WHO recommendation regarding advice to rest at home as primary prevention of pre-eclampsia and hypertensive disorders of pregnancy

Pregnant woman resting on her bed.

WHO recommendation regarding advice to rest at home as primary prevention of pre-eclampsia and hypertensive disorders of pregnancy

Recommendation

Advice to rest at home is not recommended as an intervention for the primary prevention of pre-eclampsia and hypertensive disorders of pregnancy in women considered to be at risk of developing these conditions. 

 (low-quality evidence, weak recommendation)

 

Publication history

First published: October 2011

Updated: no update planned

Assessed as up-to-date: October 2011

 

Remarks

  • The guideline development group acknowledged that there may be situations in which different levels of rest, either at home or in hospital, may be indicated for individual women. The above recommendations do not cover advice regarding overall physical activity and manual or office work.
  • Women may need to be hospitalized for reasons other than bedrest, such as for maternal and fetal surveillance. The guideline development group agreed that hospitalization for maternal and fetal surveillance is resource intensive and should be considered as a priority for research and future recommendations.

 

Background

Hypertensive disorders of pregnancy are an important cause of severe morbidity, long-term disability and death among both mothers and their babies. Worldwide, they account for approximately 14% of all maternal deaths, whereas in Latin America and the Caribbean, they contribute to approximately 22% of all maternal deaths.(1)

Among the hypertensive disorders that complicate pregnancy, pre-eclampsia and eclampsia stand out as major causes of maternal and perinatal mortality and morbidity. The majority of deaths due to pre-eclampsia and eclampsia are avoidable through the provision of timely and effective care to the women presenting with these complications.

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, guided by the GRADE approach.(2, 3) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on prevention and treatment of pre-eclampsia eclampsia (2011).(4)

A Cochrane systematic review was conducted, on rest compared to unrestricted activity in women at risk for pre-eclampsia and hypertensive disorders of pregnancy.(5) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks. 

WHO convened a Guideline Development Group (GDG) meeting on recommendations for prevention and treatment of pre-eclampsia or eclampsia in April 2011, where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

 

Recommendation question

For this recommendation, we aimed to answer the following question/s:

  • in normotensive pregnant women at risk for pre-eclampsia (P), does rest or advise to reduce physical activity (I) compared to maintaining normal activity (C), affect the risk of developing pre-eclampsia and hypertensive disorders of pregnancy (O)?

 

Evidence Summary

Rest for prevention of pre-eclampsia and its complications

Evidence related to the effect of rest or advice to reduce physical activity for the prevention of pre-eclampsia and its complications came from a Cochrane review of two small trials involving a total of 106 normotensive women at moderate risk of developing pre-eclampsia.(5) One of the trials (32 women) compared 4-hour daily rest at home in a left lateral position with unrestricted activity while the other (74 women) compared 15 minutes twice daily rest at home plus nutritional supplementation with unrestricted activity plus placebo. None of the critical outcomes was assessed in either of the trials. Gestational hypertension and pre-eclampsia were reported in both trials and were selected as proxy outcomes for this recommendation. When daily rest at home was compared with unrestricted activity, there was a significant reduction in the risk of pre-eclampsia [one trial, 32 women; relative risk (RR) 0.05, 95% confidence interval (CI) 0.00–0.83], but no statistical difference was observed in the risk of gestational hypertension (one trial, 32 women; RR 0.25, 95% CI 0.03–2.00) (EB Table 1). Compared with unrestricted activity plus placebo, rest at home plus nutritional supplementation resulted in significant reduction of both proxy outcomes (gestational hypertension: one trial, 74 women; RR 0.15, 95% CI 0.04–0.63 and pre-eclampsia: one trial, 74 women; RR 0.12, 95% CI 0.03–0.51) (EB Table 2). The findings for these proxy outcomes were considered imprecise because of the very small sample size and scarce data.

 

Implementation considerations

  • The successful introduction of this recommendation into national programmes and health-care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. The adaptation and implementation processes may include the development or revision of existing national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into a locally appropriate document that can meet the specific needs of each country and health service. Any changes should be made in an explicit and transparent manner.
  • A set of interventions should be established to ensure that an enabling environment is created for the use of the recommendations (including, for example, the ability to regularly monitor women considered high risk for pre-eclampsia or hypertensive disorders of pregnancy), and that the behaviour of the healthcare practitioner changes towards the use of this evidence-based practice.
  • In this process, the role of local professional societies is important and an all-inclusive and participatory process should be encouraged.

 

Research implications

The 2011 GDG identified the following high-priority research question on this intervention:

  • The benefits and potential harms of advice to rest at home or bedrest under clinical observation at a health-care facility to prevent or treat hypertensive disorders of pregnancy.

 

Related Links

WHO recommendations on prevention and treatment of pre-eclampsia and eclampsia (2011) - full document and evidence tables (EB Table 51)

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Supporting systematic review:

Meher S, Duley L. Rest during pregnancy for preventing pre-eclampsia and its complications in women with normal blood pressure. Cochrane Database of Systematic Reviews, 2006, (2):CD005939.

 

References

  1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33. Epub 2014/05/05. doi: 10.1016/S2214-109X(14)70227-X. PubMed PMID: 25103301.
  2. WHO Handbook for Guideline Development (second edition). Geneva: World Health Organization; 2014.
  3. Schünemann H, Brożek J, Guyatt G, Oxman A. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. 2013.
  4. WHO recommendations for prevention and treatment pre-eclampsia and eclampsia. Geneva: World Health Organization, 2011.
  5. Magee L, Sadeghi S. Prevention and treatment of postpartum hypertension. Cochrane Database Syst Rev. 2005(1):CD004351. Epub 2005/01/25. doi: 10.1002/14651858.CD004351.pub2. PubMed PMID: 15674943.

 

Citation

WHO Reproductive Health Library. WHO recommendation regarding advise to rest at home as primary prevention of pre-eclampsia and hypertensive disorders of pregnancy (October 2011). The WHO Reproductive Health Library; Geneva: World Health Organization.