rest for postoperative recovery after Department of Obstetrics, orthopedic procedures,1,2 specifically promoting the Gynecology and Reproductive benefit of rest on diseases of the hip joint. This work Sciences led to increased popularity of bed rest as a thera- Division of Maternal Fetal peutic intervention in medical practice. It was not Medicine Mount Sinai School of Medicine until the mid-1950s that bed rest began to fall out of New York, NY practice, when the National Aeronautics and Space Email: [email protected] Administration (NASA) used bed rest as a surrogate for weightlessness in space and began documenting Published online in Wiley Online Library (wileyonlinelibrary.com). DOI:10.1002/msj.20243 2011 Mount Sinai School of Medicine 292 C. BIGELOW AND J. STONE:BED REST IN PREGNANCY physiologic side effects of activity restriction.3 is clear that bed rest is used frequently, and for a Maloni4 summarizes NASA’s research, which found variety of indications, many authors have discussed that the supine position (a surrogate for bed rest) Almost 20% of women will be leads to several physiologic adaptive changes, includ- ing changes in hydrostatic gradients and alterations in placed on bed rest at some point the cardiovascular/cardiopulmonary, fluid and elec- during their pregnancy. trolyte, hormonal, hematologic, musculoskeletal and its apparent lack of efficacy and myriad adverse neurosensory/vestibular systems. These physiologic 4,11,13,15,17 alterations ultimately lead to debilitative symptoms effects. A recent survey of MFM providers during bed rest and recovery, including muscle assessed attitudes toward the prescription of bed rest 5 6,7 for 2 complications of pregnancy: preterm labor and atrophy and bone demineralization. Maloni also 18 highlights an organizational framework based on the premature rupture of membranes (PROM). More aerospace research to explain some of the adverse than 70% of MFM physicians recommended bed rest effects of bed rest and guide future directions for for preterm labor, and almost 90% recommended it research on antepartum bed rest.4 In addition, many for PROM. Despite these practice recommendations, studies later documented adverse behavioral and the majority of these physicians reported little to no sociocultural alterations associated with bed rest dur- expected benefit from bed rest. ing pregnancy.5,8– 10 Thedeclineintheuseofbed True adherence to bed rest can be quite low, and vary depending on whether bed rest is pre- rest was further fueled by studies that demonstrated 19 worse outcomes when bed rest was used as the pri- scribed in the hospital or at home. Formerly, mary therapy for acute low back pain, uncomplicated physicians prescribed sedation with bed rest, in order myocardial infarction, pulmonary tuberculosis, and to improve women’s compliance to restricted activ- acute infectious hepatitis.11 Early return to function ity. This practice, fortunately, has fallen out of use. and encouragement of patients to improve activity Women often push the limits of their activity restric- tion due to uncertainty about the effectiveness of the are now goals of care in many fields that previously 20 recommended bed rest as a therapeutic measure. intervention and the ambiguity surrounding their Activity restriction in obstetrics, however, is sur- limitations while on bed rest. Although women are prisingly still pervasive. Bed rest in pregnancy was aware of the recommendation to stay in bed for various complications of pregnancy, many of them first recommended in midwifery texts in the mid- 21 1800s, and became increasingly popular with the fail to comply with this treatment. Mothers placed formalization of prenatal care in the early 1900s.1 on home bed rest often grapple with the temptation 19 Even in the Victorian era, women were ‘‘confined’’ to perform more activity than recommended. Many by childbirth, with the term estimated date of con- barriers to compliance with antepartum bed rest have finement still used in obstetric practices today. The been identified, including need to care for other chil- lying-in period following childbirth was, effectively, a dren, not feeling sick, household demands, lack of a 22 prolonged period of bed rest after delivery.1 Because partner or support, and having to work. of this long history of bed rest prescription by obste- tricians, this intervention has persisted in clinical CLINICAL CONDITIONS FOR WHICH practice, despite its being abandoned in other fields. BED REST IS PRESCRIBED EPIDEMIOLOGY OF THE There are a variety of clinical conditions for which USE OF ANTEPARTUM BED REST bed rest is prescribed by obstetricians. Though the list of conditions is long, the list of evidence to Bed rest is a very common obstetrical intervention. support the use of bed rest is rather short. Some Up to 95% of obstetricians utilize bed rest in their complications, such as preterm premature rupture practice for a variety of indications.12– 15 A survey of membranes (pPROM), have never been directly of both maternal fetal medicine (MFM) directors There are a variety of clinical and practicing obstetricians not only documented widespread use of bed rest (89%–93%), but also conditions for which bed rest is highlighted the tremendous variability in indications, prescribed by obstetricians. location (hospital or home), and severity of activity Though the list of conditions is restriction, even when treating the same conditions.16 Almost 20% of women will be placed on bed rest at long, the list of evidence to support some point during their pregnancy.13 Although it the use of bed rest is rather short. DOI:10.1002/MSJ MOUNT SINAI JOURNAL OF MEDICINE 293 studied, whereas others, such as threatened abortion, not mention which study group these patients were multiple gestations, hypertensive diseases of preg- in. The authors closed the study in order to orga- nancy, and preterm labor, have received slightly more nize a larger, multicenter trial to better analyze the attention in the literature. utility of bed rest, though this has not been car- ried out to date. These 2 studies were analyzed in a 2005 Cochrane review on bed rest for prevention of Threatened Abortion miscarriage, which again concluded that insufficient evidence exists for this recommendation.25 The most Threatened abortion is defined as vaginal bleeding recent study of bed rest for threatened abortion came before viability of the fetus. The majority of threat- out of Israel in 2003; the authors studied women ened abortions lead to normal pregnancy outcomes, with threatened abortion complicated by subchori- but some lead to miscarriage of the fetus. Spon- taneous abortion is most commonly due to fetal onic hematoma (a hematoma underlying the placenta or chromosomal abnormalities, though
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