Physicians finds some perils in therapeutic bed rest during pregnancy

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When Michelle Massucci went into preterm labor with twins almost four months before her due date, she followed her doctor's orders for strict bed rest.

For six weeks in the hospital, she was allowed out of bed only to shower and go to the bathroom, and some days not even to do that. For another four weeks at home, she laid on her living room couch day and night, needing family help even to get herself a sandwich.

"It's funny -- people say to me, 'I wouldn't have been able to do it,' " she said. "To be completely honest with you, you wouldn't think of doing anything other than that because the health of your babies is in your hands."

To this date, Ms. Massucci of Rosscredits bed rest with helping to keep her pregnant as long as she was -- delivering twins Justin and Madelyn at 35 weeks gestation (for twins 37 weeks is considered full-term delivery).

And for many years, that was indeed the prevailing wisdom.

But now -- just seven years after Ms. Massucci's twins were born -- strict bed rest is becoming a thing of the past.

An editorial that ran last summer in the journal Obstetrics and Gynecology used the phrase "unethical and unsupported" about therapeutic bed rest.

"Not all interventions that make some sense are scientifically valid, and this is one of them," said Ronald Thomas, division director for maternal-fetal medicine at the West Penn Allegheny Health System.

Dr. Thomas said bed rest has been a tempting solution to all manner of problems in pregnancy because it seems logical that sharply reduced activity would put less stress on the body, making an early birth less likely to occur.

"People have used it for all sorts of things -- history of preterm birth, contractions in the current pregnancy, multiple gestation," he said. "You name it, someone has suggested it as a possibility."

But what recent studies have found is that not only is there no evidence that bed rest helps any of those conditions, but that strict bed rest can do both physical and economic harm, said Hyagriv Simhan, chief of maternal fetal medicine at Magee-Womens Hospital of UPMC.

The risk of blood clots increases, he said, and women can quickly have atrophied muscles and bone demineralization that can increase the risk of osteoporosis, the brittle bone disease. In addition, women who are prevented from working can experience economic stress.

Indeed, when Ms. Massucci came home from her six weeks on hospitalized bed rest, her muscles had atrophied to the point where she struggled just to lift her leg to step up onto the curb outside her house. "To be honest, I was in pretty bad physical condition," she said. "I definitely was in a state where my muscle tone was long gone."

Dr. Thomas cautioned that there is a difference between strict bed rest, when patients are told that they should only move around for very short periods, and modifying strenuous activity. It is advisable for pregnant women to take it easy, he said, meaning that strenuous activities can and should be reduced during pregnancy.

"We all know the exceptions -- people in phenomenal shape -- but for the average patient there's always some modification of activity," he said. "You don't want to say to a patient go to bed rest and literally don't get out of bed, but on the flip side, if you do a job where you carry 100-pound bags of feed back and forth, or climb up and down steps with heavy loads, you need to modify activity."

The move away from prescribing bed rest has come gradually, as studies have stacked up showing its lack of effectiveness.

"The wheels of medical care sometimes turn slowly," said Dr. Simhan. "Fifteen years ago, there were fewer data on the topic, because it has this intuitive appeal. In the last five to 10 years, I was much less aggressive with bed rest. Beginning five years ago, we hardly do it."

Interestingly, bed rest is now something that patients sometimes request themselves, said Dr. Simhan. In extreme cases, he's seen women rent a wheelchair and have their husbands push them around -- just because they feel that bed rest intuitively should help them, and it helps them take charge of a scary situation.

Bed rest can lessen contractions, said Dr. Simhan, but while contractions often accompany preterm labor, they are not neccessarily the cause of it. Rather, doctors now think of contractions as more of a symptom than anything else.

With bed rest out of the picture, women can feel helpless during preterm labor because of a lack of effective long-term medical interventions. "In the world of prematurity prevention, we've made a ton of strides, but once a woman has had preterm labor we do not have any effective prevention strategies," said Dr. Simhan. "Prematurity is the biggest problem in obstetrics but there's more that we don't know than we do know."

That said, there are medical conditions where bed rest is warranted. If a woman is hospitalized for high blood pressure during pregnancy she is told to restrict movement, as activity raises blood pressure. If her blood pressure rises too high, doctors have to deliver the baby.

Even when Ms. Massucci went into preterm labor with her twins, doctors told her there wasn't much scientific proof that bed rest was effective. But looking back on the experience, she feels as if bed rest worked for her.

"I felt that limiting my movement did help calm the babies inside of me," she said. "But I don't know the alternative."

Anya Sostek: or 412-263-1308.

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