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Exercise Guidelines in Pregnancy

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 Sports Med 2011; 41 (5): 345-360
CURRENT OPINION 0112-1642/11/0005-0345/$49.95/0

2011 Adis Data Information BV. All rights reserved.

Exercise Guidelines in Pregnancy

New Perspectives
Gerald S. Zavorsky1,2 and Lawrence D. Longo3
1 Human Physiology Laboratory, Marywood University, Scranton, Pennsylvania, USA
2 The Commonwealth Medical College, Scranton, Pennsylvania, USA
3 Center for Perinatal Biology, School of Medicine, Loma Linda University, Loma Linda, California, USA

Abstract In 2002, the American College of Obstetricians and Gynecologists pub-

lished exercise guidelines for pregnancy, which suggested that in the absence of
medical or obstetric complications, 30 minutes or more of moderate exercise a
day on most, if not all, days of the week is recommended for pregnant women.
However, these guidelines did not define moderate intensity or the specific
amount of weekly caloric expenditure from physical activity required. Recent
research has determined that increasing physical activity energy expenditure
to a minimum of 16 metabolic equivalent task (MET) hours per week, or
preferably 28 MET hours per week, and increasing exercise intensity to 60%
of heart rate reserve during pregnancy, reduces the risk of gestational diabetes
mellitus and perhaps hypertensive disorders of pregnancy (i.e. gestational
hypertension and pre-eclampsia) compared with less vigorous exercise. To
achieve the target expenditure of 28 MET hours per week, one could walk at
3.2 km per hour for 11.2 hours per week (2.5 METs, light intensity), or pref-
erably exercise on a stationary bicycle for 4.7 hours per week (~67 METs,
vigorous intensity). The more vigorous the exercise, the less total time of exercise
is required per week, resulting in 60% reduction in total exercise time compared
with light intensity exercise. Light muscle strengthening performed over the
second and third trimester of pregnancy has minimal effects on a newborn in-
fants body size and overall health. On the basis of this and other information,
updated recommendations for exercise in pregnancy are suggested.

