findings from research on exercise during pregnancy reveal that

• Open access
• Published: 16 July 2022

Physical activity during pregnancy: a systematic review for the assessment of current evidence with future recommendations

• Leona Cilar Budler 1 &
• Marko Budler 2 , 3  

BMC Sports Science, Medicine and Rehabilitation volume  14 , Article number:  133 ( 2022 ) Cite this article

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Physical activity is essential to maternal and infant health. Healthcare professionals should inform pregnant women about benefits of physical activity to prevent possible health issues. Those recommendations should elaborate on relevant contemporary evidence. The aim of this study was to review evidence-based recommendations for physical activity during pregnancy.

A systematic search, analysis and synthesis of conducted randomised controlled trials (RCTs) was conducted from October 2021 to June 2022 in following databases: PubMed, CINAHL, ScienceDirect and Web of Science. Literature was searched using inclusion and exclusion criteria and following PRISMA recommendations.

Benefits for pregnant-women health and well-being were reported while performing aerobic exercise, lumbar stabilization and stretching exercise, water exercise, nerve and tendon-slip exercise, resistance training and strength training. For all exercise modalities it is recommended to perform moderate intensity activities during the whole time of pregnancy.

Conclusions

This systematic literature review supplements current knowledge on physical activity of pregnant women. Exercise interventions are listed and suggested in an integrative model with physical-fitness components to contextualize and promote physical activity among pregnant women.

Peer Review reports

Physical activity (PA) is defined as “bodily movement produced by skeletal muscles that results in energy expenditure” [ 1 ]. PA is believed to be essential to healthy pregnancy. Historically, Biblical writers noticed that Hebrew slave women gave birth more easily than sedentary Egyptian mistresses [ 2 ]. Moreover, it is believed that PA during pregnancy limits gestational weight-gain [ 3 , 4 , 5 ], decreases risk of maternal mental disorders after childbirth [ 6 , 7 ] and improves body image satisfaction [ 8 ]. PA in pregnancy is pivotal to facilitating positive health outcomes in infants [ 9 ].

To corroborate the role of PA in pregnancy and the expected favourable health outcomes for pregnant women and infants, this study distinguishes between the terms PA, exercise (intervention), and physical fitness that are all distinct concepts. However, these concepts (terms) are often used interchangeably. In line with a seminal paper, we deem exercise as “a subset of PA that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness”. In addition, physical fitness is deemed “a set of attributes that are either health- or skill-related” [ 10 ].

Pregnant women tend to demonstrate a lack of knowledge regarding PA during pregnancy [ 9 , 11 , 12 ]. The reasons for insufficient knowledge include but are not limited to the mothers’ race [ 13 ], socio-economic and cultural context [ 14 ], and maternal education [ 15 ]. Relatively low degree of pregnant women report that they had received prescription in terms of exercise interventions from health providers during pregnancy [ 16 ]. In addition, past research identified an important barrier to enhancing pregnant women’ knowledge about PA—the absence of PA-related domains in the development of professional healthcare professionals [ 17 ]. Due to lack of guidance, pregnant women access information about healthy lifestyle during pregnancy via the internet with questionable credibility [ 18 , 19 ].

Mottola et al. who performed a literature review and identified some benefits of prenatal PA, provided preliminary guidance for pregnant women and healthcare professionals on prenatal PAity [ 20 ]. Unsurprisingly, the women who were given guidelines for PA during pregnancy reported exercising [ 21 ].

In addition to potential issues with credible sources of information and lack of novel guidance, healthcare professionals need multiple sources to develop an “integrative approach” for promotion of PA to pregnant women [ 22 , 23 ]. From the standpoint of the authors,an “integrative approach” should, for instance, account for tailored exercise interventions that could be useful to pregnant women with specific goald, and facilitate the adherence of pregnant women to PA [ 24 , 25 ].

The aim of the current study is hence two-fold. First, we respond to more-recent calls for evidence-based recommendations that would enhance promotion of PA during pregnancy (see e.g., [ 26 ]). We have listed and contextualized the recommendations to be provided to pregnant women, professional healthcare professionals involved in nursing (e.g., midwives), and wider society. Further, by identifying exercise modalities, examining characteristics of exercise interventions with a systematic review, and corresponding health outcomes we address a recent call from DiPietro et al. [ 27 ] to advance current knowledge and empower healthcare professionals. As interventions should be tailored (e.g., goal-oriented to a physical-fitness components), our second aim is to characterize the interventions from main findings, and further elaborate characteristics such as exercise modality. By corroborating the exercise interventions for pregnant women, we can enhance the adherence to PA and improve the promotion of PA among the healthcare professionals. Ultimately, the current study concludes with the contributions to the learning system and an identification of intricate contemporary challenges to be addressed in the future research.

A systematic review is a summary of the medical literature that uses explicit and reproducible methods to systematically search, critically appraise, and synthesize a specific health issue [ 28 ]. Following steps were taken into account when performing a systematic review: (1) defining research question; (2) preliminary literature search; (3) development of search string, inclusion and exclusion criteria; (4) literature search and analysis; (5) literature synthesis; (6) assessment of literature quality and bias; and (7) interpretation of findings and proposition of future directions. When performing a systematic review, the Additional file 1 : PRISMA guidelines were followed [ 25 ] (Additional file 1 : Appendix 1).

Search methods

For the development of research question, a Population, Intervention and Outcome—PICO [ 29 ] format was used. The research question was: How do exercise interventions improve the health of physically-active pregnant women and their infants? Exclusion and inclusion criteria were developed based on the preliminary literature search and PICO research question (Table 1 ).

We searched for literature published between June 2017 and June 2022, in English language and RCTs. As described by Hiebl [ 30 ], authors can limit their literature search by publication time. However, reasons should be justified and mentioned in the limitation section. The aim of this systematic review is to get the newest and best evidence in this field, thus, only literature published in last five years were examined. We provide up-to-date evidence which is often neglected by authors of overviews [ 31 ]. We included only RCTs because they are assessed as the most credible in the hierarchy of evidence [ 23 ]. Other studies were excluded (Additional file 1 ).

A search string was developed based on preliminary literature search and was taken into account in the process of literature search (Table 2 ).

Search outcomes

Using the developed search string 2092 records were identified in four databases. After duplicates exclusion, literature was checked by title and abstract; 26 articles were retrieved and checked by the full text. Finally, 20 articles were included in the final analysis and synthesis. Steps of literature search are presented in Fig.  1 [ 32 ].

PRISMA flow diagram

Quality appraisal

The data quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system [ 33 , 34 ]. GRADE identified its five categories—study limitations, imprecision, inconsistency, indirectness, and publication bias. GRADE quality level is interpreted as high (++++), moderate (+++), low (++), or very low (+).

