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Exercise and Pregnancy

A fitness guide to: keeping in


shape for a safe and healthy
delivery, and a quick
recovery.

Alex Tieri
Advanced Health and Fitness Specialist
American Council on Exercise
Highest certification, 1 of 1000 in U.S.
Specializing in:

Pre- and Postnatal Exercise


CVD, CAD, CHD
Hypertension and Dyslipidemia,
Diabetes and The Metabolic Syndrome
Asthma
Arthritis and Osteoporosis
Elderly Optimal Living

Nutritional Consultant (AFPA)

To Be Discussed:
Benefits and Risks of exercise during pregnancy.
Physiological changes during pregnancy
Programming guidelines and considerations for
prenatal exercise
Biomechanical considerations for the pregnant
mother
Nutritional considerations
Psychological considerations
Benefits and risks following pregnancy
Programming guidelines and considerations
following pregnancy

Introduction
There is a growing trend of women who are not
physically active to view pregnancy as a time
to modify their lifestyles to include more health
conscious decisions, including exercise.
Aerobic and strength training during
pregnancy, have shown no increase in early
pregnancy loss, late pregnancy complications,
abnormal fetal growth, or adverse neonatal
outcomes, suggesting previous
recommendations have been overly
conservative (Clapp, 1989; ONeil, 1996).

Benefits and Risks During


Pregnancy
Regular exercise is associated with lower incidence of
excessive maternal weight gain, gestational
diabetes(GDM), pregnancy induced hypertension,
varicose veins, deep vein thrombosis, dyspnea, and lowback pain (Davies et al.,2003; Weissgerber et al.,2006)
Women who continue regular weight bearing exercise
throughout the entire pregnancy tend to have easier,
shorter and less complicated deliveries (Clapp, 2002).
Pregnant exercisers had average weight increases of 29
lbs well within normal range, and a body fat mass 3%
lower than pregnant non-exercisers (Clapp & Little,
1995).

Gestational Diabetes(GDM)
Is when glucose intolerance is first recognized during pregnancy.
Maternal muscular insulin resistance is normal during midpregnancy, to ensure adequate glucose regulation for fetal growth
and development.
Women with GDM the insulin increase is exacerbated, resulting in
maternal hyperglycemia, resulting in complications in labor and
delivery, as well as Caesarean section.
Risk factors include: Hispanic, Asian, African Descent; age >35;
overweight BMI >25; obese BMI >30; or a history of insulin
resistance.
Participation in recreational activities within the first 20 weeks of
gestation decreases risk of GDM by almost 50% (Dempsey et al.,
2004)
GDM is treated primarily through nutritional management by a
registered dietician, and exercise.

Preeclampsia
Is usually diagnosed 20 weeks after pregnancy is characterized by persistent
hypertension (140/90 mmHg) and proteinuria >0.3g (ACOG, 2002a).
Associated complications: preterm birth, abruptio placentae, renal failure,
pulmonary edema, cerebral hemorrhage, circulatory collapse, eclampsia, and
immediate delivery.
Associated risk factors: abnormal placental development, predisposing maternal
constitutional factors, oxidative stress, immune maladaptation, and genetic
susceptibility.
Regular leisure-time physical activity in early pregnancy is associated with a
reduced incidence of preeclamsia (Weissgerber et al., 2004)
Several protective mechanisms from exercise are thought to play a role in
preeclampsia prevention, including enhanced placental growth and vascularity,
enhanced antioxidant defense systems, reduction of the systematic
inflammatory response, and improved endothelial function (Weissgerber et al.,
2006).
Ambulatory management is the norm with treatment for preeclampsia, while
exercise intervention is unclear of positive affects, exercise should be physician
monitored.

Maternal Obesity
In the U.S. the percentage of women aged 20-39, who are
overweight has climbed to 49% amongst white women and 70%
among African-American women (Okosun et al., 2004).
Ovulatory infertility increases progressively with increasing BMI,
as so the risks of polycystic ovarian syndrome and menstrual
irregularities.
In a study of two year infertile obese women losing between 1022 lbs, 77% were able to conceive (Clark et al., 1998)
Authors hypothesized improved fertility resulted from reduced
insulin resistance and lower insulin concentrations on
reproductive hormone profiles.
Risk of fetal complications, preeclampsia, GDM, large-forgestational-age infants requiring C-section increase with degree
of overweight and obesity (Rooney & Schauberger, 2002).

