exercise and pregnancy - slide 1

Exercise During Exercise During PregnancyPregnancy

LTC Fred H. Brennan, Jr., DOLTC Fred H. Brennan, Jr., DODirector, Tri-Service Primary Care Sports Medicine Director, Tri-Service Primary Care Sports Medicine

FellowshipFellowshipUniformed Services University of the Health SciencesUniformed Services University of the Health Sciences

Bethesda, MarylandBethesda, Maryland

CaseCase

• 24 y.o. G1P0 presents at 9 wks EGA for 124 y.o. G1P0 presents at 9 wks EGA for 1stst obstetrical visitobstetrical visit

• Competes routinely in triathlons and road Competes routinely in triathlons and road racesraces

• Curious about the benefits & risk of Curious about the benefits & risk of continuing to train & possibly competing continuing to train & possibly competing while pregnantwhile 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?

OverviewOverview

• Physiology of Physiology of Exercise and Exercise and PregnancyPregnancy

• Risks and BenefitsRisks and Benefits• Guidelines for Guidelines for

Exercise in PregnancyExercise in Pregnancy• The Pregnant AthleteThe Pregnant Athlete• Injury PatternsInjury Patterns• Exercise PrescriptionExercise Prescription• College athleteCollege athlete

Useful ReferencesUseful References

• ACOG CommitteeACOG Committee. Opinion no. 267: exercise . Opinion no. 267: exercise during pregnancy and the postpartum period. during pregnancy and the postpartum period. Obstet GynecolObstet Gynecol 2002; 2002;9999:171–3 :171–3

• Artal RArtal R. Exercise during pregnancy. Safe and . Exercise during pregnancy. Safe and beneficial for most. beneficial for most. Phys and Sports Med Phys and Sports Med 1999;1999;2727:51–60 :51–60

• www.casmacms.org/PositionStatements/www.casmacms.org/PositionStatements/PregnancyEng.pdf PregnancyEng.pdf

Useful ReferencesUseful References

• Kelly AK. Practical exercise advice during Kelly AK. Practical exercise advice during pregnancy. Guidelines for active and inactive pregnancy. Guidelines for active and inactive women. women. Phys and Sports Med June Phys and Sports Med June 2005;33(6)2005;33(6)

• Davies GA. Joint SOGC/CSEP clinical practice Davies GA. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the guideline: exercise in pregnancy and the postpartum period.postpartum period. Can J Appl PhysiolCan J Appl Physiol 2003; 28(3): 2003; 28(3): 330-41330-41

• Morris SN. Exercise during pregnancy: a critical Morris SN. Exercise during pregnancy: a critical appraisal of the literature. appraisal of the literature. J Reprod MedJ Reprod Med 2005; 2005; 50(3):181-850(3):181-8

Physiologic Adaptations to Pregnancy & Interactions with Exercise

Physiology OverviewPhysiology Overview

• Significant physiologic changes occur Significant physiologic changes occur in pregnancyin pregnancy

• Objective data on the impact of Objective data on the impact of exercise on the mother, fetus, and exercise on the mother, fetus, and course of pregnancy are limitedcourse of pregnancy are limited

• Theoretical concerns must be Theoretical concerns must be understood to allow physicians to understood to allow physicians to advise women who wish to exercise in advise women who wish to exercise in pregnancypregnancy

Feto-Placental Growth Feto-Placental Growth RegulationRegulation

Rate of Substrate (Glucose) Delivery to the Placental Site =Glucose Concentration x Blood Flow

Tonic Release of Placental Growth Suppressive Peptides into Fetal Circulation

Production of Insulin-like growth factors (IGF) & IGF Binding Proteins by liver and at a tissue specific level

Rate of Feto-Placental Growth at a Tissue-Specific Level

CardiovascularCardiovascular

• Both exercise and pregnancy increase:Both exercise and pregnancy increase:– Heart rateHeart rate– Stroke volumeStroke volume– Cardiac outputCardiac output

