Believe in Bed Rest for PTB? The AWARE Study

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1:54the EDC, remember that was the estimated date of confinement, I remember the EDC, then it changed to estimated due date EDD, now people just call it, of course, the due date. But the estimated date of confinement really represented the historical part of obstetrics, where as a patient neared, you know, the 40 week mark, she was expected to kind of withdraw from social life, kind of say, you know, adios to family and friends, I'm going to my confinement, and lie in bed, kind of waiting for contractions to start, guys, no joke, this was the thing, and it kind of started based on where you were in the world, anywhere from 34 weeks or 36 weeks until delivery, you were confined, you had to rest for childbirth. What? I mean, that was why it was called the estimated date of confinement. So nobody uses that anymore, and nobody uses bed rest, however, however, it's amazing that we're still talking about bed rest for things like pre-term birth.

2:57Yep, brand new publication from the green journal, this actually just got added to the published ahead of print list on February the 22nd, 2026, it's not even officially out yet. Now, this is not its own study, this is an ancillary study, in other words, it's kind of like a sub-analysis of two randomized trials for pre-term birth prevention in women with short cervical length. Now, those are independent studies, those are have nothing to do with what we're talking about here, except that part of those cohorts were then asked to track their movement, their activity based on a number of steps, we'll get into it after the intro, and then it was divided between low number of steps and a high number of steps, not tell you what those actually are after the intro. And the authors wanted to see did activity restriction actually have any influence on gestational age for delivery. Now, I know we've been here before, so on the one hand this is nothing new, however, on the other hand, it reveals something entirely new, which nobody really expected, it's a little surprising.

4:03So I'm going to give you that twist, that little turn of the data, when we explain the study right after the intro, so believe in bed rest for pre-term birth, should you or should you not let's get into that right after this intro. This is Dr. Chappas, OBGYN, Clinical Pearls, no spin podcast. Podcast family, I'm happy to share information from one of our corporate sponsors, perspective, medical, in a C-section every second counts, especially when managing postpartum hemorrhage, but traditional surgical draping often hides the very signs that we need to see concealed bleeding around or under the patient, introducing the OBGYN physician designed hemorrhage view C-section drape.

5:04It's designed to provide clear and direct visualization of the patient to allow assessment of any concealed bleeding. Now, you can recognize hemorrhage earlier and monitor bleeding in real time without compromising the sterile field. Whether you're placing the uterine balloon or administering uterotonics or assisting in the second stage C-section, you now have clear visualization you need to act fast. So let's be proactive, not reactive, in the recognition and management of hemorrhage. Visit perspectivemedical.org to learn more about the hemorrhage view C-section drape or to request a trial option. Alright, let's just start off with what we know, not opinion, a kind of fact here and based on over 20 years of data, let me just say something here. When I was a resident in the lands, that's Parkland, yeah, bed rest was still kind of thing. I mean, 5 South High Risk Ward patients still have strict bed rest.

6:04Well, because we thought that was a good thing. Alright, there's a lot of things in medicine change as the data is challenged and we're like, oh gosh, that was not a good idea because bed rest during pregnancy is associated with some really bad things. Okay, including, of course, DVT. That's the big one of Venus Stasis, Virgil's Triad, it's kind of kicked up and on and then we just have them be immobile. That's not good, thromboembolism is really a big thing. Then there's of course the physical deconditioning, not good as somebody prepares to go into a mini marathon called labor. There's proven bone loss with bed rest in pregnancy and the short of it is no proven benefit for preventing preterm birth or improving any other pregnancy outcome. And plus, yes, unfortunately, there's more. Other studies have even shown some metabolic consequences of this, some metabolic derangements from bed rest. Can you believe it? Including an increased risk of gestational diabetes with one steady showing, listen to this guys, a 4% increased risk for every day of inpatient bed rest.