1. Introduction amount of weight during pregnancy can result in

Regular aerobic exercise is an important
component for the maintenance of overall health.
Exercise is especially important in pregnancy, as
women of childbearing age are at increased risk
of gestational diabetes mellitus (GDM), which
has been strongly linked with obesity.[1,2] As more
women tend to gain an excessive amount of weight
during pregnancy, they also tend to retain the
weight after delivery.[3,4] Gaining an excessive
obesity-associated co-morbidities, which are a
major health concern in the US.[5]
In 2002, the American College of Obstetricians
and Gynecologists (ACOG) published exercise
guidelines for pregnancy.[6] These suggested that
in the absence of medical or obstetric complica-
tions, 30 minutes or more of moderate exercise a
day on most, if not all, days of the week is recom-
mended for pregnant women. These guidelines
were based on the 1995 joint recommendations
346
by the Centers of Disease Control and Preven-
tion (CDC) and the American College of Sports
Medicine (ACSM).[7] However, these were gen-
eral public health recommendations, with no
clarity on the definition of moderate intensity
exercise or the recommended amount of weekly
physical activity energy expenditure.
It has been 15 years since those initial CDC
and ACSM recommendations were establish-
ed, and 9 years since their adoption by ACOG.
Since then, new science has emerged that has en-
hanced our understanding of the amount of
physical activity expenditure per week required
and the intensity of exercise needed to improve
health outcome and quality of life. In 2007, up-
dated physical activity recommendations were
published by the ACSM and the American Heart
Association (AHA).[8,9] These included defini-
tions of moderate and vigorous exercise, and
provided recommendations for muscle strength-
ening activities (table I).
As such, we believe these updated 2007 rec-
ommendations should be used to establish new
ACOG guidelines for pregnancy in the absence of
medical or obstetric complications. Pregnancy is
not a state of confinement, yet pregnant women
spend less time performing vigorous exercise with
less duration and frequency than non-pregnant
women.[12] Indeed, women who maintain their ex-
ercise regimen during pregnancy continue to exercise
at a higher intensity than those who stop.[13] Over
time, these women gain less weight, deposit less fat,
have increased fitness and have a lower cardiovas-
cular risk profile in the perimenopausal period
than women who cease to exercise in pregnancy.[13]
Therefore, the purpose of this clinical opinion
is 2-fold: (i) to provide evidence that increasing
weekly physical activity expenditure while in-
corporating vigorous exercise provides the best
health outcome for pregnant women and their
infants; and (ii) to create new exercise guidelines
for pregnancy that are relatively specific, and that
1 Excessive weight gain during pregnancy is defined as 9.0 kg in overweight women (pre-pregnancy body mass
index [BMI] = 25.029.9 kg/m2), or 5.9 kg in obese women (pre-pregnancy BMI 30 kg/m2). For pregnant women
of normal pre-pregnancy bodyweight (BMI = 20.024.9 kg/m2), optimal weight gain during pregnancy is between
2.1 and 9.9 kg. For pregnant women whose pre-pregnancy BMI is <20 kg/m2, optimal weight gain during preg-
nancy is 4.19.9 kg.[25]
2011 Adis Data Information BV. All rights reserved.
Zavorsky & Longo
Table I. The American College of Sports Medicine (ACSM) and
American Heart Association (AHA)s physical activity recommend-
ations for men and non-pregnant womena
Aerobic activity Muscle strengthening activity
Adults aged 1865 y perform a For adults aged 1865 y, 812
minimum of 30 min moderate repetitions each of 810
intensity exercise for 5 d/wk or muscular strength exercises
20 min vigorous intensity should be performed on 2 or
exercise 3 d/wkb more non-consecutive d/wk
using the major muscle groups
For adults >65 y, moderate For adults >65 y, 1015
intensity = 1214 on the Borg repetitions each of 810
RPE 620 point scale; vigorous exercises on 2 or more non-
intensity = 1516 on the Borg consecutive d/wk using the major
RPE 620 point scale[10] muscle groups with an effort level
of 1214 to 1516 on the Borg
RPE 620 point scale[10]
a These are the 2007 updated ACSM and AHA recommendations
from Haskell et al.[8] and Nelson et al.[9] Moderate intensity
is now classified as activities that require 36 METs
(10.521 mL/kg/min) and vigorous activity is classified as
>6 METs (>21 mL/kg/min).[8] Moderate intensity exercise can be
walking at 4.8 km/h, 3.3 METs); walking briskly at 6.4 km/h
(5 METs); washing a car, garage, sweeping floors or washing
windows (3 METs); slow to fast ballroom dancing (34.5 METs);
badminton (4.5 METs); or swimming leisurely (6 METs).[11]
Vigorous intensity can be walking at a very brisk pace at 7.2 km/h
(6.3 METs); jogging at 8.0 km/h (8 METs); walking on a treadmill
at 5.6 km/h (5% grade, 6.1 METs); swimming at a moderate/hard
feeling of effort (811 METs).[11]
b Moderate = 36 METs; vigorous >6 METs.
METs = metabolic equivalent tasks; RPE = rating of perceived exertion.
incorporate the emerging research findings over
the past decade.
2. Increasing the Amount of Vigorous
Intensity Exercise is an Important Goal
for Pregnant Women, Especially Those
Who are Overweight or Obese
Obese women have an increased risk of fetal,
neonatal and maternal morbidity;[14-24] therefore,
prevention of excessive weight gain1 during
pregnancy is important for the welfare of both
mother and child.[16,26] Regular physical activity
Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy
performed before[1,25,27] and during pregnancy[1]
has been shown to reduce the incidence of GDM,
for example, by at least 30%, depending on the
amount of weekly physical activity energy expen-
diture and intensity of exercise. Vigorous exercise
is important to prevent weight gain in pregnancy
and throughout life.2 Recent data demonstrate
that skeletal muscle work efficiency changes dra-
matically when bodyweight is altered.[28] With
weight gain from lack of physical activity, effi-
ciency of skeletal muscle decreases,[28] which at
the outset is fine as more calories are burned with
heavier weight. However, weight gain from phys-
ical inactivity usually means an increase in fat
mass, which, biochemically, has been found to
decrease the bodys ability to gain future muscle
due to the attenuation of anabolic processes;[29]
therefore, an obese individual has an impeded
ability to gain muscle. With weight loss through
physical activity, caloric expenditure decreases,
not just because muscles have less weight to carry
around, but due to a reduction in the ratio of
glycolytic to oxidative enzymes in muscle without
significant changes in enzymatic activity related
to fatty acid oxidation.[28] As such, with weight
loss, significantly fewer calories are expended with
physical activity,[28] and an increase in weight will
occur once again. A programme of vigorous in-
tensity exercise may stop the yo-yo effect of the
weight gain/weight loss cycle.[30]
Non-oxidative type IIb muscle fibres (which
minimally burn fat) are increased in obese
women,[31,32] and are directly related to body
mass index (BMI). The larger the BMI, the more
type IIb muscle fibres a woman possesses. In ad-
dition, the larger the BMI, the lower the percent-
age of type I oxidative (fat burning) fibres.[33]
Weight loss by itself[34] or weight loss with physical
activity[35,36] can, but not always,[28] improve mus-
cle oxidative capacity in obese women with or with-
out diabetes. If the muscle oxidative capacity is
increased with physical activity, then the capacity
to burn fat throughout the day is increased.
2 Vigorous exercise is defined by the ACSM as an oxygen consumption (VO2) of >21 mLO2/kg/min, which is
taken to be >6-fold greater than the resting metabolic
. rate (>6 METs). However, this article shows that some
pregnant women are not able to exercise at that VO2. Therefore, the. definition of. vigorous exercise should be
defined as 60% of heart rate reserve (HRR) [preferably] or 65% of VO2 reserve (VO2R).
2011 Adis Data Information BV. All rights reserved.
347
Vigorous intensity exercise that increases the
energy expenditure post-exercise compared with
low-intensity exercise,[37,38] should limit weight
gain in overweight and obese pregnant women. In
fact, for a given energy expenditure, vigorous
exercise programmes induce a greater loss of
subcutaneous fat compared with a programme of
moderate intensity.[39] Thus, we propose that
higher intensity exercise may be an alternative
means to improve oxidative capacity .and increase
post-exercise oxygen consumption (VO2) so that
body fat percentage is reduced to a greater extent
compared with traditional low-intensity exercise,
and weight gain is limited in overweight and
obese pregnant women.
Considerable evidence supports the use of
higher intensity exercise to reduce body fat per-
centage. Specifically, in overweight individuals,
a 14-week exercise programme consisting of
moderate-intensity exercise (6070% aerobic capa-
city) was compared with an exercise programme
of high-intensity exercise (7590% aerobic capac-
ity). Both groups exercised three times per week,
and both expended the same amount of calories.[40]
The high-intensity group reduced their total body
fat percentage from 27% to 22% (p < 0.05), while
the moderate-intensity group did not see a reduc-
tion.[40] Another study demonstrated that mod-
erate exercise intensity (4055% of aerobic capacity)
for 8 months did not reduce total fat mass
(-2 3 kg) to the same extent as vigorous exercise
(6580% of aerobic capacity, -5 3 kg), even when
controlled for the same weekly distance and the
same total training time.[41] This has been shown
elsewhere,[42] although, the exercise bouts were
not isocaloric.
Another compelling reason why pregnant women
should perform vigorous exercise as tolerated, is
that the duration of labour is inversely associated
with aerobic capacity after adjusting for birthweight
(p = 0.03).[43] Kardel and colleagues[43] investigat-
ed the effect of aerobic capacity on duration of
labour in 40 nulliparous women (aged 30 4 years)
.
Sports Med 2011; 41 (5)
348
who started labour spontaneously. Aerobic capa-
city was measured in these women (bodyweight
= 77 9 kg) at 3537 weeks of gestation. Dura-
tion of labour was defined as the time between
3 cm cervical dilation with regular uterine con-
tractions and delivery. The mean aerobic capa-
city was 2.1 0.3 LO2/min and duration of labour
583 317 minutes. The potential determinants of
the duration of labour, identified by a Pearson
correlation were tested in a multivariate model.
They concluded that increased aerobic fitness
was associated with shorter labour in nulliparous
women who started labour spontaneously. Other
earlier research confirms Kardels study. Clapp[44]
found that his well trained groups who exercised
during pregnancy had a significant shorter first
stage of labour by 118 minutes than a group who
had stopped exercising before the end of the first
trimester. Beckmann and Beckmann[45] found
that nulliparous women who exercised regularly
before becoming pregnant also had a signifi-
cantly shorter labour (first and second stages) by
~8 hours in total compared with a non-exercising
control group.
The minimal threshold for independent living
requires an aerobic capacity of approximately
15 (women) to 18 (men) mLO2/kg/min,[46,47]
which is four to five metabolic equivalent tasks
. an exciting new possibility. However, until fur-
(METs) [a value of one MET = resting VO2,
or ~3.5 mLO2/kg/min]. Thankfully, only about
1% of women of childbearing age are at or below
this minimum threshold.[48] Normal weight preg-
nant women in the second and third trimester
(pre-pregnancy BMI = 23 kg/m2) have an aerobic
capacity that ranges from 1.4 to 2.6 LO2/min, which
equals about 2739 mLO2/kg/min.[49-53] Unfit, over-
weight (pre-pregnancy BMI = 25.0 to 29.9 kg/m2)
or obese pregnant women (pre-pregnancy BMI
30 kg/m2) who are unaccustomed to exercise
have a low aerobic capacity relative to bodyweight
(1822 mLO2/kg/min).[50,54] Endurance-trained
pregnant athletes have an aerobic capacity re-
ported to be around 50 mLO2/kg/min.[55,56] Aero-
bic capacity in LO2/min remains quite stable
between the second and third trimester; however,
the aerobic capacity measured in mLO2/kg/min
may decrease by 10% by the third trimester due to
maternal weight gain.[52]
2011 Adis Data Information BV. All rights reserved.
Zavorsky & Longo
One way to incorporate vigorous exercise is
the use of interval training, which incorporates
.
brief intense
. bouts of exercise (>80% of VO2 re-
serve [VO2R]) with periods of rest. This has been
found to be time efficient while improving oxida-
tive capacity in skeletal muscle to the same extent
as traditional low-intensity continuous exercise.[57,58]
Interval training has been shown to. be safe and
more effective in improving peak VO2 and left
ventricular function in patients with coronary
artery disease than the traditional method of con-
tinuous moderate exercise.[59-61] In 75-year-old
subjects, which included overweight women with
stable post-infarction heart failure, 12 weeks of in-
terval training increased aerobic capacity by 46%,
several heart function parameters by 2030% and
improved their quality of life.[61] These changes
were significantly greater compared with 12 weeks
of regular continuous training.[61]
A major consideration is that if elderly over-
weight women with heart failure and/or coronary
artery disease can successfully perform interval
training, then this type of research should be im-
plemented in pregnancy to establish the extent to
which type of exercise periodic intense exercise is
feasible, safe and results in appropriate exercise
adherence. Interval training during pregnancy is
ther studies are performed, it is our opinion that
pregnant women should build up to continuous,
steady-state aerobic exercise of about 65% of
aerobic capacity (vigorous exercise), which is ~60%
of heart rate reserve (HRR) or ~7075% of maxi-
mum heart rate (HRmax).[62] This recommendation
is within the range of the recommendations from
the Society of Obstetricians and Gynecologists of
Canada (SOGC)/Canadian Society for Exercise
Physiology.[63]
3. Increasing Weekly Physical Activity
Energy Expenditure is an Important
Goal for Pregnant Women
Increasing weekly physical activity energy ex-
penditure has been found to reduce the incidence
of the metabolic syndrome,[64] GDM[25] and sys-
temic inflammation,[65] while delaying ageing[66]
and disability.[67] The risks of coronary heart
Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 349