• Theoretical risk:Theoretical risk: Competing effects on Competing effects on regional blood flow distributionregional blood flow distribution– Exercise decreases splanchnic blood flowExercise decreases splanchnic blood flow– In pregnancy, flow preferentially shunted to In pregnancy, flow preferentially shunted to

uterine, renal & cutaneous circulationsuterine, renal & cutaneous circulations– Both glucose and oxygen delivery to placental Both glucose and oxygen delivery to placental

site is reducedsite is reduced

Cardiovascular IICardiovascular II

• Women who perform regular weight Women who perform regular weight bearing exercisebearing exercise– Augment pregnancy associated increases Augment pregnancy associated increases

in plasma volumein plasma volume– Increase intervillous spaces blood volumeIncrease intervillous spaces blood volume– Increase placental volumeIncrease placental volume– Increase cardiac outputIncrease cardiac output

• What does this suggest?What does this suggest?– Increased rate of placental blood flow at Increased rate of placental blood flow at

restrest– Increase in 24 h glucose & oxygen deliveryIncrease in 24 h glucose & oxygen delivery

Substrate Delivery & Substrate Delivery & UtilizationUtilization

• Non-pregnant athleteNon-pregnant athlete– Wt-bearing exercise increases glucose oxidationWt-bearing exercise increases glucose oxidation– Sympathetic response mobilizes glucose stores Sympathetic response mobilizes glucose stores

& stimulates gluconeogenesis& stimulates gluconeogenesis– ResultResult: rise in glucose levels for at least the first : rise in glucose levels for at least the first

hourhour

• Pregnant athletePregnant athlete– Sympathetic response bluntedSympathetic response blunted– Glucose oxidation & lipogenesis are increasedGlucose oxidation & lipogenesis are increased– ResultResult: fall in glucose levels during & after : fall in glucose levels during & after

exerciseexercise

Oxygen DeliveryOxygen Delivery

• Pre-pregnancy sustained exercisePre-pregnancy sustained exercise– oxygen delivery to muscles & skinoxygen delivery to muscles & skin– oxygen delivery to most visceraoxygen delivery to most viscera

• During pregnancy oxygen delivery during During pregnancy oxygen delivery during exercise appears to be maintained byexercise appears to be maintained by– Maternal hemoconcentrationMaternal hemoconcentration– Improved perfusion-perfusion balance at the Improved perfusion-perfusion balance at the

placental interphaseplacental interphase– ConclusionConclusion: No evidence for compromised O: No evidence for compromised O2 2

deliverydelivery

PulmonaryPulmonary

• Both exercise and pregnancy increase Both exercise and pregnancy increase – Minute ventilationMinute ventilation– Oxygen consumptionOxygen consumption

• During pregnancyDuring pregnancy– Resting energy expenditure is increased Resting energy expenditure is increased – Augmented work of breathing during exerciseAugmented work of breathing during exercise– ResultResult: exercise requires higher VO: exercise requires higher VO22 (oxygen (oxygen

uptake) compared with that required in a uptake) compared with that required in a nonpregnancy statenonpregnancy state

• VOVO2 2 max decreases because body weight max decreases because body weight increases with pregnancyincreases with pregnancy

ThermoregulatoryThermoregulatory• Both exercise and pregnancy increase Both exercise and pregnancy increase

– Metabolic rate Metabolic rate – Increased heat productionIncreased heat production

• Theoretical concerns:Theoretical concerns:– Elevation in maternal core temperature due to Elevation in maternal core temperature due to

exercise could reduce fetal heat dissipationexercise could reduce fetal heat dissipation– Possible teratogenic effect at temp>102.6Possible teratogenic effect at temp>102.6

• Healthy, fit pregnant women have been Healthy, fit pregnant women have been shown to tolerate thermal stressshown to tolerate thermal stress

Changing Thermal Response Changing Thermal Response to Endurance Exercise in to Endurance Exercise in

PregnancyPregnancy• 18 well-trained recreational athletes18 well-trained recreational athletes• 20 minutes of cycling at room 20 minutes of cycling at room

temperature & 60-65% VOtemperature & 60-65% VO22 max max

• Maximum core temperature achieved Maximum core temperature achieved during cycling decreased throughout during cycling decreased throughout gestationgestation

• Appear to be related to a decrease Appear to be related to a decrease rectal temperature at rest & rectal temperature at rest & increased sweatingincreased sweating

Am J Obstet Gynecol. 1991; 165;: 1684-9.

