(마더세이프 라운드) exercise in pregnancy

Exercise in pregnancy

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이정민

INTRODUCTION

• Pregnancy is recognized as a unique time for lifestyle modifications.

• Regular exercise during pregnancy

promote for its overall health benefits

: maintain or improve physical fitness

help with weight management

enhance psychological well-being

BENEFITS OF EXERCISE DURING PREGNANCY-I

• maintain or improve fitness Obstet Gynecol. 2012

• prevent excessive gestational weight gain Cochrane Database Syst Rev. 2012

• prevent or reduce low back pain Int J Gynaecol Obstet. 2011

• reduce the risk of developing GDM and preeclampsia

• reduce having a cesarean delivery

BENEFITS OF EXERCISE DURING PREGNANCY-I

• Moderate exercise : not a direct cause of any adverse pregnancy outcome

• Physical activity/exercise : not increase the risk of preterm delivery

Med Sci Sports Exerc. 2012

• No strong evidence of clinically significant improvements in other pregnancy

outcomes (duration of labor) Acta Obstet Gynecol Scand. 2014

• Greater risk of joint injuries, falling and abdominal trauma during exercise

;; abdominal trauma placental abruption

( lead to fetal death or morbidity)

BENEFITS OF EXERCISE DURING PREGNANCY-II

• The fetus : tolerate maternal exercise in uncomplicated pregnancies

Any fetal responses : transient with no lasting adverse effects

• Standard tests of fetal well-being : generally reassuring after short-duration,

strenuous exercise in both active and inactive pregnant women

Am J Obstet Gynecol. 2012

• Transient maternal hypoxia

transient fetal tachycardia , a transient increase in fetal blood pressure

fetal protective mechanisms ( increase blood flow and facilitate

exchange of the respiratory gases across the placenta)


• Maternal exercise increase of FHR by 10 ~ 30 bpm

: not deleterious to the fetus ( independent of GA and intensity of exercise)

Am J Obstet Gynecol. 1986

• The increase in rate may be accompanied by a reactive FHR pattern

(ie, FHR accelerations); postexercise reactivity is generally achieved

within 20 minutes. Biophysical profile scores were reassuring.

Obstet Gynecol. 2012


• The Effect of Supervised Prenatal Exercise on Fetal Growth: A Meta-analysis


- Prenatal exercise reduced the odds of having a large newborn by 31% without

altering the risk of having a small newborn or gestational age at delivery.

- Newborns of mothers assigned to exercise : lighter than nonexercising controls

- Maternal gestational weight gain and cesarean delivery : reduced

- CONCLUSION : structured prenatal exercise reduces the risk of having a large

newborn without a change in the risk of having a small newborn

GUIDELINES - United States

The American College of Obstetricians and Gynecologists (ACOG) 2009

- reaffirmed 2002 guideline for exercise during pregnancy and the postpartum

- recommend ( in the absence of either medical or obstetric complications)

pregnant women exercise at a moderate level for 30 minutes or more

per day on most, if not all, days of the week.

- Vigorous exercise is not recommended during pregnancy

( not studied sufficiently)

GUIDELINES - Canada

• The Canadian Society for Exercise Physiology (CSEP)

Canadian Physical Activity Guidelines 2011

: 18 to 64 years : at least 150 minutes of moderate- to vigorous-intensity

aerobic physical activity per week, in bouts of 10 minutes or more, and

stated that muscle-and bone- strengthening activities using major muscle

groups on at least two days per week were also beneficial

: pregnant women should consult a health professional to understand the

types and amounts of physical activity appropriate for them based on their

individual clinical circumstances.

GUIDELINES - United Kingdom

• The Royal College of Obstetricians and Gynecologists (RCOG)

: all pregnant women participate in aerobic and strength-conditioning

exercise as part of a healthy lifestyle during their pregnancy

• Previously sedentary women should begin with 15 minutes of continuous

exercise three times a week, gradually increasing the frequency and

duration to 30-minute sessions 4 to 7 times a week.

