Exercise During PregnancyExercise During Pregnancy
LTC Fred H. Brennan, Jr., DOLTC Fred H. Brennan, Jr., DO
Director, Tri-...
CaseCase
• 24 y.o. G1P0 presents at 9 wks EGA for 124 y.o. G1P0 presents at 9 wks EGA for 1stst
obstetrical visitobstetric...
OverviewOverview
• Physiology of ExercisePhysiology of Exercise
and Pregnancyand Pregnancy
• Risks and BenefitsRisks and B...
Useful ReferencesUseful References
• ACOG CommitteeACOG Committee. Opinion no. 267: exercise during. Opinion no. 267: exer...
Useful ReferencesUseful References
• Kelly AK. Practical exercise advice during pregnancy.Kelly AK. Practical exercise adv...
Physiologic Adaptations to
Pregnancy & Interactions
with Exercise
Physiology OverviewPhysiology Overview
• Significant physiologic changes occur inSignificant physiologic changes occur in
...
Feto-Placental Growth RegulationFeto-Placental Growth Regulation
Rate of Substrate (Glucose) Delivery to the Placental Sit...
CardiovascularCardiovascular
• Both exercise and pregnancy increase:Both exercise and pregnancy increase:
– Heart rateHear...
Cardiovascular IICardiovascular II
• Women who perform regular weight bearingWomen who perform regular weight bearing
exer...
Substrate Delivery & UtilizationSubstrate Delivery & Utilization
• Non-pregnant athleteNon-pregnant athlete
– Wt-bearing e...
Oxygen DeliveryOxygen Delivery
• Pre-pregnancy sustained exercisePre-pregnancy sustained exercise
–  oxygen delivery to ...
PulmonaryPulmonary
• Both exercise and pregnancy increaseBoth exercise and pregnancy increase
– Minute ventilationMinute v...
ThermoregulatoryThermoregulatory
• Both exercise and pregnancy increaseBoth exercise and pregnancy increase
– Metabolic ra...
Changing Thermal Response toChanging Thermal Response to
Endurance Exercise in PregnancyEndurance Exercise in Pregnancy
• ...
NeuroendocrineNeuroendocrine
• Exercise increases circulating levels ofExercise increases circulating levels of
– Norepine...
Mechanical EffectsMechanical Effects
• Altered center of gravityAltered center of gravity
– growing breast, uterusgrowing ...
Risks and Benefits
RisksRisks
• Theoretical risks:Theoretical risks:
– Hypoxemia/HypoglycemiaHypoxemia/Hypoglycemia
– Fetal teratogenesisFeta...
RisksRisks
• Theoretical risks:Theoretical risks:
– Hypoxemia/HypoglycemiaHypoxemia/Hypoglycemia
– Fetal teratogenesisFeta...
Sour Milk?Sour Milk?
• NeitherNeither quantityquantity nornor
qualityquality of breast milkof breast milk
produced appears...
BenefitsBenefits
• Improved cardiovascular fitnessImproved cardiovascular fitness
• Control of maternal weight gainControl...
Course of Labor after EnduranceCourse of Labor after Endurance
Exercise in PregnancyExercise in Pregnancy
ExerciseExercise...
Psychological Well-BeingPsychological Well-Being
• Improved moodImproved mood
• Decreased stressDecreased stress
• Improve...
Postpartum Well-BeingPostpartum Well-Being
• Improved weight lossImproved weight loss
• Improved psychological well-beingI...
Neonatal & Childhood BenefitsNeonatal & Childhood Benefits
• Clapp JF: Morphometric andClapp JF: Morphometric and
neurodev...
Preventing & Treating GDMPreventing & Treating GDM
• Exercise may be beneficial in the primaryExercise may be beneficial i...
Expert Guidance
Guidelines for Exercise in PregnancyGuidelines for Exercise in Pregnancy
• ACOG in evolutionACOG in evolution
– 19851985: ...
ACOG 2002ACOG 2002
• Recognition that regularRecognition that regular
exercise is beneficial toexercise is beneficial to
e...
Absolute ContraindicationsAbsolute Contraindications
• Hemodynamically significant heart diseaseHemodynamically significan...
Relative ContraindicationsRelative Contraindications
• Severe anemiaSevere anemia
• Unevaluated maternal cardiacUnevaluate...