7:17You're like, well, what is that about? Easy. If muscles aren't using the sugar, sugar accumulates, triggers more insulin, triggers more insulin resistance. It's fighting human presidential actogen. So 4% increased risk for every day of inpatient bed rest. Nuts. So elevated blood glucose levels or a thing increased insulin resistance is a thing all based on your friend activity restriction. And then some go the philosophical route in their discussion and their debate against bed rest. I've read some fascinating commentary stating a patient who is confined to bed rest in addition to it not having any proven benefit actually goes against the ethical principles of patient autonomy and beneficence and justice. So wow. Yeah. So even throw it out the medical ethics curve ball to that. That is why SMFM a cog, the Royal College of OBGYN and a variety of other international sources don't recommend bed rest even.

8:21Listen to this guy is even for treated cervical insufficiency. There's been various data points that have looked at circlage alone versus circlage and bed rest and circlage wins for reduction in preterm birth with no additional benefit for bed rest. So once even a patient gets a circlage for cervical incompetence, you don't either do bed rest. I mean, trust the treatment given. Trust the the the signs in that and go on your way. So even with treated cervical sufficiency, bed rest is not recommended. So we've known this and we've known this for a while, which brings us to this new publication added to the published ahead of print list again on February the 22nd, 2026 in the green journal. Now remember, this isn't it's standing alone study is the subanalysis of two other trials, but by name, this is called the aware study. All right. So not the arrive arrive has to do with induction of labor. Remember that at 39 weeks mainly know it's electively.

9:27And we know the kind of trouble that that led to and that's why it's kind of been walked back. This is the aware study. Okay. So the aware study, the aware study is actually quote activity restriction in pregnancy and the risk of early delivery. And quote, once again, this is in the green journal, not yet officially out, but this is a nice way to capture data that's already there. And it's actually a way to kind of clock patients physical activity where it's not just recall. Okay. So let me explain how this worked. So patients were recruited between 16 weeks and 24 weeks of pregnancy. These were patients who were found to have a short cervical length. Okay. So they already have a little bit higher risk because they've got a short cervical length. Remember, based on two previous randomized trials. So starting at 16 up to 24 weeks, hey, do you want to get recruited in here and where a wrist accelerometer? So in other words, kind of the thing that kind of counts your steps per day. I watch does it. The garment watch does it. It's kind of similar to that idea.

10:33Now, the primary outcome was latency from time of enrollment to delivery based on how many steps you took. Okay. Sedimentary was fewer than 3,500 steps. Now, I know it sounds like a lot. Really it isn't guys. We do, I mean, every step counts. So go in your kitchen and back kind of adds up the bathroom and back kind of adds up. So 3,500 if you're thinking that's sedentary. Yeah, I mean, it's actually, I mean, it's not like it's zero steps, but it's actually not that much compared to those that had quote unquote regular activity that was more than 3,500 steps per day. Right. So those that were fewer than 3,500 were then compared in terms of their outcomes to those who had 3,500 or more steps per day. And then included just as we said right now in the objective, the timing from recruitment to delivery 32, 34 or 37 weeks. Okay. Now, this isn't 1000 of thousands of patients. It was 117 who completed the accelerometer data. So 117 had had their low numbers calculated for that time period.

11:47Now, at enrollment, the median gestational age was about 23 weeks to be accurate. It was 22.8. So fine. So these are still kind of in that scary zone. We definitely want to have delivery at that time. But here's the catch. Okay. The primary outcome latency from time of enrollment to delivery. Here it is guys. Shocker was not different between the groups. The hazard ratio was basically one. Okay. It was 0.95 and the confidence interval was 0.88. So that was under one and then it crossed one just to the other side at 1.03. So it hovered over one as a confidence interval and the hazard ratio was basically at one, meaning literally no difference. Okay. Now listen to this. I told you those going to be a little catch here. And this, this is a weird one. Again, this is just based on some analysis of this. Who knows, but this is weird. Quote. Participants with fewer than 3,500 median steps per day. So those that had activity restriction. And I get it. It's not strict bed rest.

