Bed Rest In Pregnancy- More Harm Than Benefit?

Dr Sujoy DasguptaMBBS (Gold Medalist, Hons)

MS (Obst & Gynae- Gold Medalist)DNB (Obst & Gynae)

Assistant Professor: Gouri Devi Institute of Medical Sciences, Durgapur

Visiting Consultant: Indian Air Force

Secretary, Bulletin & Website Committee: Bengal Obstetric & Gynaecological Society (BOGS)- 2015-16

Bed Rest in Medicine

• Bed rest refers to “voluntarily” lying in bed as a treatment

Silas Weir Mitchell (1880)

Charlotte Perkins Gilman (1892)

Gain of Bed Rest

Bed Rest

Hysteric Patient

No bed rest

Productivity

Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354:1229-33

• Lumbar puncture • Spinal anesthesia • Radiculography • Cardiac catheterization • Skin graft of burn • Liver biopsy • Fixation of femoral

fracture • Pressure sore surgery • Gastric surgery

• Acute Hysteria• Panic Disorder• Acute low back pain• Uncomplicated myocardial

infarction• Pulmonary tuberculosis• Rheumatic Fever• Acute Viral Hepatitis • Spontaneous labor • Proteinuric hypertension during

pregnancy • Early threatened abortion

• There is no evidence to support the use of bed rest as therapeutic measure in modern medicine.

• Not only it is ineffective, but is associated with physical, emotional, social and financial burdens.

I am not interested in

the DIAGNOSIS, I will advise COMPLETE

BED REST !!!!!

Something is BETTER THAN NOTHING !!!!

At least we are TRYING

SOMETHING!!!!!

“There is NO HARM in Bed rest”

• Simulates physiology of space flight

• Thrombosis• Constipation• Hyperacidity• Depression and Anxiety• Family stress• Financial worries• Weakened bones and

muscles

Bed Rest in Obstetrics• Why wouldn’t you endure a

little extra annoyance (you’re pregnant, after all) if it would help keep your tiny,

oh-so-vulnerable fetus floating inside the fortress of your womb

as long as possible?

“If we have anything to learn from the history of medicine it is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

“Therapeutic” Bed Rest in Pregnancy- Unethical and Unsupported by Data. McCall CA, Grimes DA, Lyerly AD Obstet Gynecol 2013;121:1305–8

• Every woman receive INFORMED CONSENT

• If a woman feels that increasing her daily rest lessens anxiety, then we are not suggesting this should be discontinued

Do not try this !!!

Bed Rest is advised commonly in…

• Threatened Miscarriage• Recurrent Miscarriage• APH• Preterm Labour• High risk of preterm labour• Cervical Insufficiency• PROM• IUGR• Preeclampsia

Miscarriage

Rest = Glue?????

Genetic Thrombophilia

Endocrine

InfectionImmunological

Unknown

Cochrane Review

• Until further evidence is available the policy of bed rest cannot be recommended for women

1. with threatened miscarriage 2. at high risk of miscarriage*

*Aleman A, Althabe F, Belizán JM, Bergel E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003576

Cochrane Review (….. Contd.)Relative Risks (RR)

95% of Confidence interval (CI)

GA of miscarriage

Bed Rest

2.50 1.22-5.11

12 weeks

No Bed Rest 13.5 weeks

Bed rest after IVF

• Bed rest might negatively affect the outcome of IVF/ICSI cycles via stress/anxiety mechanisms*

*Craciunas L, Tsampras N. Bed rest following embryo transfer might negatively affect the outcome of IVF/ICSI: a systematic review and meta-analysis. Hum Fertil (Camb). 2016 Mar 17:1-7

Preterm Labour

Cochrane Review

• Although bed rest in hospital or at home is widely used as the first step of treatment, there is no evidence that this practice could be beneficial*

• Potential benefits and harms should be discussed with women facing an increased risk of preterm birth

*Sosa CG, Althabe F, Belizán JM, Bergel E. Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database Syst Rev. 2015 Mar 30;3:CD003581

• 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.

• Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects, such as loss of employment, should not be underestimated.

Multiple Gestation

Cochrane Review

• No reduction in the risk of preterm birth or perinatal death is evident with bed rest in multiples

• This policy cannot be recommended for routine clinical practice.*

*Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD000110.

Cervical Insufficiency

To prevent premature delivery

Belief• The reclining posture

reduces the force of gravity on the cervix

Evidence• Bed rest is not superior to

placebo for treatment of the mid-trimester extremely short cervix (≤15 mm)*

*Skupski DW, Lin SN, Reiss J, Eglinton GS. Extremely short cervix in the second trimester: bed rest or modified Shirodkar cerclage? J Perinat Med. 2014 Jan;42(1):55-9.

PROM

Theories

• Rest will reduce the leakage and prolong pregnancy

• Pooling of fluid in the vagina will invite infection

• Bed rest is an ineffective method to prolong duration of pregnancy in PROM irrespective of the GA of leakage and so it is not recommended.1-2

1. Biggio JR Jr. Bed rest in pregnancy: time to put the issue to rest. Obstet Gynecol. 2013 Jun;121(6):1158-60.

2. Cardell M, Stjernholm YV. Bed rest during risk for premature birth may do more harm than good. Lakartidningen. 2012 Sep 5-11;109(36):1556.

Put the “Rest” to rest

Harms of bed rest

Physical Effects*

• Loss of muscle tone, calcium loss, bone demineralization• Constipation, hyperacidity• Fatigue• Shortness of breath• Delay in recovery during the postpartum period

• Glucose intolerance (Diabetes)• Difficulty in BP control (Preeclampsia) • Low Birth Weight Baby (IUGR)

*Dunn, L. L., Handley, M. C., & Carter, M. R. Antepartal Bed rest: Conflicts, Costs, Controversies and Ethical Considerations. Online Journal of Health Ethics. 2006, 3(1)

Emotional Effects• Stress• Anxiety• Sleep Disturbances• Reduced adaptability to post partum status• Depression (PP Depression) 1-2

1. Heaman, M. Stressful life events, social support, and mood disturbance in hospitalized and non-hospitalized women with pregnancy-induced hypertension. Canadian Journal of Nursing Research. 2006, 24(1), 23-37.

2. Maloni, J.A., Brezinski-Tomasi, J.E., & Johnson, L.A. Antepartum bed rest: Effect upon the family. JOGNN, 2011, 30(2), 165-173.

Roy’s Adaptation Model*

• Adjustment to motherhood is already a huge transition and a great challenge

• Women with a high risk pregnancy will become physically deconditioned from bed rest

* Roy, C.L. The Roy adaptation model. 2013. bc.edu/school/son/faculty/featured/theorist/Roy_Adaptation_Model.html

Financial Factors

• Burden to family members

• Third Party Payers

Why still so popular among Obstetricians?

• As many as 95% of obstetricians report recommending activity restriction or bed rest, in some form, in their practices*

*“Therapeutic” Bed Rest in Pregnancy- Unethical and Unsupported by Data. McCall CA, Grimes DA, Lyerly AD Obstet Gynecol 2013;121:1305–8

• “we really don’t have anything to offer you”

• “I’m sorry ma’am, there is nothing we can do”

• “We are advising complete bed rest”

• “Well, there’s no evidence bed rest helps, but it is something we can try”

Inherently Soothing and therapeutic words

•Bed

•Rest

Bed????

Rest????

“Rest” in our body

• Antepartum bed-rest treatment should be discontinued until evidence of effectiveness is found.

One Minute Silence !!!!!

Bed Rest

Thank You