07.02.2015

Exercise in pregnancy guidelines acog

Regular physical activity in all phases of life, including pregnancy, promotes health benefits. Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. A thorough clinical evaluation should be conducted before recommending an exercise program to ensure that a patient does not have a medical reason to avoid exercise.
Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.
Obstetrician–gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy. Regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychologic well-being.
Additional research is needed to study the effects of exercise on pregnancy-specific outcomes, and to clarify the most effective behavioral counseling methods and the optimal intensity and frequency of exercise. Pregnancy results in anatomic and physiologic changes that should be considered when prescribing exercise. Despite the fact that pregnancy is associated with profound anatomic and physiologic changes, exercise has minimal risks and has been shown to benefit most women. Most of the studies addressing fetal response to maternal exercise have focused on fetal heart rate changes and birth weight. Regular aerobic exercise during pregnancy has been shown to improve or maintain physical fitness (8, 9, 27).
Pregnancy is an ideal time for behavior modification and for adopting a healthy lifestyle because of increased motivation and frequent access to medical supervision. The principles of exercise prescription for pregnant women do not differ from those for the general population (2).
Because blunted and normal heart-rate responses to exercise have been reported in pregnant women, the use of ratings of perceived exertion may be a more effective means to monitor exercise intensity during pregnancy than heart-rate parameters (44).
Pregnant women who were sedentary before pregnancy should follow a more gradual progression of exercise. Prolonged exercise should be performed in a thermoneutral environment or in controlled environmental conditions (air conditioning) with close attention paid to proper hydration and caloric intake. Several reviews have determined that there is no credible evidence to prescribe bed rest in pregnancy, which is most commonly prescribed for the prevention of preterm labor.
Obese pregnant women should be encouraged to engage in healthy lifestyle modification in pregnancy that includes physical activities and judicious diets (5).
Competitive athletes require frequent and closer supervision because they tend to maintain a more strenuous training schedule throughout pregnancy and resume high-intensity postpartum training sooner as compared to others. The American Medical Association Council on Scientific Affairs 1984 guidelines on weight limits for occupational lifting during pregnancy have been used by clinicians for many years but are not specific, do not define the terms repetitive and intermittent lifting, and do not consider the type of lifting (55).
Regular aerobic exercise in lactating women has been shown to improve maternal cardiovascular fitness without affecting milk production, composition, or infant growth. Women who begin their pregnancy with a healthy lifestyle (eg, exercise, good nutrition, nonsmoking) should be encouraged to maintain those healthy habits. Department of Health and Human Services issued physical activity guidelines for Americans (2). In pregnancy, physical inactivity and excessive weight gain have been recognized as independent risk factors for maternal obesity and related pregnancy complications, including gestational diabetes mellitus (GDM) (5–7). The most distinct changes during pregnancy are increased weight gain and a shift in the point of gravity that results in progressive lordosis. During exercise, pregnant women should stay well-hydrated, wear loose-fitting clothing, and avoid high heat and humidity to protect against heat stress, particularly during the first trimester (19). The most common sports-related injuries in pregnancy are musculoskeletal, by and large related to lower extremities edema (80%) and joint laxity (22). Although the evidence is limited, some benefit to pregnancy outcomes has been shown, and there is no evidence of harm when not contraindicated. A thorough clinical evaluation should be conducted before recommending an exercise program to ensure that a patient does not have medical reasons to avoid exercise. Although an upper level of safe exercise intensity has not been established, women who were regular exercisers before pregnancy and who have uncomplicated, healthy pregnancies should be able to engage in high-intensity exercise programs, such as jogging and aerobics, with no adverse effects.


