AlanM. Smith

Bed rest in pregnancy.

In obstetrics, we often lack solid data upon which to base clinical recommendations for preventing pregnancy complications or for optimizing pregnancy outcomes after complications develop. Many proposed interventions for the prevention of adverse pregnancy outcomes have failed to demonstrate a salutary effect, and, for many of these complications, we remain empty-handed without evidence-based therapeutic alternatives. In these situations, our objectivity and knowledge tell us that no specific therapeutic intervention is capable of improving the natural history. However, it is often difficult to accept that there really is nothing more we can offer and to convince a patient and her family of the same. In some situations, faced with no proven options, physicians sometimes recommend bed rest. Our natural inclination is that doing something is better than doing nothing. The origins of recommending bed rest for treatment of medical maladies dates to the time of Hippocrates, but it was in the latter half of the 19th century, after the publication of a series of lectures by Dr. John Hilton, a president of the Royal College of Surgeons, that the frequency of its use increased. Hilton taught that multiple ailments could be cured with prudent use of rest. Although originally aimed at orthopedic disorders, this principle was applied in multiple fields with little question of its benefit for nearly 100 years. Bed rest as part of routine pregnancy care, especially in the postpartum period, has been practiced for hundreds of years, its commonality reflected in the nomenclature of “lying-in” hospitals and the term “date of confinement.” Gradually, however, data accumulated regarding the adverse physical effects of prolonged bed rest, including muscle deconditioning, bone demineralization, cardiovascular deconditioning with loss of plasma volume, venous thrombosis, and alterations in the endocrine and immune systems. This led to changes in the use of bed rest for treatment of medical conditions such as myocardial infarction, pulmonary infections, and postoperative recovery. Similarly, recommendations for prolonged bed rest during or after uncomplicated pregnancy dissipated. However, bed rest remains one of the most commonly prescribed treatments to improve reproductive outcomes in complicated pregnancies, despite a lack of evidence that it improves any obstetric or neonatal outcomes. As many as 95% of obstetricians report recommending activity restriction or bed rest, in some form, in their practices. Nearly 20% of gravid women in the United States—approximately 800,000 per year—will be placed on bed rest between 20 weeks of gestation and delivery. Seventy-one percent of maternal–fetal medicine specialists responding to a recent survey would recommend bed rest after arrested preterm labor, and 87% would recommend it after preterm premature rupture of membranes, despite the fact that 72% and 56% felt there was limited or no benefit to bed rest in the setting of preterm labor or preterm premature See related articles on pages 1181 and 1305.

THE TEACHING OF ANATOMY

on by tradition to other times and generations of students, the respective conditions and needs of which are not the same. If we are to guard against this insidious influence, which in every field of endeavour is fruitful of waste and misdirection of energy, we must from time to time take stock of our methods and ask ourselves whether they are really those best adapted to meet the needs of the ever-changing circumstances. In so venerable a subject as anatomy there has been ample time for the hampering influences of tradition to develop; and the danger from them is much more serious than in the case of many of the newer subjects of the medical curriculum, which have been immune from the risks of such conventionalisation as is inseparable from old age. Anatomy has not responded?perhaps, it will be claimed, solely because there has been no need for it to respond?so rapidly and completely as, say, such a mushroom growth as pathology, in adaptation to the altering needs of the time. Two main criticisms of a general nature must be brought against the teaching of anatomy in most British schools. First, there is the extreme narrowness of the conception that all the anatomist has to teach his students is the dissection of the dead body, and by means of