Exercise and Fetal Response


In uncomplicated pregnancies fetal injury is highly unlikely, and most
potential risks are hypothetical , such as these:
Selective redistribution of blood flow away from the fetus during
prolonged exercise may interfere with the transplacental transport of
O2, Co2, and nutrients.
Aquatic exercise has a smaller decrease in plasma volume compared to land
exercises, and hydrostatic pressure maintains blood flow around the central
organs.

Transient hypoxia could result in fetal tachycardia and an increase in


fetal blood pressure, as a protective mechanism to help transfer O2
and decrease Co2 across the placenta.
There are no reports to link these adverse events with maternal exercise,
most studies show a minimal to moderate increase in fetal heart rate by 1030bpm (Wolfe et al., 1988).

Intrauterine growth restriction due to strenuous physical activity, has


been shown to occur with inefficient nutrition, resulting in low-birthweight.
Overall, it appears that birth weight is not effected by exercise in women with
sufficient energy intake (Ahlborg Bodin & Hogsteadt, 1990).

Contraindications and Risk


Factors
Women with or without a previously sedentary
lifestyle should be encouraged to exercise.
However, women with a complicated pregnancy
should be discouraged from exercise for fear of
impacting an underlying disorder (ACSM,
2006;ACOG, 2002b; SOGC & CSEP, 2003).
most physical activities are safe throughout
pregnancy. However, overly vigorous activity in
the 3rd trimester, activities with a high risk of
falling, altitude >6000 ft, and scuba diving
should be avoided.

Continued:
Absolute contraindications: Relative contraindications:
Hemodynamically significant
heart disease
Restrictive lung disease
Incompetent cervix/Cerclage
Multiple gestation at risk for
premature labor
Persistent 2nd or 3rd trimester
bleeding
Placenta previa after the 26th
week
Premature labor during
current pregnancy
Ruptured membranes
Preeclampsia

Severe anemia
Unevaluated arrhythmia
Chronic bronchitis
Poorly controlled T1Diabetes
Extreme morbid obesity
Extreme underweight BMI<12
Extremely sedentary lifestyle
Intrauterine growth restriction
in current pregnancy
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled
hyperthyroidism
Heavy smoker

Cease exercise and seek medical


help

Bloody discharge from vagina


Gush of fluid from vagina(ruptured membranes)
Sudden swelling(possible preeclampsia)
Persistent/ severe headaches or visual
disturbances(hypertension)
Spell of faintness or dizziness
Swelling, pain, and redness in one calf(phlebitis)
Elevation of HR or BP persisting after exercise
Excessive fatigue, palpitations, or chest pain
Persistent contractions >6-8 hr
Unexplained abdominal pain
Insufficient weight gain <2.2lbs month
Decreased fetal movement
Amniotic fluid leakage

Physiological Changes During Pregnancy


Musculoskeletal average weight gains of 25-40 lbs(15-25%
pre-natal weight), significantly increases forces across joints,
causing discomfort to normal, arthritic, and unstable joints.
Mechanical stress of the back, pelvis, hips, and legs increase as COG
moves up and outward, sometimes resulting in low-back pain.
During the 1st trimester hormones relaxin and progesterone are
released to expand the uterine cavity, by increasing joint laxity, which
could possibly cause strains in other ligaments.

Cardiovascular hormones initiate reduced responsiveness and


relaxation in smooth muscle cells of blood vessels, causing
many early unpleasant symptoms, and a vascular under fill. To
compensate hormones tell the kidneys retain salt and water to
increase blood volume.
By mid pregnancy, cardiac outputs are increased 30-50%, and resting
HR can be up by 15bpm greater than before pregnancy(Morton, 1991).
Motionless standing, and laying in a supine position can cause a
significant decrease in cardiac output, and should be avoided.

