1exercise in pregnancy
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Exercise in pregnancy
제일병원 전임의신유정
Table of contents Physiologic changes in pregnancy Type, intensity, and frequency of exercise Benefit of exercise in pregnancy Contraindications of exercise in pregnancy Warning signs to terminate exercise while
pregnant Maternal advice after exercise recommenda-
tion Exercise in postpartum
Physiologic changes in pregnancy
Nutritional requirement Cardiovascular changes Respiratory changes Mechanical changes Thermoregulatory changes Metabolic changes
Nutritional requirement After the 13th weeks of pregnancy, about 300kcal per
day are required to meet the metabolic needs of pregnancy
This energy requirement is increased through exer-cise.
In weight bearing exercise, such as walking, the en-ergy requirement progressively increases with the increase in weight during the course of the preg-nancy.
A related consideration to nutrition and exercise dur-ing pregnancy is adequate carbohydrate intake.
Artal et al, 2003
Cardiovascular changes
Pregnancy induces – increase in maternal blood volume, cardiac output, and
resting pulse – decrease in maternal systemic vascular resistance.
– Hemodynamics depends on position– Cardiac output in third-trimester pregnancy is maximal
– in the left or right lateral recumbent position.
– Decreased cardiac output– Supine position– Motionless standing Clark et al, 1991
Jovanovic-Peterson et al, 1989
Respiratory changes During pregnancy minute ventilation increases by almost
50%, largely as a result of increased tidal volume.
– increase in arterial oxygen tension to 106-108 mmHg in the first trimester, decreas-ing to a mean of 101-106 mmHg by the third trimester.
– increase in oxygen uptake, and a 10-20% increase in baseline O2 consumption.
– Because of the increased resting oxygen requirements and the increased work of breathing brought about by physical effects of the enlarged uterus on the di-aphragm, there is decreased oxygen available for the performance of aerobic exer-cise during pregnancy.
– in some fit women, there do not appear to be associated changes in maximum aer-obic power or acid-base balance during exercise in pregnancy when compared with the nonpregnant state
Artal et al. 1986, Prowse et al.1965
Templeton et al,1976
Mechanical changes The enlargement of uterus and breasts that
occurs during normal pregnancy results in a shift in the physical center of gravity in the pregnant woman. – loss of balance may prove dangerous
Hormonal influences may result in general-ized increases in joint laxity, predisposing the pregnant woman to mechanical trauma or sprains.
Calguneri et al. 1982, Artal etal.1991
Thermoregulatory changes Both basal metabolic rate and heat production increase
during pregnancy
Teratogenecity – 39.2°C, with hot tub use in early pregnancy– an increase in maternal core body temperature during embryo-
genesis exceeding 1.5°C has been observed to cause cessation of neuronal mitotic cell growth in the ependymal layer of the de-veloping brain.
– Nonpregnant women exercising at 70% of maximal effort on a treadmill for 20 minutes, the core body temperature rose by an average of 1.5°C.
– Fit individuals are known to thermoregulate their core tempera-ture more efficiently.
Hytten et al.1980, Artal et al.1991, Edwards et al.1986, Milunsky et al.1992
2002 ACOG recommendationExercise in pregnancy
In the absence of either medical or obstetric com-plications during pregnancy
women should perform 30 minutes or more of moderate-intensity exercise on most, if not all, days of the weeks.
Moderate exercise – Defined as activity for 30 or more minutes a day, 5 or more
days a week– ex. : Brisk walking, bicycling, vacuuming, gardening, or any activity
that causes small increases in breathing or heart rate
ACOG, 2002
Centers for Disease Control, US physical activity statistics: definitions. 2006
Type of exerciseSafe Avoid
Aerobic exercise Progressive resistive strengthen-ingStretching exercisesYogaStationary bicyclingJoggingWalkingStair climbingTreadmill useWater exerciseSwimming
Supine position after the first trimesterMotionless standing
Recreational sports with a high potential for contact, such as ice hockey and baseball
Increased risk of falling, such as horseback riding and gymnas-tics
Advised not to scuba dive be-cause the fetus is at risk of de-compression sickness
Artal et al. 1991, Clark et al.1991, Camporesi et al. 1996 , ACOG 2002
Intensity of exercise ACSM(American college of sports medicine) recommend
that intensity should be 60-90% of maximal heart rate or 50-85% of either maximal oxygen uptake or heart rate re-serve.