NeuroendocrineNeuroendocrine

• Exercise increases circulating levels Exercise increases circulating levels ofof– NorepinephrineNorepinephrine– EpinephrineEpinephrine

• Theoretical concernsTheoretical concerns: excess : excess catecholamines and prostanglandins catecholamines and prostanglandins will result in contractions & preterm will result in contractions & preterm laborlabor

Mechanical EffectsMechanical Effects

• Altered center of Altered center of gravity gravity – growing breast, growing breast,

uterus and fetusuterus and fetus– increased lumbar increased lumbar

lordosislordosis

• Increased risk of fallIncreased risk of fall• Increased joint laxityIncreased joint laxity

– Theoretic increased Theoretic increased risk for strains/sprainsrisk for strains/sprains

Risks and Benefits

RisksRisks

• Theoretical risks:Theoretical risks:– Hypoxemia/Hypoxemia/

HypoglycemiaHypoglycemia– Fetal teratogenesisFetal teratogenesis– Preterm laborPreterm labor– Low birth weightsLow birth weights– Sprains/strainsSprains/strains

RisksRisks

• Theoretical risks:Theoretical risks:– Hypoxemia/HypoglycemiaHypoxemia/Hypoglycemia– Fetal teratogenesisFetal teratogenesis– Preterm laborPreterm labor– Low birth weightsLow birth weights– Sprains/strainsSprains/strains

• Negative outcomes have Negative outcomes have notnot been identified: been identified:– SABSAB– Pregnancy complicationsPregnancy complications– PTL/preterm birthPTL/preterm birth– Altered birth weightAltered birth weight– Higher injury ratesHigher injury rates

Sour Milk?Sour Milk?

• Neither Neither quantityquantity nor nor qualityquality of of breast milk breast milk produced appears produced appears to be affected by to be affected by moderate exercisemoderate exercise

BenefitsBenefits

• 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, SOBSwelling, leg cramps, fatigue, SOB

• Positive influence of labor & delivery Positive influence of labor & delivery (Clapp et (Clapp et al)al)– Decreased risk of operative or assisted deliveriesDecreased risk of operative or assisted deliveries– Shorter active laborShorter active labor– Increased fetal tolerance of laborIncreased fetal tolerance of labor

• Possible reduced risk of preeclampsia, GDMPossible reduced risk of preeclampsia, GDM

Course of Labor after Course of Labor after Endurance Exercise in Endurance Exercise in

PregnancyPregnancyExerciExercisese(n=87)(n=87)

ContrControlol(n=44)(n=44)

Incidence of PTLIncidence of PTL 9%9% 9%9%

Length of GestationLength of Gestation 277 d277 d 282 d282 d

Incidence of c-sectionIncidence of c-section 6%6% 30%30%

Incidence of operative Incidence of operative vaginal deliveryvaginal delivery

6%6% 20%20%

Duration of laborDuration of labor 264 264 minmin

382 382 minmin

Clinical evidence of fetal Clinical evidence of fetal distressdistress

26%26% 50%50%Am J Obstet Gynecol 163: 1799-1805, 1990.

Psychological Well-BeingPsychological Well-Being

• Improved moodImproved mood• Decreased stressDecreased stress• Improved self-Improved self-

imageimage• Increased sense of Increased sense of

control and relief control and relief of tensionof tension

Semin Perinatol 20: 70-76, 1996.

Postpartum Well-BeingPostpartum Well-Being

• Improved weight lossImproved weight loss• Improved psychological well-beingImproved psychological well-being• No adverse impact on No adverse impact on

breastfeeding.breastfeeding.