Data extraction

Data were extracted using standardized data form in Microsoft Excel® by two reviewers. The first reviewer exported data and second reviewer checked for data accuracy. The literature screening was carried out independently by two researchers. Disagreements were solved by consensus. We extracted study characteristics such as study sample, exercise intervention, main study results and conclusions.

Data synthesis

A narrative synthesis was conducted for all included studies. Results were synthesized by PA modality and intensity or duration of PA. Also, results were synthesised due to the intervention effectiveness.

In total, 20 articles were included in the final analysis (Table 3 ). Studies which fit the inclusion criteria were analysed due to sample, intervention, results and conclusions. Excluded studies are listed in the Additional file 2 : Appendix 2.

Studies included in the analyses involved various number of participants. Those numbers varied between minimum of 20 [ 27 ] and maximum of 1023 pregnant women [ 38 ]. All studies had intervention and control group. However, all studies did not report mean and standard deviation for each group. Interventions were the following: moderate aerobic exercise, lumbar stabilization and stretching exercise, resistance training, water exercise, various moderate-intensity exercises, physical conditioning program, cycling program, nerve and tendon-slip exercise, and individual or group sessions with a personal trainer. Studies outcomes are assessed as positive or negative for pregnant women or infant in the Table 4 . Details about each intervention are provided in the Table 5 . In the remainder of this study the observed studies are assessed for quality using the GRADE system (table in Additional file 3 : Appendix 3). All studies included were RCTs because of the search criteria. RCTs are seen as a high-quality body-of-knowledge [ 34 ]. When assessing quality of each evidence, study design, study limitations, inconsistency, indirectness, imprecision and risk of bias were considered. The results of the assessment are as follows. Among 18 units-of-analysis, three were assessed as moderate quality, eight as low quality, and seven as very low quality. In these seven, quality scored was lower due to numerous limitations (e.g., the absence of the control group, small study sample, lack of blinding, lack of robust analyses, etc.), higher deviations in CIs for interventions, or risk of bias.

Out of 20 identified RCTs, 11 (55.00%) reported positive results of implemented intervention on maternal or infant health outcomes (Table 4 ). Others showed no changes or did not report the result.

To help professional healthcare professionals in promoting PA we further categorize interventions by exercise modality (Table 5 ). Among a range of exercise modalities, four exercise modalities, namely strengthening, stretching, balance, and aerobic exercises, are commonly found in the existing body of literature that focuses on positive results of physical activity interventions on health outcomes [ 52 , 53 , 54 , 55 ].

Table 5 categorizes main findings with respect to exercise modality and their expected positive results on pregnant-women health and well-being. The favourable health outcomes of performing moderate aerobic exercise were most extensively examined [ 35 , 45 ], followed by strengthening see e.g., [ 42 ], or a hybrid form using both [ 38 , 44 ]. For aerobic exercise, treadmill, walking, and other aerobic-exercise programs are advised (see Table 5 ). A more comprehensive hybrid form of PA program included moderate aerobic exercise with gradual warm-up; aerobics; light muscle strengthening; balance; stretching; strengthening; and relaxation with final talk [ 35 ]. In addition, [ 56 ] proposed an exercise program of both aerobic and strength training among Norwegian pregnant women to examine vitamin-D mediated effect on maternal and fetal health outcomes.

Some of the remaining studies also focused on specific sub-types of, for instance, stretching [ 36 ], and aerobic exercise [ 47 ]. In fact, practitioners are advised to suggest pregnant women the tendon slip exercises and the nerve-gliding exercises. Gestational diabetes mellitus was the main research subject by [ 4 ]. Authors revealed that, complementary to healthy eating, exercise limits the gestational weight gain. What is more, their findings pinpoint to a comprehensive approach, comprised of, for instance, moderate PA, reducing sedentary time, and strengthening.

Fontana Carvalho et al. [ 36 ] reported that involved pregnant women were included in either lumbal stabilization exercise group or lower limb and trunk stretching exercise group. Both interventions showed positive results in pain reduction caused by or perceived as a result of pregnancy. Rodríguez-Blanque et al. [ 38 ] reported that pregnant women performed a moderate PA consisting of a warm-up; aerobic exercise, strengthening, and stretching with relaxation to limit the negative effects on the body and to optimise well-being, mood and sleep patterns. Finally, positive results were also seen by combing individual diet and PA [ 39 ]. Moreover, PA intervention entailed positive results in maternal diet quality. Similarly, [ 40 ] proposed a supervised PA program consisting of warm-up, aerobic exercise, strengthening, balance, and stretching with relaxation. Hereby, intensity of PA was mild-to-moderate. The PA showed positive results in weight loss at 6 weeks post-partum.

Among the combined exercise modalities, [ 35 ] introduced a 10-min warm-up (walking and stretching) with a main section that lasted 30–35 min and included moderate intensity aerobic and resistance exercises. Activity ended with a cool down (walking, stretching, relaxation and pelvic floor muscle training). Gustafsson et al. [ 45 ] proposed a 12-week standardized PA program where women were encouraged to perform exercise modalities at home at least twice a week. Fontana Carvalho et al. [ 36 ] reported success of exercise interventions with a combination of stabilization of lower limbs and stretching. With an aim of reducing carpal-tunnel symptoms, pregnant women also conducted tailored nerve and tendon slip exercises on daily basis [ 41 ]. With respect to duration, [ 44 ] suggested water exercise to be followed for 12 weeks. Finally, a PA program aimed at conditioning was developed to encourage pregnant women to perform exercises throughout the entire pregnancy [ 40 ].

Our findings reveal that past research on PA in pregnancy focused mostly on health outcomes for the pregnant women and infants. Similar to Evenson et al. (2014), our analysis revealed heterogeneity of findings in terms of exercise modality, duration, and intensity. To overcome some of these shortcomings, we call for a standardization in terms of measurable and comparative characteristics of PA in pregnancy. Following this train-of-thought, a commonly used FITT framework (see e.g., [ 57 ]) has been applied to numerous sub-domains where exercise prescriptions from the healthcare professionals play a significant role, ranging from patients with cancer [ 58 ], exercise prescriptions for cardiometabolic health [ 59 ], and occasionally as a one-size-fits-all to general population [ 60 ].

