Exercise In Pregnancy1

1,648 views
1,504 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,648
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
103
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Exercise In Pregnancy1

    1. 1. Exercise in Pregnancy Jennifer Hale, M.D. Valley Baptist Family Practice Residency
    2. 2. Objectives <ul><li>Discuss risks and benefits of exercise for both mother and baby </li></ul><ul><li>Describe physiologic adaptations to exercise during pregnancy </li></ul><ul><li>Review absolute and relative contraindications to exercise during pregnancy </li></ul><ul><li>Prescribe an individualized exercise program for a pregnant athlete </li></ul><ul><li>Practice what we preach ! </li></ul>
    3. 3. <ul><li>“ We are all athletes…some of us are in training, and some of us are not” </li></ul>
    4. 5. Historical Perspective <ul><li>“ The midwives answered Pharaoh, ‘Hebrew women are not like Egyptian women; they are vigorous and give birth before the midwives arrive.’” </li></ul><ul><li>Exodus 1:19 </li></ul>
    5. 6. Fun Facts <ul><li>↑ HDL, ↓ triglycerides </li></ul><ul><li>↓ blood pressure </li></ul><ul><li>Improved endothelial function </li></ul><ul><li>Improved glycemic control </li></ul><ul><li>↓ risk of CAD </li></ul><ul><li>↑ longevity </li></ul><ul><li>↓ cancer risk </li></ul><ul><li>↓ proinflammatory cytokines </li></ul><ul><li>↓ oxidative stress </li></ul><ul><li>Improved psychological well-being </li></ul>
    6. 7. Continued… <ul><li>↑ energy </li></ul><ul><li>↓ weight gain </li></ul><ul><li>↑ strength/endurance </li></ul><ul><li>↓ back pain </li></ul><ul><li>Improved sleep </li></ul><ul><li>Improved sense of well-being </li></ul><ul><li>↓ risk GDM </li></ul><ul><li>↓ risk pre-eclampsia </li></ul>
    7. 8. Continued… <ul><li>CDC and ACSM Recommendations: </li></ul><ul><li>30-60min moderate-intensity physical activity “on most—preferably all—days of the week” </li></ul><ul><li>At least 60min to prevent weight gain, increase fitness, achieve full health benefits </li></ul>
    8. 9. (Not So) Fun Facts <ul><li>Less than 25% pregnant women exercise regularly </li></ul><ul><li>40-60% are completely inactive during pregnancy </li></ul><ul><li>Pregnancy seen as “confinement” </li></ul><ul><li>Non-white women 50% less likely to exercise </li></ul><ul><li>Rest/relaxation seen as more important </li></ul><ul><li>Most women decrease or stop all exercise while pregnant </li></ul>
    9. 10. ACOG Guidelines (1985) <ul><li>Overly conservative </li></ul><ul><li>HR <140bpm </li></ul><ul><li>No exercise over moderate intensity </li></ul><ul><li>No longer than 15min </li></ul><ul><li>Avoid valsalva (weight lifting) </li></ul><ul><li>No exercise in supine position after 1 st trimester </li></ul>
    10. 11. Where We’ve Come From <ul><li>Zahereiva et al. </li></ul><ul><li>From 1952-1972 </li></ul><ul><li>-27% female athletes competing consecutively gave birth between Olympic games </li></ul><ul><li>-most report feeling ‘more fit’ after childbirth </li></ul><ul><li> </li></ul><ul><li>“ They became stronger, had greater stamina and were more balanced in every way after having a child.” </li></ul>
    11. 12. Physiologic Adaptations during Pregnancy and Exercise <ul><li>Cardiovascular </li></ul><ul><li>Pulmonary </li></ul><ul><li>Thermoregulatory Control </li></ul><ul><li>Musculoskeletal </li></ul>
    12. 13. Cardiovascular <ul><li>Rest </li></ul><ul><li>↑ plasma volume </li></ul><ul><li>↑ baseline heart rate </li></ul><ul><li>↑ cardiac output </li></ul><ul><li>↑ stroke volume </li></ul><ul><li>↓ systemic vascular resistance </li></ul><ul><li>Exercise </li></ul><ul><li>↓ BP </li></ul><ul><li>↓ vagal tone as pregnancy advances </li></ul><ul><li>Blunted HR response to exercise </li></ul>