Finally, although physical activity and dehydration in pregnancy have been associated with a small increase in uterine contractions (47), there is only anecdotal evidence that even strenuous training causes preterm labor or delivery. Obese women should start with low-intensity, short periods of exercise and gradually increase as able. A more recent proposed guideline addresses these issues and is based on the National Institute for Occupational Safety and Health equation that determines the maximum recommended weight limit. Resuming exercise activities or incorporating new exercise routines after delivery is important in supporting lifelong healthy habits. Women with uncomplicated pregnancies should be encouraged to engage in physical activities before, during, and after pregnancy. The role of exercise in reducing the risks of gestational diabetes mellitus in obese women.
Exercise throughout pregnancy does not cause preterm delivery: a randomized, controlled trial. The effect of participation in a regular exercise program upon aerobic capacity during pregnancy.
Aerobic exercise and submaximal functional capacity in overweight pregnant women: a randomized trial. Prospective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy.
Exercise during pregnancy reduces the rate of cesarean and instrumental deliveries: results of a randomized controlled trial. The effects of physical activity and physical activity plus diet interventions on body weight in overweight or obese women who are pregnant or in postpartum: a systematic review and meta-analysis of randomized controlled trials. Prolonged exercise in pregnancy: glucose homeostasis, ventilatory and cardiovascular responses.
A comparison of cardiopulmonary adaptations to exercise in pregnancy at sea level and altitude. The Treatment of Obese Pregnant Women (TOP) study: a randomized controlled trial of the effect of physical activity intervention assessed by pedometer with or without dietary intervention in obese pregnant women. Clinical guidelines for occupational lifting in pregnancy: evidence summary and provisional recommendations. Those who do not have healthy lifestyles should be encouraged to view the preconception period and pregnancy as opportunities to embrace healthier routines.
For healthy pregnant and postpartum women, the guidelines recommend at least 150 minutes per week of moderate-intensity aerobic activity (ie, equivalent to brisk walking).
Some patients, obstetrician–gynecologists, and other obstetric care providers are concerned that regular physical activity during pregnancy may cause miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery.
These changes lead to an increase in the forces across joints and the spine during weight-bearing exercise.
Because of a physiologic decrease in pulmonary reserve, the ability to exercise anaerobically is impaired, and oxygen availability for strenuous aerobic exercise and increased work load consistently lags. Although exposure to heat from sources like hot tubs, saunas, or fever has been associated with an increased risk of neural tube defects (20), exercise would not be expected to increase core body temperature into the range of concern. A cohort study that assessed umbilical artery blood flow, fetal heart rates, and biophysical profiles before and after strenuous exercise in the second trimester demonstrated that 30 minutes of strenuous exercise was well tolerated by women and fetuses in active and inactive pregnant women. Observational studies of women who exercise during pregnancy have shown benefits such as decreased GDM (6, 30–32), cesarean and operative vaginal delivery (9, 33, 34), and postpartum recovery time (9), although evidence from randomized controlled trials is limited. Motivational counseling tools such as the Five A’s (Ask, Advise, Assess, Assist, and Arrange), originally developed for smoking cessation, have been used successfully for diet and exercise counseling (42, 43). An exercise program that leads to an eventual goal of moderate-intensity exercise for at least 20–30 minutes per day on most or all days of the week should be developed with the patient and adjusted as medically indicated.
High-intensity or prolonged exercise in excess of 45 minutes can lead to hypoglycemia; therefore, adequate caloric intake before exercise, or limiting the exercise session, is essential to minimize this risk (46). Scuba diving should be avoided in pregnancy because of the inability of the fetal pulmonary circulation to filter bubble formation (48). In recent studies examining the effects of exercise among pregnant, obese women, the women have demonstrated modest reductions in weight gain and no adverse outcomes among those assigned to exercise (39, 52). Several reports indicate that women’s level of participation in exercise programs diminishes after childbirth, frequently leading to overweight and obesity (58, 59).


Nursing women should consider feeding their infants before exercising in order to avoid exercise discomfort of engorged breast. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
Exercise, defined as physical activity consisting of planned, structured, and repetitive bodily movements done to improve one or more components of physical fitness (1), is an essential element of a healthy lifestyle, and obstetrician–gynecologists and other obstetric care providers should encourage their patients to continue or to commence exercise as an important component of optimal health. The physiologic respiratory alkalosis of pregnancy may not be sufficient to compensate for the developing metabolic acidosis of strenuous exercise. In those instances where women experience low-back pain, water exercise is an excellent alternative (35). As long as a woman can carry on a conversation while exercising, she is likely not overexerting herself (45). A study applied the National Institute for Occupational Safety and Health’s lifting equation to define recommended weight limits for a broad range of lifting patterns for pregnant women in an effort to define lifting thresholds that most pregnant workers with uncomplicated pregnancies should be able to perform without increased risk to maternal or fetal health (57). Exercise routines may be resumed gradually after pregnancy as soon as medically safe, depending on the mode of delivery, vaginal or cesarean, and the presence or absence of medical or surgical complications. Although the evidence is limited, some benefit to pregnancy outcomes has been shown and there is no evidence of harm when not contraindicated.
Obstetrician–gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy.
In the absence of obstetric or medical complications or contraindications (Box 1, Box 2), physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to continue or to initiate safe physical activities (Box 3). Decreases in subjective work load and maximum exercise performance in pregnant women, particularly in those who are overweight or obese, limit their ability to engage in more strenuous physical activities (15). Studies have shown that exercise during pregnancy can lower glucose levels in women with GDM (36, 37), or help prevent preeclampsia (38).
Women should be advised to remain well hydrated, avoid long periods of lying flat on their backs, and stop exercising if they have any of the warning signs shown in Box 4.
Physical activity and exercise during pregnancy promotes physical fitness and may prevent excessive gestational weight gain. The World Health Organization and the American College of Sports Medicine have issued evidence-based recommendations indicating that the beneficial effects of exercise in most adults are indisputable and that the benefits far outweigh the risks (3, 4). In women who have obstetric or medical comorbidities, exercise regimens should be individualized. Blood volume, heart rate, stroke volume, and cardiac output normally increase during pregnancy, while systemic vascular resistance decreases. Aerobic training in pregnancy has been shown to increase aerobic capacity in normal weight and overweight pregnant women (16–18). Exercise has shown only a modest decrease in overall weight gain (1–2 kg) in normal weight, overweight, and obese women (39, 40). Exercise may reduce the risk of gestational diabetes, preeclampsia, and cesarean deliveries. These hemodynamic changes establish the circulatory reserve necessary to sustain the pregnant woman and fetus at rest and during exercise. Additional research is needed to study the effects of exercise on pregnancy-specific conditions and outcomes, and to further clarify effective behavioral counseling methods and optimal type, frequency, and intensity of exercise.
An exercise program that leads to an eventual goal of moderate-intensity exercise for at least 20–30 minutes per day on most or all days of the week should be developed with the patient and adjusted as medically indicated. Motionless postures, such as certain yoga positions and the supine position, may result in decreased venous return and hypotension in 10–20% of all pregnant women and should be avoided as much as possible (14).
Additional research is needed to study the effects of exercise on pregnancy-specific outcomes and to clarify the most effective behavioral counseling methods, and the optimal intensity and frequency of exercise.



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