Applying a framework similar to FITT to pregnant women would allow for quantifying the common characteristics of PA in pregnancy (e.g., intensity). The development of such framework that would guide the hands-on recommendations from the healthcare professionals would require acknowledging for any challenges pregnant women might have as a result of, for instance, deteriorating health, lack of physical fit, and maturity of pregnancy [ 61 , 62 ]. Finally, a growing number of pregnant women have a propensity to remain physically fit notwithstanding pregnancy. Physical fitness is defined as a»state characterized by: (a) an ability to perform daily activities with vigour; and (b) demonstration of traits and capacities that are associated with low risk of premature development of physical inactivity [ 63 ]. In a broader sense, one’s physical fitness represents their capability to carry out a range of exercise modalities and daily tasks. Campbell et al. [ 64 ] emphasize the need to improve this capability concomitantly with the management any fatigue, stress, or change in health condition which is especially relevant assertion to the pregnant women. Moreover, there is a need for development of efficient physical activity interventions for pregnant women. Marini et al. [ 65 ] proposed a study protocol to design physical activity intervention for pregnant women to include in childbirth preparation classes evaluating its feasibility and efficacy on quality of life, PA levels and other outcomes.

The physical fitness is achieved, maintained and facilitated by prescribing exercise that accounts for the components of physical fitness. These components might differ with respect to the existing literature; however, most commonly the components are cardiorespiratory fitness [ 66 ], muscular strength [ 67 ], muscular endurance [ 68 ], body composition [ 69 ], and flexibility [ 55 , 70 ]. Elaborating on the physical-fitness components could reveal complementary outcomes (in addition to health outcomes identified by the current study and past research) relevant to pregnant women that aim to advance their PA. We suggest the future research to focus on further examination of the complementary role of maintaining physical fitness, to account for the associated health- and physical-fitness-related outcomes, and to overcome aforementioned context-based challenges for pregnant women (e.g., timing of PA).

The existing learning system in nursing can advance by moving towards an integrative approach that accounts for multiple sources, network collaboration, and continuous investigation of PA. We facilitate the learning processes of healthcare professionals by elaborating on exercise modalities, and commencing a discussion over the components of physical fitness. Acknowledging physical-fitness components could enhance adherence of pregnant women to PA (see e.g., [ 39 ]), and empower healthcare professionals who promote PA.

It is evident that research does not focus on different components of PA or components of physical fitness. In line with DiPietro et al. [ 27 ] we argue that the future research should focus on providing recommendations tailored for the »peri-pregnancy« period, i.e. before, during, and after a childbirth. Second; whilst the current study adds to tailoring exercise interventions by elaborating exercise modality and physical-fitness components, lack of detailed information not only about pregnant women but also about the pre-pregnancy condition prevents from optimizing interventions for particular cohorts of pregnant women.

Future research should focus on multiple sources to overcome aforementioned challenges that limit the development of tailored evidence-based PA recommendations. Furthermore, we suggest that, in addition to health outcomes, the future research devotes more attention to the role and plausibility of PA for achieving or maintaining physical-fitness components of pregnant women. Such enriched guidelines could enhance adherence and favourable health outcomes of pregnant women, and improve promotion of PA among the healthcare professionals. However, future research should identify appropriate healthcare professionals to distribute PA recommendations (see e.g., [ 23 ]), and, in addition, barriers that prevent from effective distribution of physical activity recommendations. Finally, to complement the existing body of the literature with PA recommendations for pregnant women, future research should ensure the scientific nature of such reviews by e.g., addressing the listed limitations, and expanding the data obtained.

The current study reveals a lack of context-dependency, for instance characteristics of pregnant women such as age, previous PA levels, comorbidities, other measures (e.g., BMI), mental well-being, pregnancy status (e.g., early or late pregnancy, health issues during pregnancy, micronutrient levels etc.), non-communicable diseases with viral infections (see e.g., [ 71 , 72 ]), and other factors such as personal attitude (see e.g., [ 73 ]) that could compromise the development and realization of PA. However, the current study also has some methodological limitations in addition to the limited feasibility of data analysis. First, we deliberately examined the more-recent literature in order to get novel and credible selection of evidence. We omitted analysing non-published papers or papers without a free access. Second, a heterogeneity of findings partially prevented from more thorough analyses. Finally, we did not use data processing software, which to some degree reduces the reliability of the qualitative analysis.

Conclusion with research agenda

The current study demonstrates numerous favourable health outcomes of PA during pregnancy. Recommendations given by practitioners to pregnant women focus on preforming at least 150 min per week moderate-intensity aerobic PA. However, further explanations are not provided. That being said, practitioners can use our systematic literature review to examine favourable maternal and infant health outcomes with a range of exercise modalities (strengthening, balance, stretching, and exercise modalities combined) in addition to aerobic exercise. Furthermore, the practitioners can learn from the current study about the importance of physical-fitness components. As adherence is consistently deemed a critical success factor for PA [ 74 ], accounting for the physical-fitness components, i.e., goal-oriented (tailored), in exercise interventions, could remarkably improve the adherence of pregnant women to PA.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Body mass index

Gestational diabetes mellitus

The grading of recommendations, assessment, development, and evaluation system

Number of participants

Oral glucose tolerance test

p value of statistical significance

Physical activity

Population, intervention and outcome

Randomised controlled trial

Study of water exercise during pregnancy

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Acknowledgements

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and affiliations.

Faculty of Health Sciences, University of Maribor, Zitna ulica 15, 2000, Maribor, Slovenia

Leona Cilar Budler

School of Economics and Business, University of Ljubljana, Kardeljeva ploscad 17, 1000, Ljubljana, Slovenia

Marko Budler

Fitness Association of Slovenia, Cesta 24. junija 23, 1231, Ljubljana, Slovenia

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LCB and MB were involved in the study conceptualization and design of the systematic review. LCB and MB were responsible for generating the systematic review terms, performing the systematic searches, extracting the data, analysing the data, performing the data synthesis, and for creating the study, tables and figures. Both authors have read and approved the final study.

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Cilar Budler, L., Budler, M. Physical activity during pregnancy: a systematic review for the assessment of current evidence with future recommendations. BMC Sports Sci Med Rehabil 14 , 133 (2022). https://doi.org/10.1186/s13102-022-00524-z

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Exercise during pregnancy has a preventative effect on excessive maternal weight gain and gestational diabetes. A randomized controlled trial ☆ ☆☆

Ruben barakat, ignacio refoyo, javier coteron, evelia franco.

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Corresponding author at: Martín Fierro 7, 28040 Madrid, Spain. [email protected]

Received 2018 May 9; Accepted 2018 Nov 6; Issue date 2019 Mar-Apr.

Exercise in pregnancy is associated with better control of maternal weight gain.

Moderate regular exercise throughout pregnancy prevents gestational diabetes.

Healthy pregnant women should be encourage to exercise regularly.

Keywords: Exercise, Physical therapy, Pregnancy, Weight gain, Gestational diabetes

Excessive gestational weight gain is associated with several adverse events and pathologies during pregnancy.

The purpose of this study was to examine the effects of an exercise program throughout pregnancy on maternal weight gain and prevalence of gestational diabetes.