60 % of maximal heart rate or 50% of maximal oxygen uptake– for most pregnant women who did not engage in regular exer-
cise before pregnancy
70% of maximal heart rate or 60% of maximal oxygen up-take– for those who wish to continue to maintain fitness during preg-
nancy.Artal et al, 2003
Intensity of exercise
Daries et al, 2003
Frequency of exercise and rate of progres-sion
Previously sedentary women– Start with 15 min of exercise three times a week– Gradually increase to 30 min four times a weeks at low
to moderate intensity
Active women– Keep their routine exercise or perform at least moderate-
to-vigorous exercise – Four times a week in sessions of 30min or more
Atheletes or women who have higher fitness sta-tus– Evaluated individually– The intensity of exercise like running should be reduced
Davies et al, 2003
Benefits of exercise and activity during preg-nancy
Decreased chance of preeclampsia, second lead-ing cause of maternal death
Decreased chance of operative delivery Decreased chance of developing gestational dia-
betes Improved mood Reduction of pregnancy discomforts- backache
and lower extremity edema Possible prevention of type II diabetes Possible prevention of chronic hypertension
ACOG, 2002
Pre-eclamapsia
Tanya et al., 2003
Pre-eclamapsia
Kasawara et al., 2012
Tinoloy et al., 2014
Deomendoz et al., 20140
Exercise intervention (cesarean deliv-ery)
Deomendoz et al., 2014
Birthweight
Juhl, et al, 2010
Gestational diabetes mellitus Epidemiologic data suggest that exercise may be ben-
eficial in the primary prevention of gestational dia-betes, particularly in morbidly obese women (BMI >33)
The American Diabetes Association has endorsed exer-cise as “a helpful adjunctive therapy” for gestational diabetes mellitus when euglycemia is not achieved by diet alone
Vigorous activity : RR, 0.77 (95% CI, 0.69-0.94). Brisk walking pace : RR, 0.66 (95% CI, 0.46-0.95) com-
pared with an easy pace.
Dye et al, 1997
Jovanovic-Peterson et al 1996, Bung et al.,1996
Zhang et al, 2006
ACOG contraindications to exercise in pregnancy
Hemodynamically significant heart disease Restrictive lung disease Incomplete cervix/cerclarge Multiple gestation at risk for premature labor Persistent second- or third trimester bleeding Placenta previa after 26weeks of gestation Premature labor during current pregnancy Ruptured membranes Preeclampsia
ACOG,2002
ACOG relative contraindications to aerobic exercise during pregnancy
Severe anemia Unevaluated maternal cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes Extreme morbid obesity Extreme underweight (BMI < 12) History of extremely sedentary lifestyle IUGR in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker
ACOG,2002
Warning signs to terminate exercise while pregnancy
Vaginal bleeding Dyspnea prior to exertion Dizziness Headache Chest pain Muscle weakness Calf pain or swelling (need to rule out throm-
bophlebitis) Preterm labor Decreasing fetal movement Amniotic fluid leakage
ACOG,2002
Maternal advice after exercise recom-mendation
Should aware of uterine contractions Less than the fetal movements in 12 hours
is an indication that further investigation at a hospital is warranted
No longer suggest the routine counting of fetal movements in the second half of a woman’s pregnancy
NICE Guideline, 2004
Exercise in postpartum Many of the physiologic and morphologic changes
of pregnancy persist 4-6 weeks postpartum. Thus, prepregnancy exercise routines should be
resumed gradually based on a woman’s physical capability.
No known maternal complications are associated with resumption
Decreased incidence of postpartum depression and stress relieving
Hale et al, 1996
Koltyn et al, 1997
ACOG, 1994; ACOG 2002
Thank you for your atten-tion
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