The medical profession has not yet discovered how to effectively prevent most risks of miscarriage or early delivery, but due to popular, demand the prevailing therapy is to give a “prescription” for bed rest. As a result, each year here in the United States, approximately 18% of pregnant women will be placed on bed rest at some point during their pregnancies. A 2009 survey of maternal – fetal medicine specialists found that 71% would recommend bed rest for preterm labor and 87% would recommend bed rest for premature rupture of membranes.
An article in the June issue of Obstetrics and Gynecology, published by the American College of Obstetricians and Gynecologists, points out that this advice is not only not supported by evidence but will probably cause maternal harm. (Yes, the sentence contains a double negative.)
One of the most important arbitrators in evidence – based medicine is the Cochrane Review. It is published by a group of researchers and statisticians who examine the studies on a particular subject which have been published in peer-reviewed medical journals and then use statistical analysis to assess the combined results and the validity of the conclusions. In a search of the Cochrane Library using keywords “bed rest” and “pregnancy”, the authors of the article found that the systemic reviews do not support “therapeutic” bed rest for threatened miscarriage, hypertension, preeclampsia, preterm birth, multiple gestation or fetal growth impairment.
The authors also propose that in addition to the lack of demonstrable benefit there are potential harms to prolonged bed rest for the mother. These include clots or venous thrombosis, bone demineralization, muscle atrophy, maternal weight loss, and maternal psychological problems. We know that bed rest increases the risk for clot formation in large veins which can then lead to pulmonary embolism. Well so does pregnancy. So from a clotting point of view, bed rest in pregnancy is a double thromboembolic whammy. One study that compared the incidence of thrombosis in pregnant women placed on bed rest with those who had no bed rest found their relative risk of a thromboembolic incident was increased by a factor of 19! Moreover lack of ambulation can be very detrimental to bone density. An important study examining bone loss in pregnant women with DEXA scans found that women on bed rest had an adjusted mean loss of 4.6% compared with 1.5% in ambulatory women.
The authors go on to discuss the psychological suffering associated with prolonged bed rest during pregnancy. Women experience separation from their families and worry about their well-being. Studies have shown that depression, anxiety, hostility and self blame for a “problematic” pregnancy can result. There are also severe impacts on the children at home due to shifts in childcare as well as a financial burden from lost wages. In 1993 the societal cost of pregnancy bed rest was estimated to be $1.03 billion per year. Adjusting for consumer price index, that now equates to about $1.6 billion per year.
I personally know about the psychological impact, as well as the financial one, of bed rest in pregnancy. When I was pregnant with my second daughter, I self-diagnosed (I did my own ultrasound, don’t ask!) a large pelvic tumor which I thought might be malignant. So, at five months gestation I had abdominal surgery and a myomectomy. (The tumor was a benign fibroid and no I could not do my own surgery). I subsequently stayed home, at bed rest for the next 3 1/2 months. It was extraordinarily difficult and depressing. My older daughter was unhappy, as were my spouse, patients and colleagues. Did it make a difference? I now don’t know; I finally delivered a second, very healthy daughter at 40 weeks.
Given all these considerations (which did not include my experience), the American College Obstetricians and Gynecologists has stated that, “Although bed rest and hydration has 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. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects, such as loss of employment, should not be under estimated.”
This is probably one more instance where traditional medical advice is less than certain once the evidence is appropriately examined.