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Exercise During Pregnancy


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Title: Exercise During Pregnancy

Exercise During Pregnancy
  • Antoin M. Alexander
  • Maj USAF MC
  • Family Medicine Sports Fellow
  • Adopted from Dr. Fred Brennan

  • 24 y.o. G1P0 presents at 9 wks EGA for 1st
    obstetrical visit
  • Competes routinely in triathlons and road races
  • Curious about the benefits risk of continuing
    to train possibly competing while pregnant
  • Will her performance suffer?
  • Will she put her baby at risk?
  • Can she exercise breastfeed in the future?

  • Physiology of Exercise and Pregnancy
  • Risks and Benefits
  • Guidelines for Exercise in Pregnancy
  • The Pregnant Athlete
  • Injury Patterns
  • College athlete

Useful References
  • ACOG Committee. Opinion no. 267 exercise during
    pregnancy and the postpartum period. Obstet
    Gynecol 2002991713
  • Artal R. Exercise during pregnancy. Safe and
    beneficial for most. Phys and Sports Med

Useful References
  • Kelly AK. Practical exercise advice during
    pregnancy. Guidelines for active and inactive
    women. Phys and Sports Med June 200533(6)
  • Davies GA. Joint SOGC/CSEP clinical practice
    guideline exercise in pregnancy and the
    postpartum period. Can J Appl Physiol 2003
    28(3) 330-41
  • Morris SN. Exercise during pregnancy a critical
    appraisal of the literature. J Reprod Med 2005

Physiologic Adaptations to Pregnancy
Interactions with Exercise
Physiology Overview
  • Significant physiologic changes occur in
  • Objective data on the impact of exercise on the
    mother, fetus, and course of pregnancy are
  • Theoretical concerns must be understood to allow
    physicians to advise women who wish to exercise
    in pregnancy

  • Both exercise and pregnancy increase
  • Heart rate
  • Stroke volume
  • Cardiac output
  • Theoretical risk Competing effects on regional
    blood flow distribution
  • Exercise decreases splanchnic blood flow
  • Doppler US not shown changes in uterine or
    umbilical artery flow
  • Both glucose and oxygen delivery to placental
    site is reduced

Fetal Response To Exercise
  • 45 healthy pregnany woman studied
  • 15 nonexercisers, 15 regularly active,15 highly
  • Tested 28- 33 weeks gestation
  • Treadmil 1 to volitional fatigue
  • Treadmill 2 to 40-59 HR reserve for 30 min
  • Treadmill 2 to 60-84 HR reserve for 30 min
  • Measure Umbilical artery Doppler, FHR tracing,
    biophysical profile
  • All doppler similar pre and post exercise
  • Post exercise FHR tracing reactive lt 20 minutes
  • BPP scores all reassuring
  • Obstet Gynecol 2012 119 (3) 603-10

Cardiovascular II
  • Women who perform regular weight bearing exercise
  • Augment pregnancy associated increases in plasma
  • Increase placental volume
  • Increase cardiac output
  • What does this suggest?
  • Increased rate of placental blood flow at rest
  • Increase in 24 h glucose oxygen delivery

Substrate Delivery Utilization
  • Non-pregnant athlete
  • Wt-bearing exercise increases glucose oxidation
  • Sympathetic response mobilizes glucose stores
    stimulates gluconeogenesis
  • Result rise in glucose levels for at least the
    first hour
  • Pregnant athlete
  • Sympathetic response blunted
  • Glucose oxidation lipogenesis are increased
  • Result fall in glucose levels during after

Oxygen Delivery
  • Pre-pregnancy sustained exercise
  • h oxygen delivery to muscles skin
  • i oxygen delivery to most viscera
  • During pregnancy oxygen delivery during exercise
    appears to be maintained by
  • Maternal hemoconcentration
  • Improved perfusion at the placental interphase
  • Conclusion No evidence for compromised O2

