What is the recommended bed position for a pregnant patient with pre-eclampsia or eclampsia?

Bed Positioning for Pregnant Patients with Pre-eclampsia or Eclampsia

Strict bed rest is not recommended for pregnant patients with pre-eclampsia or eclampsia; instead, patients should be encouraged to maintain activities of daily living with some limitation of strenuous activities, and when bed positioning is necessary for monitoring or blood pressure measurement, the left lateral recumbent position should be used with caution as it may significantly lower blood pressure readings. 1

Activity Recommendations Based on Disease Severity

Severe Pre-eclampsia and Eclampsia

• Patients with severe pre-eclampsia, eclampsia, or HELLP syndrome should avoid strenuous physical activity but maintain activities of daily living prior to their likely imminent delivery. 1
• The Canadian Hypertensive Disorders of Pregnancy Working Group explicitly states that strict bed-rest in women hospitalized with pre-eclampsia is not recommended. 1
• These patients require immediate delivery after maternal stabilization with magnesium sulfate and blood pressure control. 2

Mild Pre-eclampsia

• Women with mild pre-eclampsia should avoid bed-rest or activity restriction entirely and instead be encouraged to maintain light physical activity such as walking, bodyweight exercises, or stretching. 1
• This represents a significant shift from historical management, as accumulating evidence shows that prenatal exercise in women with mild pre-eclampsia offers maternal and fetal health benefits without increased risk of harm, assuming normal fetal growth. 1

When Bed Positioning Is Clinically Necessary

Left Lateral Recumbent Position

• When hospitalization requires bed positioning for monitoring or management, the left lateral position may be used, but clinicians must recognize this position significantly reduces blood pressure measurements compared to the supported seated position. 1, 3
• The European Society of Cardiology recommends "some bed rest in the left lateral position" as part of non-pharmacological management for confirming diagnosis and ruling out severe gestational hypertension. 1
• Critical caveat: Notable reductions in blood pressure measurements occur in the left lateral recumbent position compared to the supported seated position, which could affect clinical management decisions. 3

Blood Pressure Measurement Considerations

• Care must be taken to document and consider the position in which blood pressure readings are taken, as clinically significant differences occur based on patient positioning. 3
• The recommended position for accurate blood pressure measurement is seated with arms and back supported, though this is not always feasible for inpatient pregnant women. 3

Monitoring Requirements During Hospitalization

Maternal Monitoring

• Continuous maternal monitoring should include blood pressure, deep tendon reflexes, respiratory rate, urine output (hourly via Foley catheter with target ≥100 mL/4 hours), and oxygen saturation. 2
• Blood pressure should be measured every 4 hours for non-severe hypertension, or more frequently if severe hypertension is present. 4
• Laboratory monitoring should include complete blood count, liver enzymes, and creatinine levels at least twice weekly or more frequently with clinical deterioration. 2, 4

Fetal Monitoring

• Continuous fetal heart rate monitoring and ultrasound assessment of fetal status should be performed. 2
• Initial ultrasound should include fetal biometry, amniotic fluid assessment, and umbilical artery Doppler, repeated every 2 weeks if normal or more frequently if fetal growth restriction is present. 2

Common Pitfalls to Avoid

• Do not order strict bed rest for any patient with pre-eclampsia, as this outdated practice is not supported by current evidence and may be harmful. 1
• Do not assume blood pressure readings taken in the left lateral position are equivalent to seated measurements—they may be falsely lower. 3
• Do not restrict activity in women with mild pre-eclampsia without concurrent absolute contraindications to exercise. 1
• Women with severe pre-eclampsia and concurrent intrauterine growth restriction (IUGR) should avoid moderate-to-vigorous physical activity entirely, as transient adverse responses such as reduction in placental blood flow have been observed. 1