ACOG 2002ACOG 2002
• Acknowledges the potential of exercise toAcknowledges the potential of exercise to
prevent & treat ge...
ACOG & SafetyACOG & Safety
• Safety of each sport determined by the “specificSafety of each sport determined by the “speci...
Higher Risk ActivitiesHigher Risk Activities
• Contact sports with riskContact sports with risk
of abdominal traumaof abdo...
Warning Signs to TerminateWarning Signs to Terminate
ExerciseExercise
• Vaginal bleedingVaginal bleeding
• Dyspnea prior t...
Postpartum ExercisePostpartum Exercise
• ““Prepregancy exercise routines may be resumedPrepregancy exercise routines may b...
Advising the Pregnant AthleteAdvising the Pregnant Athlete
• Will her athletic performance suffer?Will her athletic perfor...
Orthopedic Considerations
for the Pregnant Athlete
Orthopedic ConcernsOrthopedic Concerns
• No injury pattern hasNo injury pattern has
been definitely associatedbeen definit...
Common Orthopedic ConditionsCommon Orthopedic Conditions
• Low back painLow back pain
Common Orthopedic ConditionsCommon Orthopedic Conditions
• Low back painLow back pain
• Pelvic/hip painPelvic/hip pain
Common Orthopedic ConditionsCommon Orthopedic Conditions
• Low back painLow back pain
• Pelvic/hip painPelvic/hip pain
• P...
Common Orthopedic ConditionsCommon Orthopedic Conditions
• Low back painLow back pain
• Pelvic/hip painPelvic/hip pain
• P...
Common Orthopedic ConditionsCommon Orthopedic Conditions
• Low back painLow back pain
• Pelvic/hip painPelvic/hip pain
• P...
Exercise PrescriptionExercise Prescription
• Goal: Maintain maternalGoal: Maintain maternal
fitness levels and minimizefit...
NutritionNutrition
• Energy intake needs toEnergy intake needs to
be sufficient to meetbe sufficient to meet
energy expend...
Practical AdvicePractical Advice
Practical AdvicePractical Advice
• Begin discussions at the first visitBegin discussions at the first visit
• Structure ea...
More Practical AdviceMore Practical Advice
• Assure adequateAssure adequate
hydration and calories tohydration and calorie...
ACOG & the Competitive AthleteACOG & the Competitive Athlete
• First opinion statement to acknowledge theFirst opinion sta...
NCAA & PregnancyNCAA & Pregnancy
• Guideline published 2002Guideline published 2002
• Acknowledges lack of research addres...
College athlete dilemmasCollege athlete dilemmas
• Athletes required to notify athletic departmentAthletes required to not...
College athlete dilemmasCollege athlete dilemmas
• Athletes may:Athletes may:
– Hide pregnancyHide pregnancy
– Drop out of...
Take Home PointsTake Home Points
• Healthy women should be encouraged toHealthy women should be encouraged to
exercise bef...
Questions?
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  • Resting energy increased: why? Metabolic demands of the uteroplacental unit plus the increased maternal body weight;
    Most women appreciate a subjective increase in workload and a decline in maximal exercise performance.
  • Exercise and Pregnancy - Slide 1

    1. 1. Exercise During PregnancyExercise During Pregnancy LTC Fred H. Brennan, Jr., DOLTC Fred H. Brennan, Jr., DO Director, Tri-Service Primary Care Sports Medicine FellowshipDirector, Tri-Service Primary Care Sports Medicine Fellowship Uniformed Services University of the Health SciencesUniformed Services University of the Health Sciences Bethesda, MarylandBethesda, Maryland
    2. 2. CaseCase • 24 y.o. G1P0 presents at 9 wks EGA for 124 y.o. G1P0 presents at 9 wks EGA for 1stst obstetrical visitobstetrical visit • Competes routinely in triathlons and road racesCompetes routinely in triathlons and road races • Curious about the benefits & risk of continuingCurious about the benefits & risk of continuing to train & possibly competing while pregnantto train & possibly competing while pregnant • Will her performance suffer?Will her performance suffer? • Will she put her baby at risk?Will she put her baby at risk? • Can she exercise & breastfeed in the future?Can she exercise & breastfeed in the future?