• The National Institute for Health and Clinical Excellence (NICE)

; moderate-intensity physical activity at least 30 minutes per day

Pre-exercise medical screening


• General physical condition

• Exercise history

• History of heart disease and risk factors for coronary heart disease

• Orthopedic history and musculoskeletal risks

• Medication use

• History of pulmonary disease

• Anticipated type of exercise

• Handicaps or disabilities

Obstetrical screening

• Some obstetrical conditions : exercise restricted or contraindicated.

• Obstetrical complications

: intractable hyperemesis, premature labor, preeclampsia, FGR

• Some Doppler arterial waveforms deteriorate after exercise in women with

suspected uteroplacental insufficiency, which supports avoidance of

exercise in women with preeclampsia or fetal growth restriction

J Perinat Med. 2004, Am J Obstet Gynecol. 2005

From Exercise during pregnancy and the postpartum

period. ACOG Committee Opinion No.267.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2002;99:171–173; reaffirmed 2009b.

Exercise prescription

• Most pregnant women : routine prenatal care

• Women performing higher-intensity exercise

: assess the nutritional, cardiovascular, musculoskeletal status,

pregnancy risks, NST & USO (fetal growth and well-being)

1. Types of exercise to include/avoid

2. Intensity, progression in difficulty over time

3. Quantity and duration (time)

4. Frequency

Exercise prescription - Type of exercise

• Flexibility exercise individualized to reduce susceptibility to joint injury

( Because of increased relaxation of ligaments during pregnancy, joints are

supported less effectively)

• Water exercise a good for pregnant women since during immersion

• Edema is reduced Obstet Gynecol. 1988

• The forces across weight-bearing joints are reduced

• Body heat is readily dissipated into the water

• Pilates, yoga, circuit-type resistance training, weight training


• High risk of falling or abdominal trauma

ice hockey, soccer, basketball, gymnastics, horseback riding,

downhill skiing, water skiing, vigorous racquet sports, skydiving

• Scuba diving

the fetus : increased risk for decompression sickness secondary to the

inability of the fetal pulmonary circulation to filter bubble formation

• Exercise during the first few days of exposure to moderate to high altitude

(above 6000 ft [2500 m]) the reduction in oxygen availability


• Supine position predisposes pregnant women to hypotensive episodes

; exercising in this position after the first trimester should be avoided,

particularly in the second half of pregnancy

• Thermoregulatory control is altered in pregnancy

• Basal metabolic rate and heat production : increased during pregnancy

• Hyperthermia is a concern because of its potential effects on the developing

fetus

Birth Defects Res A Clin Mol Teratol. 2006


• ACOG recommends that pregnant women avoid exercises and conditions that

are likely to lead to dehydration and overheating


• For aquatic exercise, the Royal College of Obstetricians and Gynecologists (RCOG)

water temperature : not exceed 90º Fahrenheit (32º Celsius)

hydrotherapy pool temperatures : not exceed 90º Fahrenheit (35º Celsius)


Safe Avoid

Aerobic exercise

Progressive resistive strengthening

Stretching exercises

Yoga

Stationary bicycling

Jogging

Walking

Stair climbing

Treadmill use

Water exercise

Swimming

Supine position

Motionless standing

Ice hockey

baseball

horseback riding

gymnastics

scuba dive

Camporesi et al. 1996, ACOG 2002

Exercise prescription - Intensity of exercise

• Prescription of exercise intensity in pregnancy is individually tailored to

the individual’s level of physical ability, ideally involves easily quantified

activities (eg, walking, swimming, stationary cycling), and is increased

gradually

• Women who were regular exercisers before pregnancy and who have

uncomplicated, healthy pregnancies should be able to engage in high-

intensity exercise programs (eg, jogging, aerobics) with no adverse effects

Adv Exp Med Biol. 2014


• Metabolic equivalent task (MET) (energy used by the body while sitting)

1 MET = 3.5ml O2/kg/min


• Intensity based on METs

: Nonpregnant individuals are advised to participate in regular

moderate-intensity exercise routines defined as exercise of 3 to 4 metabolic

equivalents (METs) or any activity that is equivalent in difficulty to brisk

walking

: Moderate exercise appears to be an appropriate goal for the two-thirds of

pregnant women who have not been engaging in regular exercise prior to pregnancy.