    13. 14. Continued… <ul><li>ACOG Recommendations: </li></ul><ul><li>Avoid exercise in supine position after 1 st trimester </li></ul><ul><li>Avoid prolonged standing </li></ul><ul><li>HR > 140 now allowed </li></ul>
    14. 15. Pulmonary <ul><li>Rest </li></ul><ul><li>↑ tidal volume </li></ul><ul><li>↑ oxygen uptake </li></ul><ul><li>↑ resting oxygen requirements </li></ul><ul><li>↑ work of breathing </li></ul><ul><li>Exercise </li></ul><ul><li>↓ oxygen available for exercise </li></ul><ul><li>↓ maximum performance </li></ul><ul><li>SOB with less exertion </li></ul>
    15. 16. Continued… <ul><li>ACOG Recommendations : </li></ul><ul><li>No specific recommendation, except… </li></ul><ul><li>Exercise intensity should be based on symptoms </li></ul>
    16. 17. Thermoregulatory Control <ul><li>Rest </li></ul><ul><li>↑ basal metabolic rate </li></ul><ul><li>↑ heat production </li></ul><ul><li>Fetal core body temp 1ºC higher </li></ul><ul><li>↑ blood supply to skin </li></ul><ul><li>Lower sweating threshold </li></ul><ul><li>Exercise </li></ul><ul><li>↑ temp related to exercise intensity </li></ul><ul><li>↑ conduction of heat to periphery </li></ul><ul><li>Moderate exercise ↑ core temp 1.5° first 30min </li></ul><ul><li>↑ teratogenic risk? </li></ul>
    17. 18. Continued… <ul><li>Clap et al. </li></ul><ul><li>- 10 recreational joggers </li></ul><ul><li>- core body temp measured during moderate intensity exercise </li></ul><ul><li>- pre-pregnancy, 20 and 32wks </li></ul><ul><li>Results: </li></ul><ul><li>- increase in core body temp, but less so in pregnancy (1 °C lower) </li></ul><ul><li>- due to decrease in sweating threshold, etc. </li></ul><ul><li>- thus NTD not likely in humans </li></ul>
    18. 19. Continued… <ul><li>ACOG Recommendations : </li></ul><ul><li>Avoid hot, humid conditions, high altitudes </li></ul><ul><li>Wear appropriate clothing </li></ul><ul><li>Stay hydrated! </li></ul><ul><li>Innate physiologic protection against hyperthermia </li></ul>
    19. 20. Musculoskeletal <ul><li>Rest </li></ul><ul><li>Center of gravity up and forward </li></ul><ul><li>↑ back pain </li></ul><ul><li>↑ joint laxity </li></ul><ul><li>Weight gain </li></ul><ul><li>Exercise </li></ul><ul><li>May negatively affect balance </li></ul><ul><li>↑ force across hips/knees up to 100% in wt bearing </li></ul><ul><li>↑ fall risk? </li></ul><ul><li>↑ instability, risk for injury? </li></ul>
    20. 21. Continued… <ul><li>ACOG Recommendations : </li></ul><ul><li>No specific guidelines </li></ul><ul><li>Adjust activity based on gestational age, symptoms </li></ul><ul><li>Stretching/strengthening exercises </li></ul>
    21. 22. Exercise and Gestational Diabetes <ul><li>Improves glucose tolerance, blunts insulin response </li></ul><ul><li># hrs spent in exercise – ↓ risk of GDM </li></ul><ul><li>- Case control : 155 pts w/ GDM vs. 386 controls </li></ul><ul><li> First 20 wks — 48% reduction GDM </li></ul><ul><li>Greatest when combined w/ exercise 1yr prior </li></ul><ul><li>- ≥ 4.2 hrs/wk mod intensity exercise – ↓ 76% </li></ul><ul><li>May prevent initiation of insulin </li></ul>
    22. 23. Exercise and Pre-eclampsia <ul><li>Reduces risk (40%) </li></ul><ul><li>- inversely related to time/intensity </li></ul><ul><li>Sorensen et al. </li></ul><ul><li> 201 pre-eclamptic vs. 383 controls </li></ul><ul><li>- “any regular physical activity” first 20 wks 35% </li></ul><ul><li>- light/mod vs. vigorous 24% vs. 54% </li></ul><ul><li>- brisk walking ( ≥ 3mi/hr) 30-33% </li></ul><ul><li>- vigorous exercise year prior 60% </li></ul><ul><li>- stair climbing (1-4 flights/d) 29% </li></ul>
    23. 24. Other Benefits <ul><li>No ↑ risk of miscarriage </li></ul><ul><li>Possible ↓ risk preterm birth </li></ul><ul><li>↓ risk of cesarean section ? </li></ul><ul><li>Faster recovery post-partum </li></ul><ul><li>Labor duration ? </li></ul>