  • Both exercise and pregnancy increase
  • Minute ventilation
  • Oxygen consumption
  • During pregnancy
  • Resting energy expenditure is increased
  • Augmented work of breathing during exercise
  • Result exercise requires higher VO2 (oxygen
    uptake) compared with that required in a
    nonpregnancy state
  • VO2 max decreases because body weight increases
    with pregnancy

  • Both exercise and pregnancy increase
  • Metabolic rate
  • Increased heat production
  • Theoretical concerns
  • Elevation in maternal core temperature due to
    exercise could reduce fetal heat dissipation
  • Possible teratogenic effect at tempgt102.6
  • Healthy, fit pregnant women have been shown to
    tolerate thermal stress

Changing Thermal Response to Endurance Exercise
in Pregnancy
  • 18 well-trained recreational athletes
  • 20 minutes of cycling at room temperature
    60-65 VO2 max
  • Maximum core temperature achieved during cycling
    decreased throughout gestation
  • Appear to be related to a increased vasodilation
    increased sweating

Am J Obstet Gynecol. 1991 165 1684-9.
  • Exercise increases circulating levels of
  • Norepinephrine
  • Epinephrine
  • Theoretical concerns excess catecholamines and
    prostanglandins will result in contractions
    preterm labor
  • Cochran review 2010 of 14 trials- 1014 women
  • No statistically significant change in gestation
    at delivery

Mechanical Effects
  • Altered center of gravity
  • growing breast, uterus and fetus
  • increased lumbar lordosis
  • Increased risk of fall
  • Increased joint laxity
  • Theoretic increased risk for strains/sprains

Risks and Benefits
  • Theoretical risks
  • Hypoxemia/Hypoglycemia
  • Fetal teratogenesis
  • Preterm labor
  • Low birth weights
  • Sprains/strains
  • Negative outcomes have not been identified
  • SAB
  • Pregnancy complications
  • PTL/preterm birth
  • Altered birth weight
  • Higher injury rates

Sour Milk?
  • Neither quantity nor quality of breast milk
    produced appears to be affected by moderate

  • Improved cardiovascular fitness
  • Control of maternal weight gain
  • Reduced subjective discomforts of pregnancy
  • Swelling, leg cramps, fatigue, SOB
  • Positive influence of labor delivery (Clapp et
  • Decreased risk of operative or assisted
  • Shorter active labor
  • Increased fetal tolerance of labor
  • Possible reduced risk of preeclampsia, GDM

Course of Labor after Endurance Exercise in
Exercise (n87) Control (n44)
Incidence of PTL 9 9
Length of Gestation 277 d 282 d
Incidence of c-section 6 30
Incidence of operative vaginal delivery 6 20
Duration of labor 264 min 382 min
Clinical evidence of fetal distress 26 50
Am J Obstet Gynecol 163 1799-1805, 1990.
Psychological Well-Being
  • Improved mood
  • Decreased stress
  • Improved self-image
  • Increased sense of control and relief of tension

Semin Perinatol 20 70-76, 1996.
Postpartum Well-Being
  • Improved weight loss
  • Improved psychological well-being
  • No adverse impact on breastfeeding.

Neonatal Childhood Benefits
  • Clapp JF Morphometric and neurodevelopment
    outcomes at age 5 years of offspring of women who
    continued to exercise regularly throughout
  • Less body fat at birth and 5 yrs
  • Similar motor, integrative academic readiness
    as control groups
  • Higher scores on Wechsler scales and tests of
    oral language skills.

J. Pediatr 129 856-863, 1996.
Preventing Treating GDM
  • Exercise may be beneficial in the primary
    prevention of GDM, especially in morbidly obese
    women (BMI gt 33)
  • Resistance training may reduce need for insulin
    therapy in overweight women (BMI gt 25)
  • ADA endorsed exercise as helpful adjunctive
    therapy with GDM when euglycemia is not achieved
    by diet alone.