A randomized controlled trial was designed that included an exercise intervention group (EG) and standard care control group (CG). The exercise intervention included moderate aerobic exercise performed three days per week (50–55 minutes per session) for 8–10 weeks to 38–39 weeks gestation.

594 pregnant women were assessed for eligibility and 456 were included (EG n  = 234; CG n  = 222). The results showed a higher percentage of pregnant women gained excessive weight in the CG than in the EG (30.2% vs 20.5% respectively; odds ratio, 0.597; 95% confidence interval, 0.389–0.916; p  = 0.018). Similarly, the prevalence of gestational diabetes was significantly higher in the CG than the EG (6.8% vs 2.6% respectively; odds ratio, 0.363; 95% confidence interval, 0.138–0.953; p  = 0.033).

The results of this trial indicate that exercise throughout pregnancy can reduce the risk of excessive maternal weight gain and gestational diabetes.

Introduction

Pregnancy and delivery are biological processes that can have a significant impact on maternal health and newborn wellbeing. Research has shown that events that occur during pregnancy may influence both maternal and fetal future health outcomes. 1 , 2

The impact that gestational weight gain can have on health outcomes has been especially recognized by health care professionals as a potential factor that may influence maternal and fetal wellbeing. Excessive gestational weight gain is associated with several adverse events and pathologies. Many studies report complications related to the wellbeing of the mother, fetus and even the newborn and infant due to inappropriate maternal weight gain during pregnancy. 3 , 4 , 5 , 6 , 7 , 8

Gestational diabetes mellitus (GDM) is defined as “carbohydrate intolerance with onset or first recognition during pregnancy” 9 and it is among many problems that are highly related to excessive maternal weight gain. 10 Indeed the prevalence of GDM is increasing in parallel with overweight and obesity in the obstetric population. 11 , 12 Current trends for weight gain among women of reproductive age are alarming. 13 , 14

Precise estimates of GDM prevalence are not clear. A recent meta-analysis reported that the prevalence of GDM in Europe is 5.4%. 15 According to the American Diabetes Association (ADA), GDM complicates approximately 7% of all pregnancies. 16 Regardless of the variability presented in available studies, data from western countries suggests that the prevalence of GDM is increasing. 17 , 18 , 19 Women diagnosed with GDM have a higher risk for future diabetes, with approximately 50% of women developing type 2 diabetes within 5 years of delivery. 20

Many studies support the association of GDM with several adverse maternal and fetal outcomes. 21 , 22 , 23 Additionally, there are some data that suggest an increase in fetal malformation and perinatal mortality. 24 , 25 , 26

Although research supports that healthy lifestyle modifications may have a positive impact on metabolic factors among overweight and obese pregnant women, evidence for specific effective approaches to prevent GDM are needed. 27 Research to identify modifiable factors that might help prevent excessive maternal weight gain and abnormal glucose tolerance or GDM, in the pregnant population is needed and has urgent public health importance. 28 , 29 One such modifiable factor may be exercise performed during pregnancy.

The existing literature suggests that physical activity before and during pregnancy may be an effective public health and clinical strategy for GDM prevention and treatment. 30 This effect might be explained by the widely accepted influence that physical activity has on preventing weight gain. 31

Research has supported exercise during pregnancy as an effective intervention to prevent excessive gestational weight gain. 32 Furthermore, exercise during pregnancy has been identified as an effective approach to control blood sugars to help prevent and manage GDM. 33 Previous studies carried out with pregnant women however have conducted physical activity programs using small sample sizes and/or lacking supervision. 34 , 35

The main aim of this randomized controlled trial (RCT) was to examine the influence of a supervised exercise program throughout pregnancy on maternal weight gain and incidence of GDM. As a secondary objective, the effect of the exercise program on other maternal and neonatal outcomes was also examined. We hypothesized that maternal physical exercise would be associated with a reduction of both excessive maternal weight gain and prevalence of GDM without adverse effects on other maternal and newborn outcomes.

The present RCT (clinical trial registration number NCT02109588 ) was conducted between March 2014 and January 2017 following the ethical guidelines of the Declaration of Helsinki, last modified in 2000. The research protocol was reviewed and approved by the Hospital Severo Ochoa (Madrid, Spain) ethics review board (240-09). Participants enrollment began in April 2014.

Participants and randomization

A total of 594 Spanish-speaking (Caucasian) healthy pregnant women from two primary care medical centers ( Centro de Salud Los Pedroches, Centro de Salud Leganés Norte , Madrid, Spain) were recruited during their first prenatal visit ( Fig. 1 ). They were informed about the nature of the study and assessed for eligibility. Women with singleton and uncomplicated pregnancies (no type 1, 2 or gestational diabetes at baseline), with no history or risk of preterm delivery (i.e. ≥1 previous preterm delivery) and not participating in any other trial were invited to participate. Women not planning to give birth in the same obstetric hospital, or with no medical follow-up throughout pregnancy were not included in the study. Women having any serious medical conditions (contraindications) that prevented them from exercising safely were also not included. 36

Flow chart of study participants.

A computer-generated list of random numbers was used to allocate the participants into the study groups following other previous studies. Allocation ratio was 1:1. The randomization blinding process (sequence generation, allocation concealment and implementation) was performed by three different researchers. The treatment allocation system was set up so that the researcher who was in charge of randomly assigning participants to each group did not know in advance which treatment the next person would receive (i.e. concealed allocation).

Women who were randomly allocated to the Exercise Group (EG) received similar standard care and performed an exercise program throughout pregnancy. Women randomly allocated to the Control Group (CG) received obstetric standard care from health professionals. Women were excluded if they did not conform to the specifications of the allotted group. All the participants signed an informed consent.

Exercise intervention 37 , 38

Pregnant women in the intervention group received standard care and all aspects of a structured and supervised moderate exercise intervention program three days per week (55–60 min per session) from the 8–10th week of pregnancy (immediately after the first prenatal ultrasound) to the end of the third trimester (weeks 38–39). The exercise protocol was supervised by a qualified of physical activity and sport science professional (ten years of experience). A total of 83–85 group training sessions were originally planned for each participant in the event of no preterm delivery. The exercise program met the standards of the American College of Obstetricians and Gynecologists 36 and included the following seven sections:

Gradual warm-up

Aerobic exercises

Light muscle strengthening

Coordination and balance exercises

Stretching exercises

Pelvic floor strengthening

Relaxation and final talk

Women used a heart rate (HR) monitor (Accurex Plus, Finland) during the training sessions (HR was consistently under 70% of age-predicted maximum) and the rating of perceived exertion scale ranged from 12 to 14 (Somewhat Hard). 39

The exercise session started with a light-intensity, 10-min warm-up consisting of walking and static stretching (avoiding muscle pain) of most muscle groups (upper and lower limbs, neck and trunk muscles). Similarly, the exercise session finished with a light-intensity, 10-min cool-down including the same exercises as the warm-up period plus relaxation and pelvic floor muscle training. As a motivational strategy, a final talk was done to promote extensive counseling and provide information to ensure that the participants received clear instructions on how to have an active pregnancy and emphasizing the importance of regular (not occasional) exercise throughout pregnancy.

