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It’s amazing to me that this is something still worth writing about, but unfortunately obstetricians and high-risk OB specialists around the country continue to use and prescribe bed rest or activity restriction to treat various conditions of pregnancy, including preterm labor, premature rupture of membranes, placental abruption, preeclampsia, threatened abortion, intrauterine growth restriction, oligohydramnios, multiple gestations, etc.

Here’s the easy part:

In fact, there is nothing controversial at all about bed rest except that so many providers continue to use it formally or informally in their practices even though there is simply no evidence that it is beneficial while there is significant evidence that it is harmful. The issue of bed rest and activity restriction in pregnancy beautifully illustrates the main problem with medicine today: physicians refuse to follow evidence-based guidelines (like the two above) even when they exist. The issue is not the evidence or the lack of quality studies or the lack of dissemination of the data; the issue is entirely physician attitudes. This is not a new topic; we have known for years that bed rest and activity restriction are of no value and are net-harmful to pregnant women; yet, as I write, physicians across the country issue casual statements like, “Maybe you should take it easy for a few days” or they issue formal orders like, “You should lie in bed all day except to take a 10 minute shower and use the bed-side commode.”

A 2013 editorial in Obstetrics and Gynecology by Biggio reported these facts:

  • 95% of obstetricians prescribe bed rest
  • This costs $2-7 billion annually
  • 76% of MFMs believe there is limited to no evidence of its value for preterm labor, yet 71% prescribe it (56% and 87% for PPROM)
  • Nearly 1 million families per year are adversely affected by bed rest

If you’re a physician who is doing these practices, please keep reading. If you’re a patient who is on activity restriction, know that your doctor doesn’t believe in evidence-based medicine.

So now that hard part.

Let’s examine the benefits and risks of activity restriction in pregnancy.

First the benefits:

  • None.

McCall et al. reviewed the literature on bed rest in 2013. They found 6 Cochrane reviews which together analyzed 17 trials of 4,110 women; these studies showed no benefit for bed rest for the treatment of hypertension in pregnancy, prevention of miscarriage, prevention of preeclampsia, prevention of preterm birth, multiple gestations, or growth restriction. Nothing really more can be said about this issue: whatever you might anecdotally believe, there is simply no benefit to bed rest that has ever been observed in a quality trial. Like many practices in medicine, it was adopted without evidence and became dogma long before it was ever studied. But like tocolytics, once we learned that it didn’t work, most doctors didn’t stop prescribing it.

Here are some studies to save you the time of looking:

  • The 1994 West Los Angeles Preterm Birth Prevention Project assigned 432 high risk women to bed rest and another 834 to no bed rest. There was no difference in the rate of preterm birth among the two groups.
  • Elliott et al. in 2005 randomized 73 women with preterm labor to activity restriction or no activity restriction. They found no difference in the timing of delivery.
  • Grobman et al. in 2013 published a secondary analysis of 646 nulliparous women who had a shortened cervix and were treated with progesterone (17-OHP). A subset of 252 of these women were also prescribed activity restriction. The group of women who were assigned to activity restriction were more likely to deliver preterm than no activity restriction (AOR 2.37, p < 0.001).
  • The Generation R Study, published in 2012, included an analysis of physically demanding work on fetal growth and adverse pregnancy outcomes. They concluded that there were “no consistent significant associations between physically demanding work nor working hours in relation to small for gestational age, low birth weight or preterm delivery.”
  • Clapp, in 1990, found that women who continued their running or aerobics exercise programs during pregnancy (including the third trimester) did not have an increased incidence of preterm labor or other pregnancy problems but did have a lower risk of cesarean delivery, a quicker labor, and less meconium and fetal distress.
  • Barakat et al. have published a series of randomized studies from 2012 to 2016 which have shown that regular exercise throughout pregnancy results in a lower cesarean and instrumental delivery rate, less maternal weight gain, less depression, a shorter first stage of labor, and less maternal hypertension and fetal macrosomia.
  • Jukik et al. in 2012 reported that “our data support a reduced risk of preterm birth with vigorous recreational activity.”

We could go on, but this is the type of data reported over and over again about level of activity and risks of adverse pregnancy outcomes. Note also that, if any association does exist, it is that the more the activity, the better the pregnancy outcomes, including the risks of preterm delivery.