Neonatal & Childhood Neonatal & Childhood BenefitsBenefits

• Clapp JF: Morphometric and Clapp JF: Morphometric and neurodevelopment outcomes at neurodevelopment outcomes at age 5 years of offspring of age 5 years of offspring of women who continued to women who continued to exercise regularly throughout exercise regularly throughout pregnancy.pregnancy.– Less body fat at birth and 5 Less body fat at birth and 5

yrsyrs– Similar motor, integrative & Similar motor, integrative &

academic readiness as control academic readiness as control groupsgroups

– Higher scores on Wechsler Higher scores on Wechsler scales and tests of oral scales and tests of oral language skills.language skills.

J. Pediatr 129: 856-863, 1996.

Preventing & Treating Preventing & Treating GDMGDM

• Exercise may be beneficial in the primary Exercise may be beneficial in the primary prevention of GDM, especially in prevention of GDM, especially in morbidly obese women (BMI > 33)morbidly obese women (BMI > 33)

• Resistance training may reduce need for Resistance training may reduce need for insulin therapy in overweight women insulin therapy in overweight women (BMI > 25)(BMI > 25)

• ADA endorsed exercise as helpful ADA endorsed exercise as helpful adjunctive therapy with GDM when adjunctive therapy with GDM when euglycemia is not achieved by diet alone.euglycemia is not achieved by diet alone.

Expert Guidance

Guidelines for Exercise in Guidelines for Exercise in PregnancyPregnancy

• ACOG in evolutionACOG in evolution– 19851985: HR : HR <<140 BPM with maximum duration 140 BPM with maximum duration

of exercise = 15 minutesof exercise = 15 minutes– 19941994: Less cautious and began to stress the : Less cautious and began to stress the

health benefits of exercisehealth benefits of exercise– 20022002: 30 minutes or more of moderate : 30 minutes or more of moderate

exercise a day recommendedexercise a day recommended

• SOGC/CSEPSOGC/CSEP– 2003: 2003: All women without contraindications All women without contraindications

should participate in aerobic & strength-should participate in aerobic & strength-conditioning exercise.conditioning exercise.

ACOG 2002ACOG 2002

• Recognition that Recognition that regular exercise is regular exercise is beneficial to even beneficial to even pregnant women pregnant women and should be and should be encouraged.encouraged.

• All women should All women should be evaluated be evaluated clinically before clinically before recommendations recommendations made.made.Obstet Gynecol 2002; 99: 171-173.

Absolute Absolute ContraindicationsContraindications

• 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: 171-173

Relative Relative ContraindicationsContraindications

• Severe anemiaSevere anemia• Unevaluated maternal Unevaluated maternal

cardiac arrhythmiacardiac arrhythmia• Chronic bronchitisChronic bronchitis• Poorly controlled type Poorly controlled type

1 diabetes1 diabetes• Extreme morbid Extreme morbid

obesityobesity• Extreme underweight Extreme underweight

(BMI < 12)(BMI < 12)• Heavy smokerHeavy smoker

• History of extremely History of extremely sedentary lifestylesedentary lifestyle

• IUGR in current IUGR in current pregnancypregnancy

• Poorly controlled Poorly controlled hypertensionhypertension

• Orthopedic limitationsOrthopedic limitations• Poorly controlled Poorly controlled

seizure disorderseizure disorder• Poorly controlled Poorly controlled

hyperthyroidismhyperthyroidism


ACOG 2002ACOG 2002

• Acknowledges the potential of exercise Acknowledges the potential of exercise to prevent & treat gestational diabetes to prevent & treat gestational diabetes mellitusmellitus

• Recommends avoiding exercise Recommends avoiding exercise involving bothinvolving both– the supine position “as much as possible”the supine position “as much as possible”– prolonged periods of motionless standingprolonged periods of motionless standing

• Notes that strenuous activity has not Notes that strenuous activity has not been linked to poor fetal growth or been linked to poor fetal growth or outcomesoutcomes


ACOG & SafetyACOG & Safety

• Safety of each sport determined by Safety of each sport determined by the “specific movements required by the “specific movements required by that sport.”that sport.”