The main section of the exercise session after the warm-up was 30–35 min in length and included moderate-intensity aerobic exercises and resistance exercises. Aerobic exercises consisted of low-impact aerobic dance, involving the upper and lower limbs. Aerobic dance bouts were approximately 3–4 min long and included stretching and relaxation followed by a one minute break.

Light muscle strengthening was also included in each session. Strengthening exercises engaged major muscle groups (pectoral, back, shoulder, upper and lower limb muscles) to promote good posture, prevent low back pain and strengthen the muscles used in labor and the pelvic floor (third trimester). Exercises were performed using the full range of motion and involved barbells (3 kg/exercise) and low-medium-resistance elastic bands (Therabands). The exercises included biceps curls, arm extensions, arm side lifts, shoulder elevations, bench presses, seated lateral row, lateral leg elevations, leg circles, knee extensions, knee (hamstring) curls, ankle flexions and extensions. Exercises involving extreme stretching and joint over-extension, ballistic movements or jumps were avoided, and exercises in the supine position on the floor were not performed for more than 2 min.

As pregnancy progresses, women may experience difficulty with balance therefore all coordination and balance exercises consisted of easy activities using sport equipment (foam balls, cords, etc.) for support.

To maximize program safety, adherence and efficacy, all sessions were: (i) supervised by a qualified fitness specialist (ten years of experience) and with an obstetrician's assistance; (ii) accompanied by music; and (iii) performed in the Health Care Center in a spacious, well-lit room under favorable environmental conditions (altitude 600 m; temperature 19–21 °C; humidity 50–60%). An adequate intake of calories and nutrients was confirmed before the start of each exercise session.

The intervention involved group sessions of 12–15 participants.

Adherence to the training program was ≥80% in the intervention group that was measured by a qualified fitness specialist using a checklist of attendance for each session.

Standard-care (CG)

The women assigned to the standard care CG attended regular scheduled visits to their obstetricians and midwives (according to Hospital protocol), usually every 4–5 weeks until the 36–38th week of gestation and then weekly until delivery. They received general nutrition and physical activity counseling from their health-care provider.

Women were not discouraged from exercising during pregnancy on their own. However, similar to our previous studies women in the CG were asked about exercise habits once each trimester using a “Decision Algorithm” (by telephone). 37

Participant demographics

Information about demographics, including pre-pregnancy Body Mass Index (BMI), parity, educational level, previous physical activity habits, smoking status, previous pre-term birth and previous miscarriage was obtained at the first prenatal visit either by reviewing the medical records or by a telephone interview. The inclusion/exclusion criteria was determined at this initial visit by the attending obstetrician.

Primary outcomes

Total maternal weight gain (kg) and excessive gestational weight gain (yes/no) were recorded. Total gestational weight gain was calculated on the basis of the pregravid weight (first prenatal consult) and weight at the last clinic visit before delivery (week 36–38). Excessive gestational weight gain was defined according to the recommendations of the 2009 Institute of Medicine (IOM) guidelines 40 categorized by pre-pregnancy BMI for each woman: >18 kg for underweight; >16 kg for normal weight; >11.5 kg for overweight; and >9 kg for obese women. Cases of gestational diabetes and 1 h Oral Glucose Tolerance Test (OGTT) information was collected from hospital records (week 24–26).

Secondary outcomes

Maternal gestational age at delivery, type of delivery and birth weight were collected from hospital records. Newborns were classified as having macrosomia when birth weight was >4000 ×  g and low birth weight was defined as <2500 ×  g . 41 Primary and secondary outcomes were assessed by healthcare professionals.

Statistical analyses

Sample size was determined based on a priori widely accepted power calculation. 42 In total, 340 subjects were needed to achieve 80% power to detect a statistically significant difference in maternal weight gain taking into account previous data on this variable. The sample size was intentionally increased to account for patient withdrawal and possible problems for follow-up.

A Kolmogorov–Smirnov test was performed to verify the normality of the data in the study variables and showed that it was non-parametric ( p  < 0.05). Thus, Mann–Whitney tests were performed to analyze possible differences between the groups for continuous variables (maternal weight gain, oral glucose tolerance test (OGTT), maternal age, gestational age, pre-pregnancy BMI and birthweight). The Pearson χ 2 test was completed with the observation of standardized adjusted residuals and was used to assess differences between categorical variables (excessive weight gain, gestational diabetes, parity, mode of delivery). Statistical tests used a 2-sided 0.05 alpha level and SPSS 24.0 was used to analyze the data. All analyses were done on an intention-to-treat basis.

Results ( Fig. 1 )

Baseline characteristics.

Baseline characteristics for both groups are listed in Table 1 and were similar between groups for most of the variables.

Maternal characteristics.

Main outcomes

Differences in main outcomes (maternal weight gain, OGTT and cases of GDM) are presented in Table 2 . Maternal weight gain was significantly lower in the EG compared to the CG (12.19 vs 13.33 kg respectively, U  = 22044, p  = 0.005). In line with these results, standardized adjusted residuals in Pearson χ 2 suggested that the ratio of women that gained excessively was higher in the CG than the EG (30.2% vs 20.5% respectively; odds ratio, 0.597; 95% confidence interval, 0.389–0.916; p  = 0.018). A significant difference was also found for the OGTT results (EG = 116.56 vs CG = 121.63 mg/dL, U  = 23,158, p  = 0.045). Finally, standardized adjusted residuals in Pearson χ 2 suggested that the ratio of women diagnosed with GDM was higher in the CG than the EG (6.8% vs 2.6% respectively; odds ratio, 0.363; 95% confidence interval, 0.138–0.953; p  = 0.033).

Maternal weight gain, oral glucose tolerance test and gestational diabetes.

Kilograms (kg).

OGTT: oral glucose tolerance test.

Milligrams per deciliter (mg/dL).

Other maternal and neonatal outcomes

Other outcomes of interest analyzed in the study are presented in Table 3 . Among maternal outcomes, no differences were found for gestational age, number of preterm deliveries or mode of delivery. In regards to newborn outcomes, no differences were found for birthweight between study groups. Our results showed that, although the χ 2 test was not significant, the ratio of neonate macrosomia was slightly higher in the CG than in the EG (7.2% vs 3.4% respectively; odds ratio, 0.456; 95% confidence interval, 0.191–1.087).

Other maternal and newborn outcomes.