disease and cardiovascular disease also decrease
linearly in association with increasing physical
activity energy expenditure.[68] Johnson and col-
leagues[64] studied the effects of three different
6-month exercise programmes on components of
the metabolic syndrome: low amount/moderate
intensity (equivalent to jogging 19 km/wk at
4055% of aerobic capacity), low amount/high
intensity (equivalent to jogging 19 km/wk at
6580% of aerobic capacity) or high amount/
vigorous intensity (equivalent to jogging 32 km/wk
at 6580% aerobic capacity). These investigators
showed that the high-amount/vigorous-intensity
group had improvement in the highest number of
metabolic variables, compared with the other two
groups and a control group.[64] This makes sense
because insulin resistance is negatively related to
caloric expenditure from a single bout of exercise
(figure 1). From this study, the dose-response of
energy expenditure in reducing the risk factors
for metabolic syndrome were uncovered.[64]
Reduced risk of GDM and pre-eclampsia is seen
when women exercise between 3 months and 1 year
before or during pregnancy.[1,25,27,70,71] During
pregnancy, exercise programmes lasting at least
several weeks[72] is the best way to reduce the
fasting blood glucose level and to blunt the gly-
caemic response following a meal, whereas, single
bouts of exercise provided the fewest bene-
fits.[73,74] Zhang and co-workers[25] conducted a
prospective cohort study to assess whether the
amount, type and intensity of pregravid physical
activity are associated with GDM risk. The re-
lative risks (RRs) of GDM decreased with total
pregravid weekly physical activity (figure 2), such
that 16 MET hours per week showed a 17% re-
duction in GDM risk, and 56 MET hours per
week showed a ~30% reduction in GDM risk,
compared with subjects who did not exercise.
If the amount of pregravid weekly vigorous
physical activity (figure 2) increased (vigorous
exercise intensity 6 METs or 21 mLO2/kg/
min), the RR for GDM also decreased by 20%
and 25% if 6 and 15 MET hours per week of
vigorous physical activity is performed, respect-
ively. Rudra et al.[27] demonstrated that those
who exercised strenuously up to maximal exer-
tion using the Borg rating of perceived exertion
(RPE) scale in the year before pregnancy, showed
a 43% decrease in the risk for GDM. Also, those
that performed 30 MET hours per week of en-
ergy expenditure from physical activity in the
year before pregnancy had a 50% decrease in the
risk of GDM, compared with only a 34% de-
crease in GDM if the exercise expenditure was
<14.9 MET hours per week.[27] Dempsey et al.[1]

a b
40 30

20 15
Change from rest (%)
Change from rest (%)

0 0

20 15

40 30

60 45

80 60 *
0 1.26 2.51 3.77 5.02 6.28 <3.77 (900) >3.77 (900)
(300) (600) (900) (1200) (1500)
Total energy expenditure during exercise, MJ (kcal)

Fig. 1. Exercise-induced changes in (a) homeostasis model assessment of insulin resistance as a function of total energy expenditure during
exercise; and (b) subjects who expended <900 or >900 (kcal) during the exercise bout. The data demonstrate that whole body insulin sensitivity
from a single bout of exercise is improved only when the total energy expenditure is >900 kcal per session. Reproduced from Magkos et al.[69]
with permission from Portland Press Ltd. * p < 0.05 compared with resting state.