    24. 25. Effects on Infant <ul><li>Placenta larger, greater surface area </li></ul><ul><li>Does not change uterine/umbilical blood flow </li></ul><ul><li>FHR – accelerations, mild decelerations, then baseline </li></ul><ul><li>Lower birth weight if vigorous exercise 5-6x/wk </li></ul><ul><li>Children lighter/leaner </li></ul><ul><li>Score higher on intelligence & oral language tests </li></ul>
    25. 26. Current ACOG Guidelines <ul><li>Even more liberal than previous </li></ul><ul><li>In absence of contraindications, pregnant women can follow ACSM recommendations </li></ul><ul><li>Avoid supine positions after 1 st trimester </li></ul><ul><li>No reports that hyperthermia during exercise is teratogenic </li></ul>
    26. 28. Exercise Prescription <ul><li>Where to Start: </li></ul><ul><li>- Gather information for History & Physical Exam </li></ul><ul><li>- Gestational age </li></ul><ul><li>- Goals </li></ul><ul><li>- Grade </li></ul><ul><li>- “ F I T T” </li></ul>
    27. 29. “ F I T T” <ul><li>F requency- </li></ul><ul><li> “ most days of the week” </li></ul><ul><li>I ntensity- </li></ul><ul><li>THR vs. Borg scale </li></ul><ul><li>T ype- </li></ul><ul><li>walking/biking/running/swimming </li></ul><ul><li>T ime- </li></ul><ul><li>30-90min/day </li></ul>
    28. 30. Borg Scale
    29. 31. “ F I T T” <ul><li>F requency- </li></ul><ul><li> “ most days of the week” </li></ul><ul><li>I ntensity- </li></ul><ul><li>THR vs. Borg scale </li></ul><ul><li>T ype- </li></ul><ul><li>walking/biking/running/swimming </li></ul><ul><li>T ime- </li></ul><ul><li>30-90min/day </li></ul>
    30. 32. Sample 60-90min 30-60min 30min Time Competitive activities Also run/jog dance, tennis Walk, bike, stair, swim, aerobics Type 75-85% MHR RPE- hard 65-85% MHR RPE- mod hard to hard 65-75% MHR RPE- mod hard Intensity 4-6x/wk 3-5x/wk ≥ 3x/wk Frequency Elite Recreational Sedentary
    31. 33. Continued… <ul><li>Stretching </li></ul><ul><li>- static, not ballistic </li></ul><ul><li>- hold for at least 1min </li></ul><ul><li>Weight Lifting </li></ul><ul><li>- 10-15 repetitions </li></ul><ul><li>- low weight </li></ul>
    32. 34. Nutrition <ul><li>Four F’s : </li></ul><ul><li>F ood ↑ 150cal/day 1 st - 2 nd trimester </li></ul><ul><li> ↑ 300cal/day 3 rd trimester </li></ul><ul><li>F luids ↑ 30ml/day </li></ul><ul><li>1 lb = 500cc </li></ul><ul><li>F e (Iron) </li></ul><ul><li>F olate </li></ul>
    33. 35. Contraindications <ul><li>Absolute </li></ul><ul><li>PIH/Preeclampsia </li></ul><ul><li>Ruptured membranes </li></ul><ul><li>Incompetent cervix </li></ul><ul><li>2 nd or 3 rd trimester bleeding </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Placenta previa after 26wks </li></ul><ul><li>Heart disease </li></ul><ul><li>Restrictive Lung disease </li></ul><ul><li>Premature labor </li></ul><ul><li>Relative </li></ul><ul><li>IUGR </li></ul><ul><li>Cardiac dysrhythmias </li></ul><ul><li>Severe anemia </li></ul><ul><li>Chronic bronchitis, heavy smoker </li></ul><ul><li>Poorly controlled DM, HTN, seizure d/o, thyroid dz </li></ul><ul><li>Extremes of weight </li></ul><ul><li>Orthopedic limitations </li></ul>
    34. 36. Warning Signs <ul><li>Vaginal bleeding </li></ul><ul><li>Dyspnea prior to exertion </li></ul><ul><li>Dizziness or presyncopal symptoms </li></ul><ul><li>Headache, muscle weakness </li></ul><ul><li>Chest pain, calf pain or swelling </li></ul><ul><li>Preterm labor, leakage of fluid </li></ul><ul><li>Decreased fetal movement </li></ul>
    35. 37. Breastfeeding and Exercise <ul><li>Integral role in post-partum weight loss </li></ul><ul><li>Does NOT reduce milk production </li></ul><ul><li>Increased lactate levels in breast milk after exercise </li></ul><ul><li>Breastfeed before exercise! </li></ul>
    36. 38. Return to Competition <ul><li>No specific recommendations </li></ul><ul><li>Guided by symptoms, ability to get back into training </li></ul><ul><li>Husbands play a big role </li></ul>
