Exercise In Pregnancy1
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Exercise In Pregnancy1 Exercise In Pregnancy1 Presentation Transcript

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