The aim of the present study was to examine whether regular and supervised physical exercise during pregnancy can influence prevention of excessive maternal weight gain, and GDM, which are both closely related factors. Similar to our previous work, the main strength of the current study is the combination of light resistance, toning, aerobic dance, coordination, stretching and pelvic floor muscle training in the same program throughout pregnancy and examining the resultant effects on outcomes. The main finding of this study is that the exercise program reduced the total (mean) maternal weight gain as well as the cases of excessive weight gain and GDM.

Our results are relevant from a clinical and health care point of view due to the increasing prevalence of these two parameters in recent years, in parallel with the alarming rise of worldwide overweight and obesity. 11 , 12 Furthermore the interpretation of our results promote the use of moderate and supervised physical exercise throughout pregnancy as a method to increase prevention of pregnancy complications and improve quality of life for pregnant women without adverse effects on maternal and fetal well-being.

Regarding the external validity and generalizability of our findings the high adherence (≥80% attendance) of this large RCT for all pre-pregnancy BMI categories strongly supports the extension of the present results to the healthy pregnant population.

In regards to the newborn health outcomes, although birth weight was similar in neonates between the CG and the EG, the percentage of newborns with macrosomia was lower in the EG. We had previously observed 37 , 38 this effect, and therefore this study provides additional evidence that physical exercise may improve perinatal outcomes by preventing excessive accumulation of weight during fetal development.

Other authors have previously investigated the impact of prenatal exercise on excessive gestational weight gain and GDM. 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 Among the great variety of study designs used, RCTs are the most reliable as they allow management of independent variables (exercise program design). Current literature available on RCTs includes a great variety of exercise programs used. It might explain the difficulty in determining the exact type and frequency of exercise during pregnancy that is required to prevent and treat GDM.

From a methodological point of view the more adaptive/desirable outcomes are reported by those studies in which a supervised intervention (exercise program) including a large variety of exercises (aerobic, resistance, pelvic floor and muscle strengthening, stretching, etc.) have been provided throughout the pregnancy. 46 , 47 , 48 , 49 , 50 , 51

Regardless of the variability among exercise interventions, most researchers agree that prenatal exercise is an excellent way for controlling maternal weight gain during pregnancy. Our results are in consensus with many authors, 43 , 44 , 45 , 46 and with our previous studies on this health outcome. 47 , 48

However, as we mentioned previously the relationship between exercise and GDM has been unclear. While some evidence suggests a high efficacy in the use of exercise as a preventive method, 49 , 50 , 51 literature has been inconsistent on the effect of prenatal exercise when used as a treatment method for reducing risk factors for GDM. 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 Differences in exercise programs may explain this. In our opinion the variance in the duration of the programs, length of the sessions, adherence and especially the type of exercises used, contribute to the differences observed in the results of studies.

Strengths and limitations

The major strengths of our study include the large number of participants in this RCT, the high adherence to intervention (>80% attendance) and the identification of those women in the CG who did not remain sedentary. In our opinion, the present results provide healthcare practitioners with evidence-based information that can be used to recommend supervised physical exercise throughout pregnancy to maintain or improve the quality of life of pregnant women including labor and birth.

One limitation of the current study was that nutrition or energy intake was not assessed, however, all pregnant women had (by their obstetricians and midwives) standard care which included regular information about a healthy lifestyle during pregnancy including nutrition information. Therefore the supervised exercise program was the only difference between study groups. In addition, we found differences between the study groups for parity and educational level of participants which could potentially influence the results.

The impracticality of instituting this type of a supervised activity program for pregnant women on a mass scale may be another potential limitation of the present study. Furthermore, our study focused on a Spanish population and was conducted in two tertiary care hospitals in Madrid, which may lower the external validity of our findings.

We conclude that a supervised physical exercise program initiated early and maintained throughout pregnancy can reduce the risk of excessive maternal weight gain and GDM.

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgements

The authors would like to acknowledge the technical assistance of the Gynecology and Obstetrics Department of “Hospital Severo Ochoa” and the health practitioners of Centro de Salud Los Pedroches, Centro de Salud Leganés Norte, Madrid, Spain.

The authors also would like to acknowledge the technical assistance for the English revision to Taniya Singh Nagpal from University of Western Ontario (Canada).

This paper is part of a Special Issue on Women's Health Physical Therapy.

Trial Identifier: NCT02109588 . https://clinicaltrials.gov/ct2/show/NCT02109588

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Exercise in Pregnancy

A Clinical Review

Sally K Hinman , MD, PhD

Kristy b smith , md, david m quillen , md, m seth smith , md, pharmd.

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Sally K. Hinman, MD, PhD, Department of Community Health and Family Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609 (email: [email protected] ).

Issue date 2015 Nov.

Health professionals who care for pregnant women should discuss potential health benefits and harms of exercise. Although most pregnant women do not meet minimal exercise recommendations, there are a growing number of physically active women who wish to continue training throughout pregnancy.

Evidence Acquisition:

A search of the Web of Science database of articles and reviews available in English through 2014. The search terms exercise pregnancy, strenuous exercise pregnancy , and vigorous exercise pregnancy were used.

Study Design:

Clinical review.

Level of Evidence:

With proper attention to risk stratification and surveillance, exercise is safe for the mother and fetus. Benefits of exercise in pregnancy include reduction in Cesarean section rates, appropriate maternal and fetal weight gain, and managing gestational diabetes. Exercise as a means of preventing gestational diabetes, preeclampsia, or perinatal depression cannot be reliably supported. Overall, the current evidence suffers from a lack of rigorous study design and compliance with physical activity interventions.

Conclusion:

Research thus far has been unable to consistently demonstrate proposed benefits of exercise in pregnancy, such as preventing gestational diabetes, preeclampsia, or perinatal depression. However, moderate- and high-intensity exercise in normal pregnancies is safe for the developing fetus and clearly has several important benefits. Thus, exercise should be encouraged according to the woman’s preconception physical activity level.

Keywords: pregnancy, exercise, strenuous, review

Historically, pregnant women were considered vulnerable and were advised to reduce their level of activity. 28 In 2002, the American College of Obstetricians and Gynecologists (ACOG) updated their recommendations for exercise during pregnancy to be less restrictive 1 ; these recommendations were reaffirmed by the ACOG in 2009. However, a survey of physicians found that more than 60% of physicians were not familiar with the current ACOG guidelines for exercise during pregnancy. 9 Although limited by a small sample size that included physicians in both obstetrics and gynecology and family medicine in 1 geographic region, this study highlights the deficiency in knowledge regarding this subject. 9

In general, exercise reduces the morbidity and mortality associated with cardiovascular disease, hypertension, and type 2 diabetes mellitus among other chronic diseases. 39 Nevertheless, only 20.3% of American adults meet weekly exercise recommendations. 40 Similarly, compliance with physical activity guidelines is low both prior to and during pregnancy. 3 Additionally, studies have consistently shown that women tend to decrease their physical activity during pregnancy. 3 , 24 , 30 Since pregnancy itself is a life-changing event for many women, it is also a time when other lifestyle changes may be enacted, such as smoking cessation, adopting a healthy diet, or beginning routine exercise. Additionally, as female participation in sports increases, 45 the safety of training during pregnancy has become an important issue.