Expert Guidance
Guidelines for Exercise in Pregnancy
  • ACOG in evolution
  • 1985 HR lt140 BPM with maximum duration of
    exercise 15 minutes
  • 1994 Less cautious and began to stress the
    health benefits of exercise
  • 2002 30 minutes or more of moderate exercise a
    day recommended
  • 2003 All women without contraindications should
    participate in aerobic strength-conditioning

ACOG 2002
  • Recognition that regular exercise is beneficial
    to even pregnant women and should be encouraged.
  • All women should be evaluated clinically before
    recommendations made.

Obstet Gynecol 2002 99 171-173.
Absolute Contraindications
  • Hemodynamically significant heart disease
  • Restrictive lung disease
  • Incompetent cervix/cerclage
  • Multiple gestation at risk for premature labor
  • Persistent second- or third-trimester bleeding
  • Placenta previa after 26 weeks
  • Premature labor during current pregnancy
  • Ruptured membranes
  • Preeclampsia/pregnancy induced hypertension

Obstet Gynecol 2002 99 171-173
Relative Contraindications
  • Severe anemia
  • Unevaluated maternal cardiac arrhythmia
  • Chronic bronchitis
  • Poorly controlled type 1 diabetes
  • Extreme morbid obesity
  • Extreme underweight (BMI lt 12)
  • Heavy smoker
  • History of extremely sedentary lifestyle
  • IUGR in current pregnancy
  • Poorly controlled hypertension
  • Orthopedic limitations
  • Poorly controlled seizure disorder
  • Poorly controlled hyperthyroidism

Obstet Gynecol 2002 99 171-173
ACOG 2002
  • Acknowledges the potential of exercise to prevent
    treat gestational diabetes mellitus
  • Recommends avoiding exercise involving both
  • the supine position as much as possible
  • prolonged periods of motionless standing
  • Notes that strenuous activity has not been linked
    to poor fetal growth or outcomes

Obstet Gynecol 2002 99 171-173
ACOG Safety
  • Safety of each sport determined by the specific
    movements required by that sport.
  • Scuba diving is contraindicated
  • Exertion above 6000 feet carries risks.
  • Hyperthermia associated with exercise has not be
    shown to be teratogenic

Obstet Gynecol 2002 99 171-173
Higher Risk Activities
  • Contact sports with risk of abdominal trauma
  • Hockey
  • Basketball
  • Soccer
  • High Risk Sports with risk of both falls and
  • Gymnastics
  • Horseback riding
  • Downhill Skiing
  • Vigorous racquet sport

Obstet Gynecol 2002 99 171-173
Warning Signs to Terminate Exercise
  • Vaginal bleeding
  • Dyspnea prior to exertion
  • Dizziness
  • Headache
  • Chest pain
  • Muscle weakness
  • Calf pain or swelling
  • Preterm labor
  • Decreased fetal movement
  • Amniotic fluid leakage

Obstet Gynecol 2002 99 171-173
Postpartum Exercise
  • Prepregancy exercise routines may be resumed
    gradually as soon as it is physically and
    medically safe.
  • No adverse effects noted for even rapid return to
  • Moderate weight reduction while nursing does not
    compromise infant weight gain.
  • Associated with decreased incidence of postpartum

Obstet Gynecol 2002 99 171-173
Advising the Pregnant Athlete
  • Will her athletic performance suffer?
  • Will she lose a significant amount of aerobic
  • Will her submaximal performance be affected?
  • Can she safely continue resistance exercises?
  • Should she stop competing?
  • How soon can she return to competition?
  • Are breastfeeding and competitive athletics
    mutually exclusive?