    3. 3. OverviewOverview • Physiology of ExercisePhysiology of Exercise and Pregnancyand Pregnancy • Risks and BenefitsRisks and Benefits • Guidelines for ExerciseGuidelines for Exercise in Pregnancyin Pregnancy • The Pregnant AthleteThe Pregnant Athlete • Injury PatternsInjury Patterns • Exercise PrescriptionExercise Prescription • College athleteCollege athlete
    4. 4. Useful ReferencesUseful References • ACOG CommitteeACOG Committee. Opinion no. 267: exercise during. Opinion no. 267: exercise during pregnancy and the postpartum period.pregnancy and the postpartum period. Obstet GynecolObstet Gynecol 2002;2002;9999:171–3:171–3 • Artal RArtal R. Exercise during pregnancy. Safe and beneficial. Exercise during pregnancy. Safe and beneficial for most.for most. Phys and Sports MedPhys and Sports Med 1999;1999;2727:51–60:51–60 • www.casmacms.org/PositionStatements/PregnancyEnwww.casmacms.org/PositionStatements/PregnancyEn g.pdfg.pdf
    5. 5. Useful ReferencesUseful References • Kelly AK. Practical exercise advice during pregnancy.Kelly AK. Practical exercise advice during pregnancy. Guidelines for active and inactive women.Guidelines for active and inactive women. Phys andPhys and Sports Med JuneSports Med June 2005;33(6)2005;33(6) • Davies GA. Joint SOGC/CSEP clinical practiceDavies GA. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartumguideline: exercise in pregnancy and the postpartum period.period. Can J Appl PhysiolCan J Appl Physiol 2003; 28(3): 330-412003; 28(3): 330-41 • Morris SN. Exercise during pregnancy: a criticalMorris SN. Exercise during pregnancy: a critical appraisal of the literature.appraisal of the literature. J Reprod MedJ Reprod Med 2005; 50(3):181-82005; 50(3):181-8
    6. 6. Physiologic Adaptations to Pregnancy & Interactions with Exercise
    7. 7. Physiology OverviewPhysiology Overview • Significant physiologic changes occur inSignificant physiologic changes occur in pregnancypregnancy • Objective data on the impact of exercise on theObjective data on the impact of exercise on the mother, fetus, and course of pregnancy aremother, fetus, and course of pregnancy are limitedlimited • Theoretical concerns must be understood toTheoretical concerns must be understood to allow physicians to advise women who wish toallow physicians to advise women who wish to exercise in pregnancyexercise in pregnancy
    8. 8. Feto-Placental Growth RegulationFeto-Placental Growth Regulation Rate of Substrate (Glucose) Delivery to the Placental Site = Glucose Concentration x Blood Flow Tonic Release of Placental Growth Suppressive Peptides into Fetal Circulation Production of Insulin-like growth factors (IGF) & IGF Binding Proteins by liver and at a tissue specific level Rate of Feto-Placental Growth at a Tissue-Specific Level
    9. 9. CardiovascularCardiovascular • Both exercise and pregnancy increase:Both exercise and pregnancy increase: – Heart rateHeart rate – Stroke volumeStroke volume – Cardiac outputCardiac output • Theoretical risk:Theoretical risk: Competing effects on regional bloodCompeting effects on regional blood flow distributionflow distribution – Exercise decreases splanchnic blood flowExercise decreases splanchnic blood flow – In pregnancy, flow preferentially shunted to uterine, renal &In pregnancy, flow preferentially shunted to uterine, renal & cutaneous circulationscutaneous circulations – Both glucose and oxygen delivery to placental site is reducedBoth glucose and oxygen delivery to placental site is reduced
    10. 10. Cardiovascular IICardiovascular II • Women who perform regular weight bearingWomen who perform regular weight bearing exerciseexercise – Augment pregnancy associated increases in plasmaAugment pregnancy associated increases in plasma volumevolume – Increase intervillous spaces blood volumeIncrease intervillous spaces blood volume – Increase placental volumeIncrease placental volume – Increase cardiac outputIncrease cardiac output • What does this suggest?What does this suggest? – Increased rate of placental blood flow at restIncreased rate of placental blood flow at rest – Increase in 24 h glucose & oxygen deliveryIncrease in 24 h glucose & oxygen delivery
