(마더세이프 라운드) exercise in pregnancy
TRANSCRIPT
Exercise in pregnancy
제일병원전임의
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)
BENEFITS OF EXERCISE DURING PREGNANCY-II
• 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
BENEFITS OF EXERCISE DURING PREGNANCY-II
• The Effect of Supervised Prenatal Exercise on Fetal Growth: A Meta-analysis
Obstet Gynecol. 2015
- 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
Obstet Gynecol. 2002
• 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
Exercise prescription - Type of exercise
• 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
Exercise prescription - Type of exercise
• 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
Exercise prescription - Type of exercise
• ACOG recommends that pregnant women avoid exercises and conditions that
are likely to lead to dehydration and overheating
Obstet Gynecol. 2002
• 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)
Exercise prescription - Type of exercise
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
Exercise prescription - Intensity of exercise
• Metabolic equivalent task (MET) (energy used by the body while sitting)
1 MET = 3.5ml O2/kg/min
Exercise prescription - Intensity of exercise
• 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
Obstet Gynecol. 2015
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 !!