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
350 Zavorsky & Longo

demonstrated that pregravid women who ex-
ercised 21.1 MET hours per week during the
year before pregnancy reduced GDM risk by
74%, while women who were pregnant and ex-
pended 28 MET hours per week per week
during pregnancy reduced GDM risk by 33%
(figure 3). However, due to the large confidence
intervals for the reduction in RR for GDM
during pregnancy in the group that exercised 28
MET hours per week compared with no exercise
(RR = 0.67; 95% CI 0.31, 1.43), statistical signif-
icance was not reached. Nonetheless, this does
not negate the findings of how exercise during
pregnancy can reduce GDM risk. Therefore, it is
our opinion that there is a potential benefit for
the adoption and continuation of an active life-
style for women of reproductive age that is of
vigorous intensity prior to and during pregnancy.
To obtain energy expenditure in MET hours
per week, one multiplies the number of METs
required for the activity by the number of hours
per day multiplied by the total number of days
per week performing the activity. For example,
5 METs 0.95 hours per day 6 days per week =
28.5 MET hours per week. Second, to convert
MET hours per week into kcal/wk of energy expen-
diture, one multiples 28.5 MET hours per week
by the resting metabolic rate of 3.5 mLO2/kg/min
and by 60 min/h to get 5985 mLO2/kg/wk. Now,
the bodyweight is needed. For this example, the
bodyweight of an individual is 58.7 kg, therefore,
5985 mLO2/kg/wk 58.7 kg = 351319.5 mLO2/wk
or 351.2 LO2/wk consumed in total for physical
activity. Since 5 kcal are yielded for every L of ox-
ygen consumed, then 351.2 LO2/wk 5 kcal/L =
1756.6 kcal/wk.
The more vigorous the exercise, the less total
time of exercise is required. For example, one
can exercise 3 METs 1.6 hours per day 6 days
per week = 28.8 MET hours per week; or one can
exercise for less time at a higher intensity to
achieve the same expenditure (e.g. 5 METs 0.95
hours per day 6 days per week = 28.5 MET hours
per week). For a 54 kg woman, 28.5 MET hours per

Total physical activity

Vigorous activity
1.2

1.0

0.8
RR of GDM

0.6

0.4

0.2
8 16 24 32 40 48 56
MET h/wk

Fig. 2. Relative risks (RRs) of gestational diabetes mellitus (GDM) according to total physical activity (solid line) and vigorous activity (dotted
line) measured in metabolic equivalent task (MET) hours per week, continuous, prior to pregnancy. RRs are adjusted for age, race/ethnicity,
cigarette smoking status (never, past or current), family history of diabetes in a first-degree relative (yes, no), parity (0, 1, 2, 3), alcohol intake
(0.0, 0.15.0, 5.115.0 or >15.0 g/day), dietary factors (in quintiles of total energy, cereal fibre, glycaemic load and total fat) and body mass
index before the pregnancy. The error bars illustrate the approximate 95% CI.[25]