Continued:
Respiratory at rest, an increase in the depth of each
breath increases the amount of air inhaled by up to 50%
(Artal et al., 1986).
Progesterone increases the brains sensitivity to Co2, stimulating
over-breathing, improving the efficiency of O2 uptake from the
lungs and eliminating Co2.
10-20% improvement to baseline O2 consumption, creates a
training effect that can be carried over after birth(Pivarnik et al.,
1992).

Thermoregulatory ability to dissipate heat improves


during pregnancy, due to a decrease of the bodys set
point in normal temp, increased blood flow to the
skin(convection), and a 40-50% increase in tidal volume
creates a 40-50% increase in heat loss through exhalation.

Exercise Considerations
Avoid activities prolonged motionless standing, laying in the
supine position, activities with falling risks, and activities that
put repetitive excessive stress on the joints until cleared by
physician.
Pregnancy requires an additional 300 cals daily and whatever
cals may be lost through exercise.
During the 3rd trimester, increase carbs 30-50g/day to prevent
hypoglycemia during exercise.
Wear appropriate clothing and hydrate to prevent hyperthermia.
Use low weights with high reps.
Limit excessive stretching due to joint laxity from hormones
Use the Borg scale of RPE 1-10, between fairly light to
somewhat hard since heart rate is hormonally elevated.
Previously sedentary women should begin with 15 min of
continuous exercise 3x per week, and gradually increase it to 30
min 4x per week.

Biomechanical
Considerations
Low-back pain(LBP) happens as the abdominal muscles are
stretched, and lose their ability to help maintain a neutral
spine position. Joint laxity in the lumbar spine weakens the
ability of static support muscles to withstand the shearing
forces bringing pain in the facet joints.
Exercises to help: ROM and stretching of the back extensors, hip
flexors, scapulae protractors, internal shoulder rotators, and neck
flexors; strengthen: abdominals, gluteals, and scapulae retractors.

Posterior pelvic pain is 4x more prevalent than LBP. It is


thought to occur as the sacroiliac(SI) joint dysfunctions from
decreased stability of the pelvic girdle, pain can be brought
on from prolonged sitting and leaning forward, or standing
and leaning forward.
Exercises to help: muscles that act to stabilize the SI joint such as
internal and external obliques, lats, erector spinae, multifidus, and
gluteus maximus (Vleeming et al., 1996).

Continued
Pubic pain is caused by increased motion at the joint called
symphysitis, resulting in pain in the pubic region, groin, and
medial aspects of the thigh, during weightbearing activities
that usually involve lifting one leg, may be accompanied by a
grinding or clicking sound of the joint. This may result in a
waddling walk.
Treatment is usually to avoid weight bearing activities that
aggravate the joint, and a pelvic belt to limit motion of the
symphysis may be prescribed.

Carpal tunnel syndrome is compression of median nerve that


causes pain and tingling in the thumb, index, and middle
fingers, from swelling of repetitive work or movements of the
wrist, and possibly excess water retention. Usually goes
away after pregnancy.
Avoid loading in hyperextension, grasping objects tightly, repetitive
flexion and extension of the wrist during exercise, try to maintain a
neutral grip, with a wider circumference.

Continued
Diastasis recti is a partial or complete separation between the left
and right sides of the rectus abdominal muscle, during the later
stages of pregnancy the uterus can be seen bulging out of the
abdominal wall. Testing can be done by placing two fingers
between the abdominal muscles during a curl-up, an indicator is if
the gap is wider than two fingers. This can remain after pregnancy.
Treatment: abdominal compression exercises and curl-ups in a semi
recumbent position.

Stress urinary incontinence (SUI) is an involuntary loss of urine


from a rise in abdominal pressure. During pregnancy and labor
prolonged stretching of the pelvic floor muscles, and neural
muscular damage, interfere with normal transmission of
information regarding changes to abdominal pressure to proximal
urethra. This can last after pregnancy.
Treatment: Kegel exercises provide support to the pelvic organs;
preventing a falling of the bladder, uterus, and rectum; supporting proper
pelvic alignment; sphincter control; enhances circulation of the pelvic floor
muscles; and provides a healthy environment after labor (Dunbar, 1992).