    37. 39. Summary <ul><li>Pregnancy is a good time to establish healthy lifestyle habits </li></ul><ul><li>Those adopted during pregnancy could affect a woman’s health for the rest of her life </li></ul><ul><li>Be aware of contraindications/warning signs </li></ul><ul><li>Almost all women can safely exercise (or begin an exercise program) during pregnancy </li></ul>
    38. 40. <ul><li>QUESTIONS? </li></ul>
    39. 41. References <ul><li>ACOG. Exercise during pregnancy and the postpartum period. Clin Obstet Gyn. 2003;46 (2): 496-499. </li></ul><ul><li>Anonymous. The benefits and risks of exercise during pregnancy. J Sci & Med in Sport. 2002; 5(1):11-19. </li></ul><ul><li>Brenner IK, Wolfe LA, Monga M, McGrath MJ. Physical conditioning effects on fetal heart rate responses to graded maternal exercise. Med Sci Sports Exerc. 1999;31(6):792-799. </li></ul><ul><li>Bungum TJ, Peaslee DL, Jackson AW, Perez MA. Exercise during pregnancy and type of delivery in nulliparae. J Obstet Gyn Neonatal Nurs. 2000; 29(3):258-264. </li></ul><ul><li>Ceysens G, Rouiller D, Boulvain M. Exercise for diabetic pregnant women. The Cochrane Database. 2006; 1. </li></ul><ul><li>Clapp JF> The changing thermal response to endurance exercise during pregnancy. Am J Obstet Gyn. 1991; 165(6):1684-1689. </li></ul><ul><li>Dempsey FC, Butler FL, Williams, FA. No need for a pregnant pause: Physical activity may reduce the occurrence of GDM and Preeclampsia. ACSM 2005; 33(3):141-149. </li></ul><ul><li>Dempsey JC, Butler CL, Sorensen TK, Lee IM, et al. A case control study of maternal recreational physical activity and risk of GDM. Diabetes Res Clin Pract. 2004;66(2):203-15. </li></ul><ul><li>Ertan A, et al. Doppler examinations of fetal and uteroplacental blood flow in AGA and IUGR fetuses before and after maternal physical exercise with the bicycle ergometer. J Perinatal Med. 2004;32(3):260-265. </li></ul><ul><li>Evenson KR et al. Vigorous Leisure Activity and pregnancy outcome. Epid. 2002; 13(6):653-659. </li></ul><ul><li>Jackson MR, Gott P, Lye SJ, Ritchie JW, Clapp JF. The effects of maternal aerobic exercise on human placental volumetric composition and surface areas. Placenta 1995; 16(2):179-91. </li></ul><ul><li>Kramer MS. Aerobic exercise for women during pregnancy. The Cochrane Database. 2002; 3. </li></ul><ul><li>Larsson L, Lindqvist PG. Low-impact exercise during pregnancy-a study of safety. Acta Obstet Gyn Scandinavica. 2005; 84(1):34. </li></ul><ul><li>Leet T, Fick L. Effect of exercise on birth weight. Clin Obstet Gyn. 2003; 46(2):423-431. </li></ul>
    40. 42. Continued… <ul><li>Magann ER, Evans SF, Weitz B, Newnham, J. Antepartum, intrapartum, and neonatal significance of exercise on healthy low-risk pregnant working women. Am Coll Obstet and Gyn. 2002; 99(3):466-472. </li></ul><ul><li>Marcoux S, Brisson J, Fabia J. The effect of leisure time physical activity on the risk of preeclampsia and gestational hypertension. J Epid Comm Hlth. 1989; 43(2):147-52. </li></ul><ul><li>O’Toole ML. Physiologic aspects of exercise in pregnancy. Clin Obstet Gyn 2003; 46(2):379-389. </li></ul><ul><li>Pivarnik JM, Perkins CD, Moyerrbrailean T. Athletes and Pregnancy. Clin Obstet Gyn 2003; 46 (2):456-466. </li></ul><ul><li>Poudevigne MS, O’connor PJ. A review of physical activity patterns in pregnant women and their relationship to psychological health. Sports Med. 2006;36(1):19-38. </li></ul><ul><li>Sorensen TK, Williams MA, Lee IM, Dashow EE, Thompson ML. Recreational physical activity during pregnancy and risk of preeclampsia. Hypertension 2003; 41(6):1273-1280. </li></ul><ul><li>Wolfe, Larry A, Davies, Gregory. Canadian Guidelines for Exercise in Pregnancy. Clin Obstet Gyn 2003; 46(2):496-499. </li></ul>

    ×