12:54It's just kind of activity restriction. Okay. Let's just go with it. Quote participants with fewer than 3,500 median steps per day. Here it is. Delivered at an earlier gestational age, which was 34.9 compared to those who had more steps, which was 37.7. And they were also more likely to deliver before 34 weeks at 47% compared to 17% for those who had more than 3,500 steps. So not only was there no statistically significant difference in latency from time to enrollment in those with activity restriction, but those who had sedentary activity. Again, in this design that was described as fewer than 3,500 steps per day, it actually had an increased risk of preterm birth before 34 weeks of gestation. And overall, this earlier gestational age at delivery. So not only did it not work, but based on this data called the aware study.

14:02Bed rest for preterm birth in patients that were high risk guys. Okay. These had a short cervix actually increased the chance of preterm labor. Why? Now, there's a lot of possible theories here. I like the one of deconditioning, which is if the body's deconditioned, the baby's like, I'm out. You're not taking care of yourself. You're not moving around quarters all the time. I'm going to bail out here, eject button. I know that's very simplified. There's a lot of different factors that go into that. And there's not one, you know, definitive answer. But the point is that activity restriction increased the rate of preterm birth compared to more activity. This is the activity restriction in pregnancy and the risk of early delivery, the aware study. Oh, just had a disclosure. Just had a disclosure. This does have ties to my wonderful great state of Texas, because there's authors here, of course, from UTMB. That's in Galveston. And a little side note, my wife is B-O-I. She was born on the island. And also from UT Austin. So this has a lot of authors names that we've all recognized, including George McCones and others. I'm sorry, George Saude and others.

15:16Wonderful, wonderful authors. Dwight Rouse is on here. Yeah, George McCones is on here as well. So a lot of wonderful people. Oh, and somebody I've worked with on a separate manuscript. I've got to tell her I didn't know I didn't seem that before. One of my co-authors and something else that we have put together, Monica Longo. She's out of the NIH. I didn't realize she was on this. Ah, no wonder. It's just part of the MFM network unit, of course. So a lot of diverse locations here, including ties to Texas. Great job for Monica. I got to send her a message. She is fantastic. And again, we've authored something that will be coming out soon. So in this study, the aware study just know, just know that pre-term labor was not reduced in activity restrictions. It actually increased the rate of pre-term birth. So wacky. So there's some things that we know that we kind of have these names that go with things, right? We know the arrive trial. We know the promise trial. We have now the aware trial. So there's these names that get kicked out, you know, very frequently.

16:22And they're easy to remember arrive, of course, or in any week, conduction. And this is the aware trial talking about activity restriction. Well, I guess if we mentioned the promise trial, we should remind everyone what that is. The promise trial was the one that showed that patients with a history of recurrent pregnancy loss using vaginal progesterome. That was 400 milligrams twice a day. It did not increase the live birth rate compared to placebo, right? That was the promise trial. So I remember promise progesterome, promise progesterome that did not help with recurrent pregnancy loss, even for women with a history of it at 400 milligrams twice a day. Then we had the pro long study. See, so it's important to know these names because they do get thrown out a lot. And it's part of OB history, but they are important to know by name. The pro long trial was the one that kind of put the cabosh on I am progesterome. The pro long study for progesterome is when that showed, you know, maybe not that much of a benefit. That was back in 2019. The pro long trial was progestin's role in optimizing neonatal gestation.

17:30And yeah, you know what, 17 OHP, not that effective in reducing preterm birth under 35, 36 weeks. So ex-nate for that. So we have these names arrive, aware, promise for recurrent miscarriage, and then pro long, the one that kind of buried a 17 OHP is important to know these names. All right, sorry, little deviation there. Short of it is I'm not mad at you if you of course offer bed rest to your patients, whatever, but it's not really a thing. So outside of the deconditioning and the risk of potential being a stasis, even the metabolic consequences of this is is pretty striking. So I wanted this to be relatively quick. This just came out ahead of print in February, the 22nd, 2026 in the green journal. And I was so proud to have got Texas ties. I will send a note to my friend Monica Longo, who also will author this through the MFM network unit and the NIH.

18:30So don't do bed rest is a take home message podcast family, relatively quick here, just letting you know what is hot, hot, hot in press. And now that we've done all that, Michael, let's take it home. This is Dr. Chappas, OBGYN, clinical pearls, no spin podcast.