Effects of Exercise on Maternal and Fetal Health in Pregnancy

Exercise offers potential benefits to both maternal and fetal health. 5 , 6 , 17 , 18 , 21 , 25 - 27 , 32 , 35 , 36 , 38 , 42 , 52 , 54

Gestational Diabetes Mellitus

In parallel to its effect on the incidence of type 2 diabetes mellitus, regular exercise should also decrease the risk of gestational diabetes mellitus. 21 However, several review articles have concluded that there is insufficient evidence to support physical activity as an effective intervention to decrease the risk of developing gestational diabetes. 29 , 48 , 53 Poor compliance to exercise regimens may have contributed to the lack of significance. 48 Nevertheless, multiple studies have shown significantly lower glucose levels on the 24- to 28-week oral glucose tolerance test in physically active women. 5 , 18 Although physical activity may not prevent the development of gestational diabetes, it may help manage it. The majority of studies using exercise as an intervention to treat gestational diabetes mellitus were successful. 48 Women diagnosed with gestational diabetes at 24 to 34 weeks of pregnancy who performed resistance exercise were less likely to require insulin during the remainder of their pregnancy as compared with women with gestational diabetes in the control group. 17 Additionally, exercise modulates maternal weight gain in pregnancy 27 and reduces the risk of large-for–gestational age newborns, 32 , 42 , 52 which are concerns with gestational diabetes.

Hypertension and Preeclampsia

Hypertension and preeclampsia are significant sources of morbidity and mortality in pregnancy. 46 Although physical activity is known to be helpful in preventing cardiovascular disease, a similar association between physical activity in pregnancy and hypertension or preeclampsia has not been definitively shown. Data reported from the North Carolina Pregnancy Risk Assessment Monitoring System indicate that gestational hypertensive complications are less likely in women who are physically active before and during pregnancy. 38 Conversely, an increased risk of developing preeclampsia was shown with greater than 270 minutes of exercise per week in a prospective cohort study of 85,139 pregnant Danish women. 41 A 2012 review of randomized control, cohort, and case-control studies suggests that there is a trend toward a preventive effect of physical activity on the development of preeclampsia. 36 However, there were a dearth of studies, and the evaluation of the few studies was complicated by differing methodologies, including the quantification of physical activity and the diagnosis of preeclampsia.

Maternal-Fetal Circulation and Fetal Growth

There is theoretical concern that exercise may negatively impact the developing fetus in terms of hemodynamics and growth. 7 , 20 , 27 However, this is unsubstantiated in the current literature. Multiple studies have shown that blood flow to the fetus is not significantly altered by moderate-intensity physical activity. 7 , 20 , 23 , 50 Interestingly, an increase in total vascular volume, capillary surface area, and parenchymal density was demonstrated in the placentas of women delivering at term who had exercised during the first half or all of their pregnancy. 31 Overall, birth weight was not significantly different between physically active women and inactive women. 20 , 32 , 50 , 52 Additionally, several studies have demonstrated that women who were physically active had a decreased risk of having babies that were large for gestational age. 32 , 42 , 52 Although additional studies would be beneficial, research thus far indicates that physical activity is safe for the developing fetus.

Labor and Delivery

Regular exercise may shorten the duration of labor and reduce the risk of Cesarean section and operative-assisted vaginal delivery. 6 , 35 Improved tone of abdominal and pelvic floor musculature and aerobic fitness may be important factors. Evidence-based support for this is limited, 6 , 35 as there are few contradictory results. 8 Women who participated in an exercise program throughout their pregnancies had a lower percentage of Cesarean section and instrumental vaginal deliveries compared with a control group. 6 This was in contrast to an earlier randomized controlled trial showing that there was no significant difference in Cesarean section and instrumental vaginal deliveries for women participating in an exercise program compared with a control group. 8 However, the exercise program was only from weeks 20 to 36 of gestation compared with weeks 6 to 39 in the later study. In another study, aerobic fitness was tested only in nulliparous women, which can affect labor duration, and a higher maximal oxygen consumption (VO 2 max) as a measure of aerobic fitness was associated with an approximately 30-minute shorter labor duration. 35

Perinatal Depression

Since exercise is associated with fewer depressive symptoms in adults with clinical depression, 37 it has also been hypothesized that exercise would alleviate symptoms of depression during pregnancy 19 , 25 , 26 , 47 and postpartum. 16 Although several studies report a decrease in depressive symptoms on questionnaires in women who are physically active, 19 , 25 , 26 , 47 the findings are not consistent. One study showed that pregnant women who were exercising 1 to 2 times per week, but not 3 times or more per week, were less likely to report depression, 26 while another study reported decreased depression in pregnant women who exercised 4 times or more per week but not less than 4 times per week. 25 Additionally, it is not clear whether the lower depression scores reported are clinically significant. 47 A meta-analysis of 5 randomized controlled trials concluded that there is insufficient evidence to determine whether exercise reduces symptoms of postpartum depression. 16

Guidelines for Weight Gain in Pregnancy

Weight gain is tracked throughout pregnancy as it has important ramifications on both maternal and fetal health. Excessive weight gain is associated with gestational diabetes, preeclampsia, and postpartum weight retention. 27 In 2013, the ACOG endorsed the Institute of Medicine’s weight gain goals during pregnancy based on a woman’s body mass index (BMI) at her first prenatal visit. 2 According to these recommendations, women with a normal BMI (18.5-24.9 kg/m 2 ) should gain 25 to 35 pounds whereas overweight (BMI 25-29.9 kg/m 2 ) and obese (BMI >30 kg/m 2 ) women should aim to gain 15 to 25 pounds and 11 to 20 pounds, respectively. 2 In 1 study, approximately 40% of normal-weight women and 60% of overweight women gained more weight than the upper limit of the respective range recommended by the Institute of Medicine. 14 Exercise can help manage weight gain during pregnancy. Women who attended all 24 supervised exercise sessions during a 12-week program stayed within the Institute of Medicine’s weight gain guidelines compared with 62% of the control group. 27 Overall, the compliant members of the exercise group had significantly less weight gain and postpartum weight retention compared with the control group. 27

Guidelines for Exercise in Pregnancy

The ACOG reaffirmed their 2002 committee opinion on exercise in pregnancy in 2009. 1 Based on these recommendations, women who are currently physically active can continue exercising while those who are physically inactive are encouraged to start exercising. 1 The American College of Sports Medicine’s (ACSM) physical activity guidelines calling for “30 minutes or more of moderate exercise . . . on most, if not all, days of the week” is advised for normal pregnancies. 1 Sixteen percent of pregnant women meet these recommendations; for comparison, only 26% of nonpregnant women comply with the ACSM physical activity recommendations. 44 Additionally, pregnant women should be cautioned to avoid exercise in the supine position after the first trimester and exercise involving prolonged standing due to significant decreases in cardiac output 15 ; exercise with a high risk of contact, falling, or abdominal trauma due to the risk of injury to the mother or the fetus 4 ; exercise at altitudes greater than 5250 feet due to concerns for fetal hypoxemia 22 ; and scuba diving due to the risk of the fetus developing decompression sickness. 1 , 12 Table 1 provides a summary of the exercise guidelines.