• Scuba diving is contraindicatedScuba diving is contraindicated• Exertion above 6000 feet carries Exertion above 6000 feet carries

risks.risks.• Hyperthermia associated with Hyperthermia associated with

exercise has not be shown to be exercise has not be shown to be teratogenicteratogenic


Higher Risk ActivitiesHigher Risk Activities

• Contact sports Contact sports with risk of with risk of abdominal traumaabdominal trauma– HockeyHockey– BasketballBasketball– SoccerSoccer

• High Risk Sports High Risk Sports with risk of both with risk of both falls and traumafalls and trauma– Gymnastics Gymnastics – Horseback ridingHorseback riding– Downhill SkiingDownhill Skiing– Vigorous racquet Vigorous racquet

sportsport


Warning Signs to Warning Signs to Terminate ExerciseTerminate Exercise

• Vaginal bleedingVaginal bleeding• Dyspnea prior to Dyspnea prior to

exertionexertion• DizzinessDizziness• HeadacheHeadache• Chest painChest pain• Muscle weaknessMuscle weakness• Calf pain or swellingCalf pain or swelling• Preterm laborPreterm labor• Decreased fetal Decreased fetal

movementmovement• Amniotic fluid leakageAmniotic fluid leakage


Postpartum ExercisePostpartum Exercise

• ““Prepregancy exercise routines may Prepregancy exercise routines may be resumed gradually as soon as it is be resumed gradually as soon as it is physically and medically safe.”physically and medically safe.”

• No adverse effects noted for even No adverse effects noted for even rapid return to activity.rapid return to activity.

• Moderate weight reduction while Moderate weight reduction while nursing does not compromise infant nursing does not compromise infant weight gain.weight gain.

• Associated with decreased incidence Associated with decreased incidence of postpartum depression.of postpartum depression.


Advising the Pregnant Advising the Pregnant AthleteAthlete

• Will her athletic performance suffer?Will her athletic performance suffer?– Will she lose a significant amount of aerobic Will she lose a significant amount of aerobic

fitness?fitness?– Will her submaximal performance be affected?Will her submaximal performance be affected?

• Can she safely continue resistance Can she safely continue resistance exercises?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 Are breastfeeding and competitive athletics

mutually exclusive?mutually exclusive?

Orthopedic Considerations for the Pregnant Athlete

Orthopedic ConcernsOrthopedic Concerns

• No injury pattern No injury pattern has been definitely has been definitely associated with associated with exercise in exercise in pregnancypregnancy

• Increased joint Increased joint laxity + weight laxity + weight gain = increased gain = increased risk of joint risk of joint discomfortdiscomfort

Common Orthopedic Common Orthopedic ConditionsConditions

• Low back painLow back pain


• Low back painLow back pain• Pelvic/hip painPelvic/hip pain


• Low back painLow back pain• Pelvic/hip painPelvic/hip pain• Pubic painPubic pain


• Low back painLow back pain• Pelvic/hip painPelvic/hip pain• Pubic painPubic pain• Knee painKnee pain• Leg crampsLeg cramps


• Low back painLow back pain• Pelvic/hip painPelvic/hip pain• Pubic painPubic pain• Knee painKnee pain• Leg crampsLeg cramps• Carpal Tunnel Carpal Tunnel

SyndromeSyndrome• DeQuervain’s DeQuervain’s

TenosynovitisTenosynovitis

Exercise PrescriptionExercise Prescription

• Goal: Maintain Goal: Maintain maternal fitness maternal fitness levels and minimize levels and minimize risk to fetus.risk to fetus.

• Points to considerPoints to consider– Current fitness levelCurrent fitness level– Goals for exerciseGoals for exercise– Job/occupational Job/occupational

requirementsrequirements– Gestational ageGestational age

• Intensity: Perceived Intensity: Perceived exertionexertion

• Safety is key!Safety is key!

NutritionNutrition

• Energy intake needs Energy intake needs to be sufficient to to be sufficient to meet energy meet energy expenditure and expenditure and promote weight gain.promote weight gain.