: exercise intensity can be safely increased to 6 to 7 METs in well-conditioned

healthy mothers (walking 3.5 mph uphill is 6 METs)

Exercise prescription - Frequency and duration of exercise

• Most guidelines

: 30 minutes of exercise daily, 5 to 7 days per week Obstet Gynecol. 2002

• Exercise should be performed in a thermo-neutral environment or in

controlled environmental conditions (air conditioning).

• Caloric costs of fitness exercise are estimated and balanced by appropriate

caloric intakes.

Exercise prescription - Progression of exercise

• Pregnant women who have not been regular exercisers should follow a

gradual progression of increasing exercise, up to an accumulation of 30

minutes or more per day.

• Previously sedentary women who began exercising at 12-14 wk improved

fitness and delivery outcomes.

Clin Obstet Gynecol. 2003, Med Sci Sports Exerc. 2012

Exercise prescription - When to stop exercising

• Warning signs of potential impending complications

• The pregnant woman should stop exercising and call her healthcare provider

if she has any of the following . Obstet Gynecol. 2002

• Vaginal bleeding

• Leakage of amniotic fluid

• Lightheadedness or dizziness

• Unusual shortness of breath or dyspnea prior to exertion

• Chest pain, Headache, Muscle weakness

• Calf pain or swelling, Uterine contractions

• Decreased fetal movement

DM (GDM)

• Exercise is increasingly promoted as part of the therapeutic regimen for

nonpregnant individuals with diabetes mellitus.

• In addition to its cardiovascular benefits, exercise can also improve glycemic

control, which largely results from increased tissue sensitivity to insulin.

• Exercise may also help to reduce the risk of developing gestational diabetes

or improve glucose control in women with gestational diabetes.

Preeclampsia

• Women with preeclampsia are advised to avoid exercise since it increases

blood pressure and increases blood flow to muscle and potentially away from

the uteroplacental circulation, which already may be compromised.

Am J Epidemiol. 2004

• In women without preeclampsia, observational data suggest that regular

physical activity prepregnancy and in early pregnancy reduces the risk of

developing preeclampsia

Med Sci Sports Exerc. 2005

Obesity

• Excessive weight gain in pregnancy has been associated with obesity

in later life.

• Clinical trials under medical supervision have proven that lifestyle

intervention of weight-gain restriction and moderate exercise

can be safely prescribed in pregnancy, with favorable maternal and

fetal outcomes

Am J Clin Nutr. 2011 /Appl Physiol Nutr Metab. 2007

Risk for FGR

• low risk women(2015 systematic review of randomized trials )

: regular participation in a supervised prenatal exercise program resulted

in a clinically insignificant reduction in birthweight compared with usual

care and no increase in small for gestational age newborns


EXERCISE IN THE POSTPARTUM PERIOD

• Exercise and a healthy diet postpartum promote weight loss, which can

improve or prevent many future obesity-related risks, such as diabetes

mellitus and hypertension

• A decreased frequency of postpartum depression has been associated with

return to physical activity following pregnancy, but only if the exercise is

stress-relieving and not stress-provoking

J Sports Med Phys Fitness. 1997

EXERCISE IN THE POSTPARTUM PERIOD -Breastfeeding

• Breastfeeding women should consider feeding their infants before exercising

to avoid the discomfort of engorged breasts while exercising.

• Nursing before exercise will avoid the potential problems associated with

increased acidity of milk secondary to any build-up of lactic acid.

Thank you for your

attention !!

Health & Medicine

(마더세이프 라운드) exercise in pregnancy