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy
1.0
0.9
0.8
Adjusted RRs of GDM
(0.35, 1.47)
0.7
0.6 (0.27, 1.21)
0.5
0.4
0.3 (0.10, 0.65)
0.2
0.1
0
<21.1 >21.1 <28.0
Year before pregnancy During pregnancy
in MET h/wk in MET h/wk
Fig. 3. Adjusted relative risks (RRs) of gestational diabetes mellitus
(GDM) according to the amount of physical activity energy ex-
penditure performed in the year before and also during pregnancy,
adjusted for maternal age, race, parity and pre-pregnancy body
mass index. No physical activity was made to have a RR of 1.0.
Physical activity before and during pregnancy reduces RR of GDM.
The numbers in parentheses illustrate 95% CI.[1] MET = metabolic
equivalent task.
week = approximately 1616 kcal/wk (or 269 kcal/day
for 6 days). If one exercises 6 days in a 7-day cycle,
then the energy expenditure in MET hours per week
is calculated over 6 days of exercise.
4. Potential Risks of Exercise in Pregnancy
4.1 Cardiac Risks of Exercise
With regard to the frequency with which
myocardial infarction is triggered by exertion, it
is important to distinguish absolute from RR.
The absolute risk of a 50-year-old non-smoking,
non-diabetic individual having a myocardial in-
farction during a given 1-hour period, is ap-
proximately 1 in 1 million (0.0001%).[75,76] If an
individual is habitually sedentary, but engaged
in heavy physical exertion (>6 METs) during
that hour, the risk would increase 100-fold over
the baseline value, but the absolute risk during
that hour still would be only 1 in 10 000 (0.01%).
The research has shown that a single episode of
vigorous physical exertion can increase the short-
term risk of myocardial infarction.[77] The para-
dox, however, is that increased frequencies of
vigorous exercise at >6 METs is associated with
a reduction in the long-term risk of coronary
events. Individuals who exercise regularly not
2011 Adis Data Information BV. All rights reserved.
351
only have a lower baseline risk of myocardial in-
farction, they also have a lower RR that an
infarction will be triggered by heavy physical ex-
(0.31, 1.43) ertion.[77] There is no reason to suggest that the
maternal cardiac risk of exercise would be dif-
ferent during pregnancy.
The number of sudden cardiac arrests or other
cardiac events in the general population is one
event per 565 000 hours of exercise.[78] For indi-
viduals with known heart disease, it is one event
per 59 142 hours.[78] The absolute risk of sudden
>28.0 death during any episode of vigorous exercise
equals about one death per 1.51 million episodes
of exertion.[79] Thus, the risk of exercise in trig-
gering cardiac events is very small. Compare the
risk of triggering sudden cardiac events (which is
about 0.01%) with the CDCs death rate for ac-
cidental deaths (unintentional injuries), which is
about 0.04%.[80] As such, the risk of death from
unintentional injuries in the US is higher than the
risk of triggering cardiac events from exercise;
therefore, the risks must be placed in perspective
to a real-world context. The US death rate of all
causes (accidents, homicides, suicides, diseases,
cancer, infection, dying of old age, etc.) is about
0.8%,[80] so when compared with the risk of ex-
ercise, these other issues provide more risk to
human health than a vigorous exercise session in
sedentary pregnant women.
4.2 Risk of Regular Exercise Training Resulting
in Small for Gestational Age Infants and
Increased Risk of Preterm Birth
Small for gestational age (SGA), which is a
birthweight that is in the 10th percentile or below
for the gestational age of the infant, is usually a
consequence of compromised intrauterine devel-
opment, and is considered a risk of perinatal
morbidity and mortality.[81] Regardless of wheth-
er a woman is sedentary or an endurance ath-
lete, exercise during the first two trimesters has
not been shown to affect birthweight.[82] How-
ever, female endurance athletes who exercise
vigorously (6 per week, >1 hour per session for
10 weeks, >50% of age predicted HRmax) into the
third trimester, produce infants that are on aver-
age 212 g (95% CI 149, 276) smaller than active
Sports Med 2011; 41 (5)
352
controls (3 per week, 30 minutes per session
for 10 weeks, >50% of age-predicted HRmax), and
437 g (95% CI 268, 606) smaller than sedentary
controls.[82] Nonetheless, a 200400 g decrease in
mean birthweight is not clinically meaningful for
two reasons. First, this difference in weight is less
than the 500 g difference between the 50th per-
centile and 10th percentile in recent published
tables.[83] Second, SGA is an anthropometric
characteristic that does not necessarily have ad-
verse health implications, and is therefore com-
monly used (but not necessarily appropriately) as
a proxy for the pathological outcomes believed to
be associated with an inadequate rate of fetal
growth[84] (i.e. the majority of SGA births are
small for no demonstrative reason; an aetiology is
not found in >50% of cases of SGA).[85] Third,
more recent data published in 2010 with a larger
sample size suggests no real clinically meaningful
difference in birthweight of infants born to women
who exercise during pregnancy for >5 hours per
week compared with pregnant women who do
not exercise.[86] In this study of ~80 000 infants, it
was found that women who exercised during preg-
nancy had a decreased risk of having a SGA child
or a large for gestational age child (birthweight
greater than the 90th percentile for gestational
age).[86] These data suggest that women who ex-
ercise >5 hours per week have smaller infants by
only 11 g than those of non-exercisers;[86] therefore,
differences may not be clinically meaningful.
As a corollary, SGA-identified fetuses may not
tolerate the mild diversion of cardiac output from
the uterus to the skeletal muscles during exercise.
Therefore, there is a slight chance of post-exercise
bradycardia. This has occurred previously in a
subsequently diagnosed growth-restricted fetus.[87]
While there are many SGA fetuses who are not
growth restricted, the clinician does not know
which is which until after birth. As such, cau-
tion is advised against exercise in the growth-
restricted fetus.
In terms of preterm births, exercise during
pregnancy actually reduces the risk of complica-
tions. Using data of over 85 000 births, >5 hours a
week of exercise during pregnancy reduced the
risk of preterm birth by 18% (RR 0.81; 95% CI
0.64, 1.04).[88] When calculating energy expen-
2011 Adis Data Information BV. All rights reserved.
Zavorsky & Longo
diture, pregnant women who exercised 1015 MET
hours per week (7151071 kcal/wk for a 68 kg wo-
man) experienced a 17% reduction in the risk of
preterm births (RR 0.83; 95% CI 0.71, 0.96), and
those who exercise for more than 15 MET hours
per week (>1071 kcal/wk for a 68 kg woman) ex-
perienced a 12% reduction (RR 0.88; 95% CI 0.78,
1.00) in preterm births.[88]
4.3 Risks of Exercise Resulting in an Abnormal
Fetal Heart Rate (HR) Response
A misconception about exercise in pregnancy
is that fetal health may be compromised because
uterine blood flow can decrease progressively
with exercise intensity and duration (by up to
~20%).[89,90] However, several . compensatory
mechanisms act to preserve fetal VO2 even during
exhaustive exercise.[90,91] In sheep, the increased
haemoglobin concentration from pregnancy
maintains total oxygen delivery to the uterus and,
.
with increased uterine oxygen extraction, VO2
remains unaltered.[90] In humans, the measure-
ment of fetal umbilical and maternal uterine
pulsatility index (PI), which is the best non-
invasive technique to assess changes in resistance
to blood flow in those areas, was assessed in
pregnant women (third trimester) immediately
after strenuous exercise above the anaerobic
threshold.[92] Compared with rest, there were
modest changes in the right uterine PI without
changes in umbilical artery PI or left uterine PI
in pregnant women 2 minutes post-exercise.[92]
However, by 5 minutes post-exercise, right uter-
ine PI returned to baseline values.[92] Therefore,
sheep and human data imply that limited stren-
uous exercise above the anaerobic threshold has
minimal effects on total
. uterine and umbilical
oxygen delivery and VO2.
Fetal heart rate (FHR) monitoring has been
widely used to monitor fetal well-being before and
after exercise. The earlier studies demonstrating
fetal bradycardia (FHR <110 beats/minute for
10 seconds) during exercise[93-95] have been dis-
missed as representing motion artifact.[96,97] FHR
is increased by about 20 beats/minute within
30 seconds of strenuous exercise stoppage.[98] By
10 minutes post-exercise, FHR is 010 beats/minute
Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy
higher, compared with pre-exercise after a bicycle
test to maximal or near maximal exertion.[87,98,99]
This suggests that brief intense exercise does not
cause fetal distress. Furthermore, regular exercise
training does not alter the fetal response.[100] More
recently, researchers have demonstrated that FHR
response to strenuous maternal exercise is not a
predictor of fetal distress since the incidence did not
vary with the level of fitness, maternal BMI or fetal
weight.[98]
5. Developing New Exercise Guidelines
in Pregnancy
In 2003, the SOGC published guidelines that
were somewhat more specific than the ACOG
guidelines. The SOGC suggested that pregnant
women should perform 15 minutes of continuous
aerobic exercise 3 days per week, with progres-
sion to 30 minutes sessions four times per week in
previously sedentary women.[63] For most preg-
nant women, the intensity of exercise is recom-
mended to be 1214 (out of 20) on the Borg RPE
scale.[63] RPE is the perceived, subjective, overall
effort of exertion and fatigue from 6 (no exertion)
to 20 (maximal exertion). A rating of 6 = no ex-
ertion at all, 78 = extremely light, 910 = very light,
1112 = light, 1314 = somewhat hard, 1516 =
hard, 1718 = very hard, 19 = extremely hard and
20 = maximal exertion. This scale scores the total,
overall exertion and fatigue level of exercise. The
more exertion, the less total time of exercise is
required to reach the recommended weekly phys-
ical activity expenditure goal.
Basal resting heart rate (HR) is increased by
1015 beats/minute in pregnancy.[101-103] In turn,
HRmax is blunted by 1015 beats/minute, com-
pared with the predicted HRmax of 220 minus
age[50,54,103] (although not always[102]), the HRR
is lowered. Thus, the target HR zones are mod-
ified in the SOCG guidelines. For example, the
target HR zone for a non-obese pregnant woman
2029 years of age is 135150 beats per minute,
130145 for a woman 3039 years-of-age and
125140 for a woman 40 years of age.[63] This
equates to 7179% of predicted HRmax for the
. . . .
3 Prescription VO2 = %intensity (VO2max - resting VO2) + resting VO2.
2011 Adis Data Information BV. All rights reserved.
353
2039 years-of-age group combined. Nonetheless,
developing an HR zone generalizable to pregnant
populations may not be appropriate because of
the individual variation of resting HR, and the
large standard deviation of predicting HRmax
from age (HRmax = 220 minus age), which is
1012 beats/minute.[104]
To identify the optimal HR for a given inten-
sity in a given individual, the HRR method was
developed by Karvonen.[105] The HRR method
essentially uses the difference between HRmax
and resting HR (in which both should be mea-
sured directly and not predicted). The reserve
available is the difference between measured
HRmax and measured resting HR. Then, a given
intensity is provided, and the correct exercise
prescription HR can be determined from the
following formula:
Prescription HR = % intensity (HRmax that is
measured from an aerobic capacity test - resting
HR obtained from 5 minutes of sitting upright on
a chair) + resting HR.
HR zones are published for pregnant over-
weight or obese women.[54] However, since the
minimum intensity for improving aerobic fitness
was updated in 2002,[106] the HR zones provided
for sedentary, overweight and pregnant women
begin at an exercise intensity of 101 beats/minute,
which is too low.[54] According to Swain and
Franklin,[106] those individuals
. classified as hav-
ing low initial fitness (VO2max <40 mLO2/kg/min),
based on a graded exercise test to maximum, will
show improvements in aerobic. capacity only if
the training intensity is 30% VO2R..3 For those
with higher aerobic capacities (VO2max >40
mL/kg/min),. the minimal training intensity has to
be 45% VO2R.[106] The percentage of HRR .
(%HRR)
. is equal to the percentage of VO2R
(%VO2R) unless the woman is overweight, seden-
tary and pregnant. . In overweight, sedentary preg-
nant women, %VO2R is slightly higher. by about
5% compared
. with %HRR, until 70% VO2R after
which %VO2R and %HRR are about equal.[54]
Prescribing exercise intensity based on %HRR
provides the most accurate training prescription,
especially when the patients resting and HRmax is
Sports Med 2011; 41 (5)
354 Zavorsky & Longo