Summary of guidelines for exercise during pregnancy a

These guidelines apply to uncomplicated pregnancies. Please see text for the absolute and relative contraindications to exercise in pregnancy.

Exercise Prescription

Before advising the initiation or continuation of physical activity during pregnancy, a physician must assess the woman’s risk level. Healthy women without contraindications to exercise are considered low risk regardless of their previous activity level, whereas women with certain chronic medical conditions, including cardiovascular, respiratory, and systemic diseases, or relative contraindications are considered high risk. 10 , 13 Familiarity with absolute and relative contraindications to exercise is thus important for both the physician and patient. Absolute contraindications include gestational hypertension, preeclampsia, ruptured membranes, incompetent cervix, bleeding in the second or third trimester, multiple gestation at risk for premature labor, placenta previa, and premature labor. 1 Relative contraindications include intrauterine growth restriction, extremes of weight, and poorly controlled medical comorbidities, such as type 1 diabetes mellitus, hypertension, seizure disorder, and thyroid disease. 1 Pregnant women should also stop exercising based on signs and symptoms that may develop ( Table 1 ). 1 , 54

The frequency, intensity, type, and time duration (FITT) should be outlined according to her physical activity state prior to pregnancy. The PARmed-X for pregnancy is a set of guidelines developed in Canada to help health practitioners evaluate a pregnant woman’s ability to safely engage in physical activity as well as prescribe a basic exercise regimen. 43

Physical Training in Pregnancy

With more women competing in sports, strenuous exercise in pregnancy has become an important topic to those who wish to continue training during pregnancy. According to the ACOG, the main concerns in this population are the effect of pregnancy on competing and the effect of training on the pregnancy. 1 Continuing high-intensity exercise throughout pregnancy significantly increased the participants’ VO 2 max from week 17 gestation to 12 weeks postpartum 34 ; this training regimen of muscle strengthening, aerobic exercise, and endurance exercise could be used to guide exercise prescription for physically active women.

Although there are limited studies that examine the safety of high-intensity physical activity on the fetus, the results are mostly reassuring. 33 , 50 , 51 There was a decreased risk of preterm birth with increased frequency of first trimester vigorous recreational physical activity, and birth weight was not significantly affected by this level of physical activity. 33 Women classified as nonexercisers, moderately active, or vigorously active based on their physical activity 6 months prior to pregnancy performed a moderate-intensity exercise test during the second trimester. 50 As postexercise biophysical profiles were normal and there were no significant differences among the groups in APGAR scores or birth weights, this study suggests that physically inactive women can safely start moderate-intensity exercise while physically active women can continue or increase their activity to vigorous-intensity exercise during pregnancy. Additionally, the 3 groups of women performed a peak exercise test to detect the effect of strenuous physical activity on fetal well-being. 51 Again, biophysical profiles were ultimately reassuring in all groups. Notably, in 5 vigorously active women, there were transient fetal heart rate decelerations as well as altered uterine blood flow immediately after exercise, which raises concerns of reduced blood flow to the uterus with strenuous exercise. Similarly, in a small study of 6 pregnant Olympic-level endurance athletes, maternal-fetal circulation during and after exercise 49 showed that vigorous exercise, where the maternal heart rate was greater than 90% of the maximum, was associated with decreased uterine artery blood flow and fetal bradycardia that resolved soon after exercise was stopped. 11 , 51 Thus, even though there may be fetal cardiovascular changes associated with high-intensity exercise, they do not appear to significantly affect neonatal outcomes; however, there is cause for concern.

For women without contraindications to physical activity, exercise is safe for both the woman and developing fetus. Although there is no conclusive evidence that exercise effectively prevents gestational diabetes mellitus, preeclampsia, or perinatal depression, it does appear to have beneficial effects on reducing glucose levels, the risk of Cesarean section or instrumental vaginal deliveries, and maternal weight gain. In general, women who are physically active prior to pregnancy should be advised to maintain, and counseled that they can increase, their level of activity if desired, while physically inactive women should be encouraged to begin exercising.

The authors report no potential conflicts of interest in the development and publication of this article.

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Physical exercise during pregnancy: a systematic review

Affiliation.

• 1 Obstetric Unit, Department of Obstetrics and Gynecology, University of Campinas, Campinas, Sao Paulo, Brazil. [email protected]
• PMID: 23014142
• DOI: 10.1097/GCO.0b013e328359f131

Purpose of review: This review aims to provide an update on the recent evidence concerning exercise during pregnancy including effects for mother and fetus and the types, frequency, intensity, duration and rate of progression of exercise performed.

Recent findings: Exercises during pregnancy are associated with higher cardiorespiratory fitness, prevention of urinary incontinence and low back pain, reduced symptoms of depression, gestational weight gain control, and for cases of gestational diabetes, reduced number of women who required insulin. There is no association with reduction in birth weight or preterm birth rate. The type of exercise shows no difference on results, and its intensity should be mild or moderate for previous sedentary women and moderate to high for active women. The exercise recommendations still are based on the current guidelines on moderate-intensity, low-impact, aerobic exercise at least three times a week. Yet, new guidelines propose increasing weekly physical-activity expenditure while incorporating vigorous exercise and adding light strength training to the exercise routine of healthy pregnant women. In the case of other chronic diseases like hypertension, there are still few data, and therefore more studies should be performed to assess the safety of the intervention.

Summary: Physical exercise is beneficial for women during pregnancy and also in the postpartum period; it is not associated with risks for the newborn and can lead to changes in lifestyle that imply long-term benefits.

Publication types

• Systematic Review
• Delivery, Obstetric
• Exercise / physiology*
• Fetal Development
• Guidelines as Topic
• Labor, Obstetric / physiology
• Pregnancy / physiology*
• Pregnancy Outcome