multiple gestation
Bedrest: What’s The Point?
October 23rd, 2009This podcast discusses the rationale for the bed rest prescription, indications for bed rest and new advances in the treatment of high risk pregnancy.
Is Complete Bed Rest Best?
October 16th, 2009Recently someone made the comment that high risk pregnant women should not engage in any sort of physical activity while on prescribed bed rest. I cannot disagree more vehemently! When a pregnant woman is placed on bed rest, not only is she at risk for the usual complications of pregnancy (in addition to the particular risks that landed her on bed rest in the first place!) she then adds an increased risk for deep venous thrombosis (DVT) and embolism, pulmonary complications an muscle atrophy (wasting and loss of strength). This is why I produced Bedrest Fitness, a series of exercises pregnant women can do while on prescribed bed rest.
Numerous research studies have documented that prolonged inactivity is detrimental to health. For this reason, when a person has heart bypass surgery, as soon as they are taken off the ventilator and are breathing on their own, nurses are instructed to get them out of bed and into a chair. This sometimes occurs within in hours of open heart surgery! But the sooner patients sit in an upright position, the sooner they will begin reusing their muscles, taking deep breaths and recovering. The same thing happens for orthopedic patients. Once a hip or knee is replaced, within hours to days, physical therapists begin moving the new joint to aid in healing, range of motion and optimum utilization. Early movemtner lowers the risk of venous blood pooling in the legs , blood clot formation, embolisms (blood clots that dislodge and travel to other areas of the body), pulmonary (lung) collapse, fluid in the lungs and the development of pneumonia. So given these examples (and there are many more such as cancer patients and other surgical patients) doesn’t it seem strange that we tell pregnant women to go sit/lie down for weeks to months at a time???
I am sure that opponents and naysayers will chide me by saying, “Well then YOU take responsibility when a woman loses her baby!” I think that we can all agree that no one wants a pregnant woman to lose her baby (or babies as the the case may be). But I think that it behooves all of us, especially in this era of health care reform, to re-examine how we manage high risk pregnant women and to really ask ourselves, is complete bed rest really best?
In some cases, bed rest really is the answer. If a woman is actively bleeding from her vagina, experiencing contractions indicative of preterm labor or has severe high blood pressure and is at risk of pre-eclampsia then yes, bed rest is indicated and I think that inpatient hospital care is best in these settings. But once the bleeding stops, the contractions stop and her blood pressure is closer to the normal range is it still necessary to completely restrict a woman’s activities? Is it best to send her home without medical supervision? Is it in her and her baby’s best interest for her to remain immobile and inactive?
Researchers are just beginning to look at how high risk pregnant women are managed and are beginning to realize that perhaps restricted activity and modified bed rest are better options. If a woman is able to be up out of bed but sitting with her feet up she can work from home and engage in family activities. But some people still argue this isn’t enough, especially in the case of the incompetent cervix. They argue that the gravitational pull downward requires that a women stay reclined in bed. Again, this may not be the case.
The September 2009 American Journal of Obstetrics and Gynecology published a study, “Prediction of spontaneous preterm birth in asymptomatic twin pregnancies with the use of combined fetal fibronectin (fFn) test and cervical length”. Now first let’s qualify their findings by saying that the mothers in this study were in fact having twins but they were not otherwise high risk, i.e. they didn’t have incompetent cervices. The researchers found that in 155 twin pregnancies examined between 22 and 32 weeks gestation,
- A positive fFN test or a cervical length of <20mm increased the risk of spontaneous preterm birth at <37,<34,<32, <30 and <28 weeks gestation.
- The combination of a positive fFN test result and cervical length <20mm had a significantly higher positive predictive value for delivery at all gestational ages than either test alone.
- A positive fFN test result was a stronger predictor of spontaneous preterm birth than a short cervical length alone.
Although this is one test and on a fairly small, very specific population, we can’t ignore the potential indications. To date many women with multiple pregnancies are placed on bed rest to prolong gestation-regardless if they are having symptoms of preterm labor or other complications. While most mothers of multiples often lower their activity levels later in pregnancy out of necessity, those who wish to remain “restricted” but not “bedridden” may now have a way to determine their risk and potentially avoid bed rest.
Likewise, incompetent cervix is one of the most common reasons women are placed on prescribed bed rest. If a pregnant woman with an incompetent cervix can have a cerclage (sugical stitch placed around the cervix) and if the cervix is not effacing (thinning and shrinking), the fFN test may be used to establish which mothers actually need to be on bed rest because preterm labor is highly probable and which mothers may be able to be on modified bed rest, “house arrest” or simple modified/restricted activity.
Truly more research must be done in this area, but it is exciting to see that people are actually doing work for us high risk mamas. Maybe one day, we’ll be better able to tell who really needs to be on bed rest and who does not.
Mamas on bed rest, if you want to keep moving, try Bedrest Fitness! It’s simple yet effective at helping maintain muscle strength and mobililty. see a clip at www.mamasonbedrest.com.
Indications for Bed Rest
September 22nd, 2009Each year some 700,000 (about one in five) pregnant women will be prescribed bed rest, either modified activity or complete inactivity and confinement to bed. While bed rest has been a part of obstetrics for years, there is still controversy as to whether or not bed rest actually helps or is effective against any of the conditions for which it is prescribed.
Bed rest is commonly prescribed for women who:
- Have a multiple gestation; twins, triplets or higher order multiples
- Have an “incompetent cervix”; a cervix that begins to open prior to 37 weeks pregnancy endangering the life of the fetus and/or mother
- Preterm labor or a history of preterm labor; labor that begins before 37 weeks gestation
- History of prior miscarriage, still birth (death in utero) or premature birth (prior to 37 weeks gestation)
- intrauterine growth restriction/retardation (impaired growth)
- Placenta Previa; The placenta presenting first at the cervical opening
- Gestational Hypertension; with or without Pre-Eclampsia(toxemia)
- Gestational Diabetes
- Vaginal bleeding
- Too little amniotic fluid (oligoamnios)
While all of these conditions certainly put mama and baby at risk, to date there is no solid evidence that prescribed bed rest is effective at stopping or improving any of these conditions. In fact, studies to date show that prolonged bed rest and inactivity actually cause a worse overall physical condition to pregnant women-even those considered “high risk”. Women on prescribed bed rest may develop muscle weakness, cardiovascular deconditioning, blood clots, fatigue, drops in blood pressure when standing up, backache, bone loss, changes in metabolism, muscle aches, joint pain, difficulty walking (particularly stairs), difficulty concentrating, dizziness, shortness of breath, insomnia, and weight loss.
What has always struck me is the lack of attention to the emotional and psychological effects that prescribed bed rest has on pregnant women. When I have raised this concern to obstetricians their response typically is many of the psychosocial stressors can be dealt with once mother and baby are physically safe. However, studies have shown that maternal stress and anxiety prenatally can result in significant depression (perhaps leading to post partum depression) as well as mood changes a sense of confinement and loss of control. These psychological stressors can have significant impact on the course of the pregnancy and the health of both mother and baby. Additionally prescribed bed rest affects a pregnant woman’s entire family an can lead to child care problems, strained relationships and financial difficulties.
The next several blog posts will examine the common conditions for which bed rest is prescribed and the “proposed” benefit of bed rest on the condition. We’ll also look at what some research is revealing about bed rest in these situations and how many clinicians are rethinking how and when they prescribe bed rest for their patients.