Nutritional Considerations
After the thirteenth week of pregnancy an additional 300
calories is needed to maintain homeostasis, and an additional
for calories used during exercise.
Pregnant women should consume between 2500-2700
calories per day.
Increasing carbohydrates is especially important as pregnant
women use more at rest and exercise (Artal & Wiswell, 1996).
To avoid hypoglycemia small meals and snacks should be
eaten throughout the day especially before and after exercise.
Women considering getting pregnant should consume
adequate: folic acid, iron, calcium, vitamin D, and water to
sustain health before, during, and after pregnancy.
Normal weight women should gain 25-35 lbs; underweight
women should gain 28-40 lbs; overweight women should gain
15-25 lbs; and obese women should gain at least 15 lbs.

Psychological
Considerations

Pregnancy is associated with increased psychological stress for many women,


which includes increased anxiety, depression, and fatigue.
Depression is more common during the third trimester.
97% of women report fatigue as a concern during some point of the
pregnancy.
Studies have shown that babies of anxious or stressed mothers have low birth
weight and tend to be delivered early (Evans et al, 2001).
Ultrasound studies have shown that fetal behavior is affected by maternal
anxiety (Groome et al., 1995).
Blood flow to the baby may be impaired through the uterine arteries with high
levels of maternal anxiety (Teixeira, fisk, & Glover, 1999).
Postpartum depression affects 10-13% of women lasting 2-6 months after
delivery, with greater chances of depression in the future (Cooper & Murray,
1995).
Maternity blues refers to the tearfulness, irritability, hypochondriasis,
sleeplessness, impairment of concentration and a headache, that usually
peaks the 4th or 5th day postpartum, from the raising of hormones prolactin,
and falling levels of progesterone, estradiol, and cortisol (Harris et al., 1994).
In a study that measured physical activity and mood during pregnancy,
healthy women who maintained physical activity during pregnancy enjoyed
more mood stability (Poudevigne & OConnor, 2005).

Benefits and Risks of Exercise


Following Pregnancy
Preventing obesity and weight gain through promotion of body fat/weight loss.
Promoting aerobic fitness and strength, leading to an improved ability to
perform the acts of mothering.
Optimizing bone health by increasing bone mineral density and preventing
lactation associated bone loss, from estrogen deficit.
Lactation drains calcium by an additional 200-400mg per day.

Improving mood, self-esteem, and energy.


Acute bout of exercise has been shown to lead to decreases in acute transitory anxiety
and depression as well as increases in vigor (Kotlyn & Schultes, 1997).

A study of postnatal exercise breast milk revealed no remarkable difference as


far as nutrient loss, and lactic acid between women who performed
submaximal, maximal, and no exercise (Larson-Meyer, 2002).
c-section under goers usually report pain and tenderness in the abdomen as
well as considerable fatigue. Rehabilitation is walking as soon as possible to
prevent muscle wasting, increase circulation, and speed the healing process.
Deep breathing, kegels, and abdominal compression exercises can be done
early in the recovery process.
Structured fitness programs should be withheld until physician clearance usually
around the six-week postpartum check-up.

Physiological Changes
Postpartum
The hormone relaxin elevates 10x its normal level during
pregnancy, which promotes laxity in ligaments for
growth, this can lead to overstretching and strains, and
can last up to 8 months postpartum.
Cardiac output increases as much 40% and plasma
volume can increase 40-50% during pregnancy, levels
will return to normal within 6-8 weeks of delivery.
Minute ventilations can increase by 50%, along with
increases in tidal volume, and respiratory rate, values
return to normal 6-12 weeks postpartum.
There are no known maternal complications associated
with the resumption of exercise training postpartum
(Hale & Milne, 1996).

Postnatal Exercise
Programming
Begin slowly increase gradually.

Avoid excessive fatigue and dehydration.


Support and compress the abdomen and breasts.
Stop and evaluate with pain.
Seek medical evaluation with bleeding heavier than a
period.
1st year goal is to improve physical fitness.
Work the core, and deep pelvic muscles.
Increased breast weight from lactation, postures
associated with cuddling, holding, and feeding may lead
to upper back pain.
Stretch anterior shoulder girdle, follow with scapular retraction
and external shoulder rotation exercises, to improve posture
and ease pain with these biomechanical concerns.