• Gestational weight Gestational weight gain (total & rate) gain (total & rate) good indicator of good indicator of adequate nutritionadequate nutrition

• Quality of diet should Quality of diet should be assessed be assessed periodicallyperiodically

Practical AdvicePractical Advice

Practical AdvicePractical Advice

• 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 safe upper limit of exercise will be dictated by a women’s fitness status dictated by a women’s fitness status prior to entering pregnancyprior to entering pregnancy

• Encourage rest-activity cyclesEncourage rest-activity cycles• Promote exercise as relaxationPromote exercise as relaxation

More Practical AdviceMore Practical Advice

• Assure adequate Assure adequate hydration and calories hydration and calories to support activityto support activity

• In mid to late In mid to late pregnancy, monitor pregnancy, monitor for 2-3 fetal for 2-3 fetal movements in first 30 movements in first 30 minutes after exerciseminutes after exercise

• Do not ignore pain or Do not ignore pain or fatiguefatigue

• Routine prenatal care Routine prenatal care key!key! Maternity Support

Binder

ACOG & the Competitive ACOG & the Competitive AthleteAthlete

• First opinion statement to First opinion statement to acknowledge the competitive athlete acknowledge the competitive athlete & pregnancy& pregnancy

• Highlighted concerns:Highlighted concerns:– The potential effect of pregnancy on The potential effect of pregnancy on

competitive abilitycompetitive ability– The effects of strenuous training and The effects of strenuous training and

competition on pregnancy and the fetuscompetition on pregnancy and the fetus• ““Such athletes may require close Such athletes may require close

obstetric supervision.”obstetric supervision.”Obstet Gynecol 2002; 99: 171-173

NCAA & PregnancyNCAA & Pregnancy• Guideline published 2002Guideline published 2002• Acknowledges lack of research addressing Acknowledges lack of research addressing

intense physical exercise & pregnancyintense physical exercise & pregnancy• Cite expert opinion recommending avoid Cite expert opinion recommending avoid

participation in contact sports after 14 wks participation in contact sports after 14 wks EGAEGA

• Team physician job is to advise student-athlete:Team physician job is to advise student-athlete:– Risk, benefits, effects on competitive abilityRisk, benefits, effects on competitive ability– One-year extension of 5 yr eligibility period for One-year extension of 5 yr eligibility period for

reasons of pregnancy ??reasons of pregnancy ??

• Signed informed consent recommended if Signed informed consent recommended if athlete chooses to compete. May or may not athlete chooses to compete. May or may not protect the universityprotect the university

College athlete dilemmasCollege athlete dilemmas

• Athletes required to notify athletic Athletes required to notify athletic department when they become department when they become pregnant?pregnant?

• Allowed to play while pregnant and Allowed to play while pregnant and for how long?for how long?

• Should pregnancy be protected Should pregnancy be protected medical condition protected from medical condition protected from scholarship revocation?scholarship revocation?

• Should colleges develop programs for Should colleges develop programs for pregnant athletes?pregnant athletes?

College athlete dilemmasCollege athlete dilemmas

• Athletes may:Athletes may:– Hide pregnancyHide pregnancy– Drop out of schoolDrop out of school– Elect to have an abortionElect to have an abortion– Delay prenatal careDelay prenatal care

• Many colleges have no written policiesMany colleges have no written policies• Need safe environmentNeed safe environment• NCAA: “Stand up” to prevent NCAA: “Stand up” to prevent

revocation of scholarshipsrevocation of scholarships

Take Home PointsTake Home Points

• Healthy women should be encouraged to Healthy women should be encouraged to exercise before, during, and after pregnancyexercise before, during, and after pregnancy

• Knowledge of theoretical risks and known Knowledge of theoretical risks and known benefits are key to advising womenbenefits are key to advising women

• Individualized exercise prescription promotes Individualized exercise prescription promotes a safe, healthy pregnancy a safe, healthy pregnancy

• Potential benefits typically outweigh any risksPotential benefits typically outweigh any risks• Colleges need to adopt written “athlete Colleges need to adopt written “athlete

friendly” policies to “assist” pregnant athletesfriendly” policies to “assist” pregnant athletes

Questions?

exercise and pregnancy - slide 1

Documents