Table II. Updated aerobic exercise recommendations during pregnancya

.
Gestational age (wk) %HRR %VO2R RPE Total target exercise energy
expenditure (MET h/wk)
Previously sedentary and/or overweight/obese pregnant women unaccustomed to exercisea
13 3539 4045 1214 16
36 4555 5060 1315 28
69 60 65 1516 28
1026 60 65 1516 28
2740 45 50 1314 16
Previously healthy and/or physically active pregnant womena
13 4555 5060 1315 16
36 5060 5565 1415 28
69 60 65 1516 28
1026 60 65 1516 28
2740 50 55 1415 16
a See table III for the estimated converted total amount of energy expenditure from physical activity in kcal/wk. The Borg RPE scale is from
6 (no exertion) to 20 (maximal exertion).[10] Some of the suggested programme shown in this table for exercise intensity is based on the
American College of Sports Medicine[8,48] and elsewhere.[54] The target goal for the amount of physical activity per wk expended during
pregnancy is based on the study by Dempsey et al.,[1] which shows a 33% risk reduction in GDM in women who exercise 28 MET h/wk
during pregnancy. The complications are listed in table V.[6] These recommendations are for individuals without medical and obstetrical
complications.
GDM = gestational
. diabetes mellitus; MET = metabolic equivalent task; RPE = rating of perceived exertion; %HRR = percentage of heart rate
reserve; %VO2R = oxygen consumption reserve.

known (table II). The actual target HRs, which
have been listed elsewhere,[50,54] are not provided
in table II because each pregnant woman will have
a different resting and HRmax. Let us consider an
exercise HR for a sedentary overweight pregnant
woman with GDM. At the beginning of the
programme, the intensity would be ~3539% HRR.
If her resting HR is 90 beats/min (after sitting up-
right in a chair for 5 minutes), and measured HRmax
(measured from . a graded exercise test to volitional
exhaustion) [VO2max test] is 185 beats/minute, then