Orthopedic Considerations for the Pregnant Athlete
Orthopedic Concerns
  • No injury pattern has been definitely associated
    with exercise in pregnancy
  • Increased joint laxity weight gain increased
    risk of joint discomfort

Common Orthopedic Conditions
  • Low back pain

Common Orthopedic Conditions
  • Low back pain
  • Pelvic/hip pain

Common Orthopedic Conditions
  • Low back pain
  • Pelvic/hip pain
  • Pubic pain

Common Orthopedic Conditions
  • Low back pain
  • Pelvic/hip pain
  • Pubic pain
  • Knee pain
  • Leg cramps

Common Orthopedic Conditions
  • Low back pain
  • Pelvic/hip pain
  • Pubic pain
  • Knee pain
  • Leg cramps
  • Carpal Tunnel Syndrome
  • DeQuervains Tenosynovitis

Exercise Prescription
  • Goal Maintain maternal fitness levels and
    minimize risk to fetus.
  • Points to consider
  • Current fitness level
  • Goals for exercise
  • Job/occupational requirements
  • Gestational age
  • Intensity Perceived exertion
  • Safety is key!

Previously Sedentary Moderately Active Elite Athlete
Start with 15 min of exercise, 3 d-wk Start with 30 min of exercise, 4 d-wk Start with 30 min of exercise, 4 d-wk
Aerobic exercise, 65-75 of maximum heart rate Aerobic exercise, 65-85 of maximum heart rate Aerobic exercise, 75-85 of maximum heart rate
Walking Running Continuation of previous sports should be discussed with coach/trainer/physician and should be adjusted based upon previous activity level
Swimming Cycling/Spinning Taper down or modify protocol in third trimester
Aerobics Aerobics May return to competition within 4-6 wk of delivery depending upon method
Stationary cycling Swimming Avoid trauma and avoid cutting sports after first trimester
Goal 30 min, 4 dIwkj1 Goal 30 min 5 d-wk Goal 30-40 min, 6-7 d-wk
  • Energy intake needs to be sufficient to meet
    energy expenditure and promote weight gain.
  • Gestational weight gain (total rate) good
    indicator of adequate nutrition
  • Quality of diet should be assessed periodically

Practical Advice
Practical Advice
  • Begin discussions at the first visit
  • Structure each regimen individually
  • safe upper limit of exercise will be dictated by
    a womens fitness status prior to entering
  • Encourage rest-activity cycles
  • Promote exercise as relaxation

More Practical Advice
  • Assure adequate hydration and calories to support
  • In mid to late pregnancy, monitor for 2-3 fetal
    movements in first 30 minutes after exercise
  • Do not ignore pain or fatigue
  • Routine prenatal care key!

Maternity Support Binder
ACOG the Competitive Athlete
  • First opinion statement to acknowledge the
    competitive athlete pregnancy
  • Highlighted concerns
  • The potential effect of pregnancy on competitive
  • The effects of strenuous training and competition
    on pregnancy and the fetus
  • Such athletes may require close obstetric

Obstet Gynecol 2002 99 171-173
NCAA Pregnancy
  • Guideline published 2002
  • Acknowledges lack of research addressing intense
    physical exercise pregnancy
  • Cite expert opinion recommending avoid
    participation in contact sports after 14 wks EGA
  • Team physician job is to advise student-athlete
  • Risk, benefits, effects on competitive ability
  • One-year extension of 5 yr eligibility period for
    reasons of pregnancy ??
  • Signed informed consent recommended if athlete
    chooses to compete. May or may not protect the

College athlete dilemmas
  • Athletes required to notify athletic department
    when they become pregnant?
  • Allowed to play while pregnant and for how long?
  • Should pregnancy be protected medical condition
    protected from scholarship revocation?
  • Should colleges develop programs for pregnant

College athlete dilemmas
  • Athletes may
  • Hide pregnancy
  • Drop out of school
  • Elect to have an abortion
  • Delay prenatal care
  • Many colleges have no written policies
  • Need safe environment
  • NCAA Stand up to prevent revocation of

Take Home Points
  • Healthy women should be encouraged to exercise
    before, during, and after pregnancy
  • Knowledge of theoretical risks and known benefits
    are key to advising women
  • Individualized exercise prescription promotes a
    safe, healthy pregnancy
  • Potential benefits typically outweigh any risks
  • Colleges need to adopt written athlete friendly
    policies to assist pregnant athletes

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