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

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Presentation on theme: "Exercise During Pregnancy Antoin M. Alexander Maj USAF MC Family Medicine Sports Fellow Adopted from Dr. Fred Brennan."— Presentation transcript:

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

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3 Case 24 y.o. G1P0 presents at 9 wks EGA for 1 st obstetrical visit24 y.o. G1P0 presents at 9 wks EGA for 1 st obstetrical visit Competes routinely in triathlons and road racesCompetes routinely in triathlons and road races Curious about the benefits & risk of continuing to train & possibly competing while pregnantCurious about the benefits & risk of continuing to train & possibly competing while pregnant Will her performance suffer?Will her performance suffer? Will she put her baby at risk?Will she put her baby at risk? Can she exercise & breastfeed in the future?Can she exercise & breastfeed in the future?

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

5 Useful References ACOG Committee. Opinion no. 267: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002;99:171–3ACOG Committee. Opinion no. 267: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002;99:171–3 Artal R. Exercise during pregnancy. Safe and beneficial for most. Phys and Sports Med 1999;27:51–60Artal R. Exercise during pregnancy. Safe and beneficial for most. Phys and Sports Med 1999;27:51–60

6 Useful References Kelly AK. Practical exercise advice during pregnancy. Guidelines for active and inactive women. Phys and Sports Med June 2005;33(6)Kelly AK. Practical exercise advice during pregnancy. Guidelines for active and inactive women. Phys and Sports Med June 2005;33(6) Davies GA. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can J Appl Physiol 2003; 28(3): Davies GA. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can J Appl Physiol 2003; 28(3): Morris SN. Exercise during pregnancy: a critical appraisal of the literature. J Reprod Med 2005; 50(3):181-8Morris SN. Exercise during pregnancy: a critical appraisal of the literature. J Reprod Med 2005; 50(3):181-8

7 Physiologic Adaptations to Pregnancy & Interactions with Exercise

8 Physiology Overview Significant physiologic changes occur in pregnancySignificant physiologic changes occur in pregnancy Objective data on the impact of exercise on the mother, fetus, and course of pregnancy are limitedObjective data on the impact of exercise on the mother, fetus, and course of pregnancy are limited Theoretical concerns must be understood to allow physicians to advise women who wish to exercise in pregnancyTheoretical concerns must be understood to allow physicians to advise women who wish to exercise in pregnancy

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

10 Fetal Response To Exercise 45 healthy pregnany woman studied45 healthy pregnany woman studied –15 nonexercisers, 15 regularly active,15 highly active –Tested 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 < 20 minutes BPP scores all reassuring Obstet Gynecol 2012; 119 (3) :

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

12 Substrate Delivery & Utilization Non-pregnant athleteNon-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 athletePregnant athlete –Sympathetic response blunted –Glucose oxidation & lipogenesis are increased –Result: fall in glucose levels during & after exercise

13 Oxygen Delivery Pre-pregnancy sustained exercisePre-pregnancy sustained exercise –  oxygen delivery to muscles & skin –  oxygen delivery to most viscera During pregnancy oxygen delivery during exercise appears to be maintained byDuring pregnancy oxygen delivery during exercise appears to be maintained by –Maternal hemoconcentration –Improved perfusion at the placental interphase –Conclusion: No evidence for compromised O 2 delivery

14 Pulmonary Both exercise and pregnancy increaseBoth exercise and pregnancy increase –Minute ventilation –Oxygen consumption During pregnancyDuring pregnancy –Resting energy expenditure is increased –Augmented work of breathing during exercise –Result: exercise requires higher VO 2 (oxygen uptake) compared with that required in a nonpregnancy state VO 2 max decreases because body weight increases with pregnancyVO 2 max decreases because body weight increases with pregnancy

15 Thermoregulatory Both exercise and pregnancy increaseBoth exercise and pregnancy increase –Metabolic rate –Increased heat production Theoretical concerns:Theoretical concerns: –Elevation in maternal core temperature due to exercise could reduce fetal heat dissipation –Possible teratogenic effect at temp>102.6 Healthy, fit pregnant women have been shown to tolerate thermal stressHealthy, fit pregnant women have been shown to tolerate thermal stress

16 Changing Thermal Response to Endurance Exercise in Pregnancy 18 well-trained recreational athletes18 well-trained recreational athletes 20 minutes of cycling at room temperature & 60-65% VO 2 max20 minutes of cycling at room temperature & 60-65% VO 2 max Maximum core temperature achieved during cycling decreased throughout gestationMaximum core temperature achieved during cycling decreased throughout gestation Appear to be related to a increased vasodilation & increased sweatingAppear to be related to a increased vasodilation & increased sweating Am J Obstet Gynecol. 1991; 165;:

17 Neuroendocrine Exercise increases circulating levels ofExercise increases circulating levels of –Norepinephrine –Epinephrine Theoretical concerns: excess catecholamines and prostanglandins will result in contractions & preterm laborTheoretical concerns: excess catecholamines and prostanglandins will result in contractions & preterm labor –Cochran review 2010 of 14 trials women No statistically significant change in gestation at deliveryNo statistically significant change in gestation at delivery

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

19 Risks and Benefits

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

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

22 Benefits Improved cardiovascular fitnessImproved cardiovascular fitness Control of maternal weight gainControl of maternal weight gain Reduced subjective discomforts of pregnancyReduced subjective discomforts of pregnancy –Swelling, leg cramps, fatigue, SOB Positive influence of labor & delivery (Clapp et al)Positive influence of labor & delivery (Clapp et al) –Decreased risk of operative or assisted deliveries –Shorter active labor –Increased fetal tolerance of labor Possible reduced risk of preeclampsia, GDMPossible reduced risk of preeclampsia, GDM

23 Course of Labor after Endurance Exercise in Pregnancy Exercise(n=87)Control(n=44) 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: , 1990.

24 Psychological Well-Being Improved moodImproved mood Decreased stressDecreased stress Improved self-imageImproved self-image Increased sense of control and relief of tensionIncreased sense of control and relief of tension Semin Perinatol 20: 70-76, 1996.

25 Postpartum Well-Being Improved weight lossImproved weight loss Improved psychological well-beingImproved psychological well-being No adverse impact on breastfeeding.No adverse impact on breastfeeding.

26 Neonatal & Childhood Benefits Clapp JF: Morphometric and neurodevelopment outcomes at age 5 years of offspring of women who continued to exercise regularly throughout pregnancy. –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: , 1996.

27 Preventing & Treating GDM Exercise may be beneficial in the primary prevention of GDM, especially in morbidly obese women (BMI > 33)Exercise may be beneficial in the primary prevention of GDM, especially in morbidly obese women (BMI > 33) Resistance training may reduce need for insulin therapy in overweight women (BMI > 25)Resistance training may reduce need for insulin therapy in overweight women (BMI > 25) ADA endorsed exercise as helpful adjunctive therapy with GDM when euglycemia is not achieved by diet alone.ADA endorsed exercise as helpful adjunctive therapy with GDM when euglycemia is not achieved by diet alone.

28 Expert Guidance

29 Guidelines for Exercise in Pregnancy ACOG in evolutionACOG in evolution –1985: HR <140 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 SOGC/CSEPSOGC/CSEP –2003: All women without contraindications should participate in aerobic & strength-conditioning exercise.

30 ACOG 2002 Recognition that regular exercise is beneficial to even pregnant women and should be encouraged.Recognition that regular exercise is beneficial to even pregnant women and should be encouraged. All women should be evaluated clinically before recommendations made.All women should be evaluated clinically before recommendations made. Obstet Gynecol 2002; 99:

31 Absolute Contraindications Hemodynamically significant heart diseaseHemodynamically significant heart disease Restrictive lung diseaseRestrictive lung disease Incompetent cervix/cerclageIncompetent cervix/cerclage Multiple gestation at risk for premature laborMultiple gestation at risk for premature labor Persistent second- or third-trimester bleedingPersistent second- or third-trimester bleeding Placenta previa after 26 weeksPlacenta previa after 26 weeks Premature labor during current pregnancyPremature labor during current pregnancy Ruptured membranesRuptured membranes Preeclampsia/pregnancy induced hypertensionPreeclampsia/pregnancy induced hypertension Obstet Gynecol 2002; 99:

32 Relative Contraindications Severe anemiaSevere anemia Unevaluated maternal cardiac arrhythmiaUnevaluated maternal cardiac arrhythmia Chronic bronchitisChronic bronchitis Poorly controlled type 1 diabetesPoorly controlled type 1 diabetes Extreme morbid obesityExtreme morbid obesity Extreme underweight (BMI < 12)Extreme underweight (BMI < 12) Heavy smokerHeavy 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:

33 ACOG 2002 Acknowledges the potential of exercise to prevent & treat gestational diabetes mellitusAcknowledges the potential of exercise to prevent & treat gestational diabetes mellitus Recommends avoiding exercise involving bothRecommends 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 outcomesNotes that strenuous activity has not been linked to poor fetal growth or outcomes Obstet Gynecol 2002; 99:

34 ACOG & Safety Safety of each sport determined by the “specific movements required by that sport.”Safety of each sport determined by the “specific movements required by that sport.” Scuba diving is contraindicatedScuba diving is contraindicated Exertion above 6000 feet carries risks.Exertion above 6000 feet carries risks. Hyperthermia associated with exercise has not be shown to be teratogenicHyperthermia associated with exercise has not be shown to be teratogenic Obstet Gynecol 2002; 99:

35 Higher Risk Activities Contact sports with risk of abdominal traumaContact sports with risk of abdominal trauma –Hockey –Basketball –Soccer High Risk Sports with risk of both falls and trauma –Gymnastics –Horseback riding –Downhill Skiing –Vigorous racquet sport Obstet Gynecol 2002; 99:

36 Warning Signs to Terminate Exercise Vaginal bleedingVaginal bleeding Dyspnea prior to exertionDyspnea prior to exertion DizzinessDizziness HeadacheHeadache Chest painChest pain Muscle weaknessMuscle weakness Calf pain or swellingCalf pain or swelling Preterm laborPreterm labor Decreased fetal movementDecreased fetal movement Amniotic fluid leakageAmniotic fluid leakage Obstet Gynecol 2002; 99:

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

38 Advising the Pregnant Athlete Will her athletic performance suffer?Will her athletic performance suffer? –Will she lose a significant amount of aerobic fitness? –Will her submaximal performance be affected? Can she safely continue resistance exercises?Can she safely continue resistance exercises? Should she stop competing?Should she stop competing? How soon can she return to competition?How soon can she return to competition? Are breastfeeding and competitive athletics mutually exclusive?Are breastfeeding and competitive athletics mutually exclusive?

39 Orthopedic Considerations for the Pregnant Athlete

40 Orthopedic Concerns No injury pattern has been definitely associated with exercise in pregnancyNo injury pattern has been definitely associated with exercise in pregnancy Increased joint laxity + weight gain = increased risk of joint discomfortIncreased joint laxity + weight gain = increased risk of joint discomfort

41 Common Orthopedic Conditions Low back painLow back pain

42 Common Orthopedic Conditions Low back painLow back pain Pelvic/hip painPelvic/hip pain

43 Common Orthopedic Conditions Low back painLow back pain Pelvic/hip painPelvic/hip pain Pubic painPubic pain

44 Common Orthopedic Conditions Low back painLow back pain Pelvic/hip painPelvic/hip pain Pubic painPubic pain Knee painKnee pain Leg crampsLeg cramps

45 Common Orthopedic Conditions Low back painLow back pain Pelvic/hip painPelvic/hip pain Pubic painPubic pain Knee painKnee pain Leg crampsLeg cramps Carpal Tunnel SyndromeCarpal Tunnel Syndrome DeQuervain’s TenosynovitisDeQuervain’s Tenosynovitis

46 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!

47 Previously SedentaryModerately ActiveElite Athlete Start with 15 min of exercise, 3 d-wkStart 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 WalkingRunningContinuation of previous sports should be discussed with coach/trainer/physician and should be adjusted based upon previous activity level SwimmingCycling/SpinningTaper down or modify protocol in third trimester Aerobics May return to competition within 4- 6 wk of delivery depending upon method Stationary cyclingSwimmingAvoid trauma and avoid cutting sports after first trimester Goal 30 min, 4 dIwkj1Goal 30 min 5 d-wkGoal min, 6-7 d-wk

48 Nutrition 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

49 Practical Advice

50 Begin discussions at the first visitBegin discussions at the first visit Structure each regimen individuallyStructure each regimen individually –safe upper limit of exercise will be dictated by a women’s fitness status prior to entering pregnancy Encourage rest-activity cyclesEncourage rest-activity cycles Promote exercise as relaxationPromote exercise as relaxation

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

52 ACOG & the Competitive Athlete First opinion statement to acknowledge the competitive athlete & pregnancyFirst opinion statement to acknowledge the competitive athlete & pregnancy Highlighted concerns:Highlighted concerns: –The potential effect of pregnancy on competitive ability –The effects of strenuous training and competition on pregnancy and the fetus “Such athletes may require close obstetric supervision.”“Such athletes may require close obstetric supervision.” Obstet Gynecol 2002; 99:

53 NCAA & Pregnancy Guideline published 2002Guideline published 2002 Acknowledges lack of research addressing intense physical exercise & pregnancyAcknowledges lack of research addressing intense physical exercise & pregnancy Cite expert opinion recommending avoid participation in contact sports after 14 wks EGACite expert opinion recommending avoid participation in contact sports after 14 wks EGA Team physician job is to advise student-athlete: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 universitySigned informed consent recommended if athlete chooses to compete. May or may not protect the university

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

55 College athlete dilemmas Athletes may:Athletes may: –Hide pregnancy –Drop out of school –Elect to have an abortion –Delay prenatal care Many colleges have no written policiesMany colleges have no written policies Need safe environmentNeed safe environment NCAA: “Stand up” to prevent revocation of scholarshipsNCAA: “Stand up” to prevent revocation of scholarships

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

57 Questions?

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