39% HRR = 0.39 (18590) + 90 = 127 beats/minute.
A HR of 127 beats/minute would be her prescrip-
tion HR.
Pregnant women can monitor their HR during
pregnancy using a simple HR monitor (e.g. Polar
FS1), which is relatively inexpensive. For those
women who are not willing or able to purchase
one, then pulse rates can be monitored from their
wrists at intervals or the Borg RPE scale can
be used (see table II). An additional considera-
tion is that the definition of moderate intensity
classified as physical activity requiring 36 METs
(10.521 mLO2/kg/min), and vigorous activity
classified as >6 METs (>21 mLO2/kg/min)[8] is
circumspect, because the definition of moderate
and vigorous should be based on each individ-
uals own aerobic capacity. For example, some
pregnant women have an aerobic capacity that
approaches 46 mLO2/kg/min, which is 13 METs
or 13-fold greater than the resting metabolic
rate.[55] An activity level of 7 METs would be
moderate rather than vigorous intensity for them,
. they would only be exercising at ~53% of
as
VO2max. On the other hand, an unfit, sedentary,
overweight pregnant woman may have an aerobic
capacity of only 21 mLO2/kg/min or 6 METs.[54]
An activity level of 6 METs would not be mod-
erate
. for her, as she would be exercising at 100%
of VO2max, therefore, the terms moderate and
vigorous are relative, depending on the fitness
level of the pregnant woman. That is why exercise
intensity based on %HRR and the Borg RPE
scale are the best ways to prescribe exercise in-
tensity in all individuals, including pregnant
women with GDM, and for those who are sed-
entary or overweight.
Given that obstetricians and gynecologists
may wish to simplify exercise prescription by
eliminating the use of HRR and its calculations,

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 355

we understand the practicality of using the Borg Table III. The minimum and target amount of energy expenditure
RPE scale for exercise intensity, so we have added recommended per wk from physical activity converted to kcal/wk and
hours of activity per wk during pregnancy according to bodyweight
the scale in table II. Based on the womans weight at start of pregnancya
prior to pregnancy, the amount of weekly physi-
Weight of woman Minimum energy Target energy
cal activity energy expenditure in kcal/week at the start of expenditure of expenditure of
during pregnancy is provided in table III. How- pregnancy (kg) 16 MET h/wkb 28 MET h/wkc
ever, we also recognize that calculating the energy (kcal/wk) (kcal/wk)
expenditure from exercise in a pregnant woman 45.2 759 1328
in kcal/week may not be user friendly for the pa- 49.7 835 1461
tient or physician, so an estimated total time of 54.2 911 1594
exercise is also reported in table III (see foot- 58.7 986 1726
notes). Muscle strengthening guidelines are report- 63.2 1062 1859
ed in table IV for women who wish to supplement 67.8 1138 1992
their aerobic exercise training periodically. 72.3 1214 2125
Several physical activity questionnaires are
76.8 1290 2258
suitable for obtaining an estimate of weekly en-
81.3 1366 2390
ergy expenditure during pregnancy. We suggest
85.8 1442 2523
the use of a questionnaire that estimates previous
energy expenditure, such as the 7-day physical 90.3 1518 2657

activity recall,[107-109] the Kaiser Physical Activity 94.9 1594 2789

Survey in Women[111,112] or the Pregnancy 99.4 1669 2921
Physical Activity Questionnaire.[113] These ques- 103.9 1745 3054
tionnaires can be completed in a structured 108.4 1821 3187
1520-minute interview. Nonetheless, for simplic- 112. 9 1897 3320
ity, we provide an estimated number of hours of 117.4 1973 3453
physical activity needed per week based on two 122.0 2049 3586
different modes of exercise that would allow a
126.5 2125 3718
pregnant woman to achieve the target energy expen-
131.0 2201 3851
diture (this is listed in table III in the footnotes).
135.5 2276 3984
140.0 2352 4116
5.1 Exercise Testing to Determine Maximum
144.5 2428 4248
HR (Peak HR and Aerobic Capacity) a For every 4.5 kg increase in bodyweight, the weekly energy
expenditure increases by about 76 kcal for the minimum required
Individualizing an exercise programme for 16 MET h/wk category and 133 kcal/wk for the target 28 MET
pregnant women involves medical screening with h/wk category. The minimum and target energy expenditure is
the use of a physical activity readiness question- based on recent data by Dempsey et al.[1] and Zhang et al.[25] To
estimate the total weekly physical activity energy expenditure
naire for pregnancy,[114] an estimation of previous
from vigorous exercise, a questionnaire such as the 7-day
physical activity level and developing a programme physical activity recall can be used.[107-109] However, for
specific to the womans situation. Informing simplicity, the required number of h/wk of exercise is estimated
the patient about limitations, contraindications here. This is based on two different modes of physical activity. As
one can see, the more vigorous the exercise, the less total time of
and warning signs should also be performed exercise is required per wk.
(table V).[6] On the basis of numerous studies, b Light = approximately 6.4 h/wk walking (2.0 mph, 2.5 METs);
exercise testing to maximum exercise capacity in vigorous = approximately 2.7 h/wk bicycling on a stationary bike
pregnant women is safe for both the mother and (~67 METs).
the fetus.[43,87,92,98,99,103,115,116] Therefore, before c Light = approximately 11.2 h/wk walking (2.0 mph, 2.5 METs);
an exercise programme is given to a woman, a vigorous = approximately 4.7 h/wk bicycling on a stationary bike
(~67 METs).
graded exercise test using a cycle ergometer or
MET(s) = metabolic equivalent task(s); mph = miles per hour.
treadmill would be an ideal scenario to obtain