Now that we better understand the benefits of activity restriction in pregnancy, let’s look at the risks. Judith Maloni provides an excellent and exhaustive literature review of the negative effects of activity restriction in pregnancy, including:

  • Adverse maternal effects:
    • Increased risk of thromboembolism
    • Increased bone demineralization
    • Numerous negative cardiovascular and pulmonary changes
    • Numerous musculoskeletal changes, including muscle atrophy
    • Negative fluid and electrolyte changes
  • Adverse fetal effects:
    • Lower birth weights
  • Adverse psychological effects:
    • Depression
    • Anxiety
    • Family stress
    • Family separation
    • Financial stresses

These are not petty or trifle complications. Sciscione, in 2010, reviewed the literature extensively regarding the negative effects of bed rest. He reports an increase in the risk of thromboembolism from 0.8/1000 in pregnant women not on bed rest to 15.6/1000 among women on bed rest. This negative effect alone more than justifies a strict policy of not prescribing bed rest. The prescription of bed rest may result in an excess of more than 10,000 blood clots per year among pregnant women, with some resulting in maternal death.

Often overlooked are the financial implications of bed rest or activity restriction. In many situations, the mother may be the sole income-earner for the family, or the family may require two incomes just to get by. When the physician non-chalantly recommends that a woman not work, this may have devastating financial implications for the whole family, and often the extended family. In a survey cited by Sciscione, 71% of women placed on activity restrictions suffered significant financial hardships, and these financial difficulties often become the biggest stressor for the pregnant woman and her family.

Another problem is what McCall et al. refer to as “a false sense of agency.” When women are told to use activity restriction to prevent miscarriage, preterm birth, preeclampsia, abruption, oligohydramnios, etc., and then the dreaded event happens anyway, the women may believe that their lack of full compliance with the prescribed activity restriction is to blame. I have met dozens of women who believe that they suffered a miscarriage because of activity; I have consoled several guilt-ridden women whose baby just delivered prematurely, who are apologizing because they feel responsible since they did not remain at strict bed rest as they were told (by another physician).

This false sense of agency is cruel and immoral, and any time a physician offers non-evidenced-based advice to a common problem, there is a great risk that this will occur. Indeed, physicians need to be careful even when telling patients about known and real risks factors. For example, consider a patient with a growth restricted baby who also smokes; we know that smoking contributes to the risk of growth restriction, and the patient should be encouraged to quit smoking. However, she should not be led to believe that her baby’s growth restriction is due primarily to smoking. The magnitude of the effect for her case is unknown and the actual cause of the growth restriction is probably unknown; causing excess guilt to the patient is not productive.

McCall et al. conclude that therapeutic bed rest in pregnancy is “unethical and unsupported by data.” So why do 95% of providers still recommend it? This question is both challenging and disturbing. Here’s what we know:

  • Activity restriction is not controversial; there is not a body of mixed data that is subject to interpretation.
  • Evidence-based medicine has never supported the practice.
  • Our professional societies recommend against it.
  • It harms women.
  • It is unethical to prescribe it.

So the question is, Why would a doctor do something that is unethical, that is harmful to his patient, that is recommended against by his professional societies, and that is thoroughly rejected by science? I don’t know the complete answer to this question, but it is a theme of many of the things I write about. One conclusion that must be drawn is that physicians, in general, do not care about evidence-based medicine or science, nor do they think about clinical problems from an ethical perspective. I’m open to other suggestions.

The diagnoses for which bed rest or activity restriction are normally recommended (things like threatened miscarriage or threatened preterm labor) are all things that don’t have good treatments. Part of the problem certainly is that physicians have a hard time saying, “I’m sorry that this is happening to you. We unfortunately don’t have any good treatments and we don’t completely understand why this is even happening. There is a good chance that everything will work out and be okay, but, for now, we just have to wait and see what happens.” This desire to do something – anything – is called the therapeutic imperative.

Kathryn Montgomery, in her book How Doctor’s Think, describes the therapeutic imperative as “Always do everything for every patient forever,” but she juxtaposes this to our ethical standard of primum non nocere (first, do no harm), which she cleverly translates as “Don’t just do something, stand there.” It feels wrong to just stand there and do nothing, and this feeling is the origin of the therapeutic imperative. Fear of lawsuits (for lack of intervention) encourage this behavior even more.  Yet if our actions lead to harm, then we have violated our most fundamental ethical principles.

Sometimes the best medicine is no medicine at all.

 

By Howard Herrell, MD