BED REST AND PREVENTION OF MISCARRIAGE

When I got pregnant again after my miscarriage, I suffered threatened miscarriage. The advice I received from my doctor in Nigeria was to go on bed rest till I was well into my second trimester. In fact I was on strict bed rest till I was at least 16weeks gestation.

A Cochrane review published in 2008 questions the effectiveness of bed rest, so widely prescribed as a preventive measure in cases of threatened miscarriage or past history of miscarriage. This is because bed rest suggests that hard work and exertion are causative factors in miscarriage. I personally know, from my research on the topic of miscarriage that this has not been objectively proven.

In arguing against bed rest, the reviewers state that it may do more harm than good, increasing the likelihood of thromboembolic events (pregnancy already predisposes to formation of blood clots and staying stationary may worsen matters). They also argue that enforcing bed rest might be very stressful for the woman and her family (if she has other children or responsibilities that require her to be active) and may result in self blame if the pregnancy does progress to a miscarriage as she may feel she did not comply properly with instructions and hence caused her loss; in fact, it may have been inevitable with or without bed rest.

Based on their inclusion and exclusion criteria, they had two studies to review. These two studies randomly allocated women to either bed rest at home versus bed rest in hospital +/- medication versus no bed rest. These women did not have a history of recurrent miscarriage (i.e. three or more consecutive miscarriages) and had experienced vaginal bleeding between 7 and 16 weeks gestation.

There was no significant difference in miscarriage outcomes in all the groups.

For a difference to be statistically significant the study should be able to prove that the observed differences between the two groups could not be due to chance alone but due to a specific benefit. This was not proven.

As discussed in previous posts, there is research already in progress to identify objective markers that can predict the outcome of a pregnancy with threatened miscarriage. If more research is conducted to build on this, medical practitioners will be better equipped to manage this condition in a manner that is unequivocally effective, based on specific information  on which to base prognosis. This would definitely make us more effective and make the woman and her family less stressed.

SOURCE

Aleman A, Althabe F, Belizan JM, Bergel E, Bed rest during pregnancy for preventing miscarriage, Cochrane database of systematic reviews 2005, Issue 2, Art.No.CD003576.

THERE IS A STRONG BOND, NO MATTER HOW EARLY

Studies have confirmed that even at a gestational age of eight weeks, a strong connection already exists between a woman and her unborn baby. This is why your sensitivity to her loss, no matter the stage of the pregnancy, is essential. Healthcare professionals need to appreciate that a miscarriage is a real loss and, in most cases, the woman already feels love for and a bond with the baby being lost.

To further buttress this point, I want to share excerpts of my dairy written in the early weeks of my first pregnancy before it ended in miscarriage during the 9^th week of gestation. These are my personal thoughts and feelings, written at the time as letters to my unborn child, shared for the very first time.

·        At 5⁺⁶ weeks: “I’m so excited...it’s been a roller coaster ride of symptoms all week, but to be honest, I’m loving it!

·        At 6⁺¹ weeks: “I’ll be happy when we can feel you; even happier when we can hold you in our arms”

·        At 6⁺³ weeks: “Tried...stuffing a sweater in my trousers to see what I’d look like with a bump. The sweater looked silly (lol)”

·        At 7⁺⁴ weeks: “I think about you so much...you’re all I ever think of nowadays...I love you babe”.

·        At 8⁺³ weeks: “How are you feeling in there?...I love you babe”.

·        At 9⁺¹ weeks: “I’ve booked an appointment for my first scan...Woohoo!!! What a great time to be alive, in love and expecting a baby...I’ll be seeing you in a week’s time. Stay healthy, perfect, beautiful”

·        At 9⁺⁴ weeks: “This is the day that the pregnancy ended...I feel robbed, cheated, completely devastated...I don’t know why I can’t have you...I grieve for you and for my dreams that died with you”.

PREDICTING THE OUTCOME OF THREATENED MISCARRIAGE (2)

THE STUDY

It was a prospective longitudinal study. Women were recruited at 6-10 weeks gestational age, presenting with vaginal bleeding in the presence of a sonographically viable intra-uterine pregnancy. They were seen weekly for five weeks. At each visit, they completed a Visual Analogue Scale of pain and bleeding intensity scores.

A visual analogue scale is a measurement instrument used to assess how a patient scores their medical symptom across a scale from mild to severe; it is used to assess their perception of the symptom. Being unique to each respondent, it cannot be used to compare between subjects but it can be used to compare the patient’s responses at different times.

At the end of the 5 weeks, an ultrasound scan was used to assess the outcomes of the pregnancies.

Primary outcome – identify biomarkers with significant relationships to pregnancy outcome.

Secondary outcome – derive a Pregnancy Viability Index (PVI) this would be a measure of the likelihood of the pregnancy succeeding. 

Tertiary outcome – assess the positive predictive value (PPV) and negative predictive value (NPV) of the derived PVI.

The predictive values of a test are determined by the sensitivity and specificity of the test and of the characteristics of the population being tested. So a test with very good sensitivity (able to detect those with the disease) and very good specificity (able to rule out those without disease) will have high positive and negative predictive values.

Of the 117 women recruited, 112 completed the study. Of these, 22 went on to pregnancy demise while 90 had their pregnancies continue. All miscarriages happened within 28days of presentation.

The following factors had significant Odds Ratios (i.e. the odds that these factors featured highly in those that miscarried versus those that did not miscarry were statistically significant): History of subfertility (difficulty conceiving), the baseline bleeding score (as rated by the patients on the scale), the baseline crown-rump length (on ultrasound scan), baseline Progesterone and baseline hCG levels. 

Factors that did not have significant Odds Ratio included previous pregnancy termination, Hb level and number of previous pregnancies.

Following further statistical analysis, the two factors that retained significance were the baseline bleeding score (BS) and the serum hCG.

They derived a PVI = hCG/BS × 1.87 ×10 and a high PVI meant a resulting miscarriage.

The PPV of the PVI was 94% and the NPV was 77%.

Of course, more research with a larger number of participants is needed to trial this score and even maybe practical testing in the clinics with resulting case reports may help to prove if this index is useful. But imagine how much easier life would be if we could tell on time which women with bleeding in the first trimester would simply need reassurance or would need early targeted counselling.

REFERENCE

Adam K, Developing a robust model for predicting the outcome of pregnancies complicated by threatened miscarriage in the first trimester of pregnancy. Session 34, ESHRE Stockholm,  July 2011.