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
356
Table IV. Muscle strengthening exercise guidelines during pregnancya
For pregnant women aged 1845 y, 810 muscular strength
exercises can be performed over one to two sessions per wk (non-
consecutive days). One aerobic training session can be replaced by
a muscle strengthening session in the weight room or at home
Use lighter weights, more reps
Heavy weights may overload joints already loosened by increased
levels of the hormone relaxin during pregnancy. Thus, perhaps it
would be wise to use lighter weights and do more repetitions instead.
For example, if one usually performs leg presses with 15.8 kg for
812 reps, try 9.0 kg for 1520 reps. Or, if one typically performs a
chest press with 6.8 kg for 812 reps, try 3.6 kg for 1520 reps
Avoid walking lunges
These may raise the risk of injury to connective tissue in the pelvic
area
Watch the free weights
One should be careful with free weights as free weights may involve
the risk of hitting the abdomen. Women can use resistance bands
instead, which offer different amounts of resistance and varied ways
to do weight training and should pose minimal risk to the stomach
Try not to lift while flat on your back.
In the second and third trimester, lying on your back may cause the
uterus to compress a major vein, the inferior vena cava into which
blood from the pregnant uterus flows. This increased pressure can
be transmitted to the placenta, to compromise fetal blood flow in the
gas exchange area, thereby limiting oxygen supply to the infant.
An easy modification is to tilt the bench to an incline
Try to avoid the valsalva manoeuver
This manoeuver, which involves forcefully exhaling without actually
releasing air, can result in a rapid increase in blood pressure and
intra-abdominal pressure, and may decrease oxygen flow to the
fetus. However, on rare occasions, the uterus can be displaced
against the inferior vena cava, which can result in a decrease in blood
pressure. Thus, a decrease in blood pressure can also occur with the
valsalva manoeuver, but this is uncommon
Listen to your body
The most important rule is to pay attention to what is going on
physically. If you feel muscle strain or excessive fatigue, modify the
moves and/or reduce the frequency of the workouts. Pregnancy is
not the time to perform heavy weightlifting but muscle strengthening
according to these guidelines will burn calories and increase the
resting metabolic rate
a Light muscle strengthening training (resistance exercise training)
performed over the second and third trimester of pregnancy does
not have a negative impact on the newborn infants body size and
overall health.[110]
HRmax and current fitness. However, access to
this type of testing is limited by the number of
exercise physiologists, adequate equipment and/
or patient finances; as a result, exercise testing is
impractical for a majority of pregnant women.
As such, HRmax can be estimated by the formula
220 minus age; subsequently, the programme
2011 Adis Data Information BV. All rights reserved.
Zavorsky & Longo
outlined in table II using %HRR would be ap-
propriate. Should HR not be measured or re-
corded during exercise, the Borg RPE scale could
be a substitute for determining exercise intensity.
Exercises that stimulate large muscle groups
such as stationary cycling, swimming, walking or
jogging are recommended. A standard stationary
bicycle can substitute for one that is recumbent.
A pregnant woman who has just finished exercise
should be aware of uterine contractions. Women
should be informed that stimulation of the uterus
(i.e. as it moves inside the body from exercise) will
cause contractions or tightening. Women should
seek medical advice when these contractions be-
come increasingly painful and do not dissipate
within a reasonable time frame after exercise.
When monitoring fetal movements pre-, dur-
ing or post-exercise, the National Institute for
Health and Clinical Excellence recommends that
health professionals should no longer suggest the
routine counting of fetal movements in the sec-
ond half of a womans pregnancy.[117] Neverthe-
less, pregnant women should continue to be aware
of fetal movements throughout the day. Less
than ten fetal movements in 12 hours is an in-
dication that further investigation at a hospital is
warranted.[117]
6. Conclusions
The updated 2007 ACSM and AHA recom-
mendations are used to help establish new
guidelines for pregnancy, in the absence of med-
ical or obstetric complications. These recommen-
dations are based on recent findings that suggest
increasing the amount of physical activity ex-
penditure to at least 16 MET hours per week. To
achieve the minimum expenditure of 16 MET
hours per week, one could walk at 3.2 km per
hour for 6.4 hours per week (2.5 METS, light
intensity), or preferably exercise on a stationary
bicycle for 2.7 hours per week (6.07.0 METS,
more vigorous intensity). Incorporating vigorous
exercise at about 60% HRR, obtained from the
pregnant womans own resting and HRmax will
provide the best health outcome. Use of these
new aerobic exercise and muscle strengthening
guidelines for pregnancy (tables II, III, IV), which
Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy
Table V. Absolute and relative contraindications to aerobic ex-
ercise during pregnancy as well as warning signs to terminate
exercise while pregnant (reproduced from the ACOG Committee
opinion,[6] with permission from the American College of Obste-
tricians and Gynecologists)
Absolute contraindications
Haemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix/cerclage
Multiple gestation at risk for premature labour
Persistent second or third trimester bleeding
Placenta previa after 26-wk gestation
Premature labour during the current pregnancy
Ruptured membranes
Pre-eclampsia/pregnancy-induced hypertension
Relative contraindications
Severe anaemia
Unelevated maternal cardiac arrhythmia
Chronic bronchitis
Poorly controlled type 1 diabetes mellitus
Extreme morbid obesity
Extremely underweight (body mass index <12)
History of extremely sedentary lifestyle
Intrauterine growth restriction in current pregnancy
Poorly controlled hypertension
Orthopaedic limitations
Poorly controlled seizure disorder
Poorly controlled hyperthyroidism
Heavy smoker
Warning signs to terminate exercise while pregnant
Vaginal bleeding
Dyspnoea prior to exertion
Dizziness
Headache
Chest pain
Muscle weakness
Calf pain or swelling (need to rule out thrombophlebitis)
Preterm labour
Decreased fetal movement
Amniotic fluid leakage
are specific, safe for both mother and fetus and
which incorporate the emerging research findings
over the last decade, may result in a cohort of
pregnant women with increased fitness and health,
and infants with an enlarged prospect for a
healthy and productive life.
2011 Adis Data Information BV. All rights reserved.
357
Acknowledgements
Gerald S. Zavorsky, PhD, holds a Certified Strength and
Conditioning Specialist credential from the National Strength
and Conditioning Association and a Certified Exercise
Physiologist credential from the Canadian Society for Ex-
ercise Physiology. Lawrence D. Longo is an obstetrician-gy-
necologist with extensive expertise in exercise and pregnancy
in both animal and human models.
No sources of funding were used to assist in the prepara-
tion of the article. The authors have no conflicts of interests to
declare that are directly relevant to the content of this article.
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Correspondence: Gerald S. Zavorsky, PhD, Director, Human
Physiology Laboratory; Associate Professor, Marywood
University, 2300 Adams Avenue, Scranton, PA 18509, USA.
E-mail: zavorsky@marywood.edu
Sports Med 2011; 41 (5)