    11. 11. Substrate Delivery & UtilizationSubstrate Delivery & Utilization • Non-pregnant athleteNon-pregnant athlete – Wt-bearing exercise increases glucose oxidationWt-bearing exercise increases glucose oxidation – Sympathetic response mobilizes glucose stores &Sympathetic response mobilizes glucose stores & stimulates gluconeogenesisstimulates gluconeogenesis – ResultResult: rise in glucose levels for at least the first hour: rise in glucose levels for at least the first hour • Pregnant athletePregnant athlete – Sympathetic response bluntedSympathetic response blunted – Glucose oxidation & lipogenesis are increasedGlucose oxidation & lipogenesis are increased – ResultResult: fall in glucose levels during & after exercise: fall in glucose levels during & after exercise
    12. 12. Oxygen DeliveryOxygen Delivery • Pre-pregnancy sustained exercisePre-pregnancy sustained exercise –  oxygen delivery to muscles & skinoxygen delivery to muscles & skin –  oxygen delivery to most visceraoxygen delivery to most viscera • During pregnancy oxygen delivery during exerciseDuring pregnancy oxygen delivery during exercise appears to be maintained byappears to be maintained by – Maternal hemoconcentrationMaternal hemoconcentration – Improved perfusion-perfusion balance at the placentalImproved perfusion-perfusion balance at the placental interphaseinterphase – ConclusionConclusion: No evidence for compromised O: No evidence for compromised O22 deliverydelivery
    13. 13. PulmonaryPulmonary • Both exercise and pregnancy increaseBoth exercise and pregnancy increase – Minute ventilationMinute ventilation – Oxygen consumptionOxygen consumption • During pregnancyDuring pregnancy – Resting energy expenditure is increasedResting energy expenditure is increased – Augmented work of breathing during exerciseAugmented work of breathing during exercise – ResultResult: exercise requires higher VO: exercise requires higher VO22 (oxygen uptake)(oxygen uptake) compared with that required in a nonpregnancy statecompared with that required in a nonpregnancy state • VOVO22 max decreases because body weight increases withmax decreases because body weight increases with pregnancypregnancy
    14. 14. ThermoregulatoryThermoregulatory • Both exercise and pregnancy increaseBoth exercise and pregnancy increase – Metabolic rateMetabolic rate – Increased heat productionIncreased heat production • Theoretical concerns:Theoretical concerns: – Elevation in maternal core temperature due to exercise couldElevation in maternal core temperature due to exercise could reduce fetal heat dissipationreduce fetal heat dissipation – Possible teratogenic effect at temp>102.6Possible teratogenic effect at temp>102.6 • Healthy, fit pregnant women have been shownHealthy, fit pregnant women have been shown to tolerate thermal stressto tolerate thermal stress
    15. 15. Changing Thermal Response toChanging Thermal Response to Endurance Exercise in PregnancyEndurance Exercise in Pregnancy • 18 well-trained recreational athletes18 well-trained recreational athletes • 20 minutes of cycling at room temperature &20 minutes of cycling at room temperature & 60-65% VO60-65% VO22 maxmax • Maximum core temperature achieved duringMaximum core temperature achieved during cycling decreased throughout gestationcycling decreased throughout gestation • Appear to be related to a decrease rectalAppear to be related to a decrease rectal temperature at rest & increased sweatingtemperature at rest & increased sweating Am J Obstet Gynecol. 1991; 165;: 1684-9.
    16. 16. NeuroendocrineNeuroendocrine • Exercise increases circulating levels ofExercise increases circulating levels of – NorepinephrineNorepinephrine – EpinephrineEpinephrine • Theoretical concernsTheoretical concerns: excess catecholamines: excess catecholamines and prostanglandins will result in contractions &and prostanglandins will result in contractions & preterm laborpreterm labor
    17. 17. Mechanical EffectsMechanical Effects • Altered center of gravityAltered center of gravity – growing breast, uterusgrowing breast, uterus and fetusand fetus – increased lumbar lordosisincreased lumbar lordosis • Increased risk of fallIncreased risk of fall • Increased joint laxityIncreased joint laxity – Theoretic increased riskTheoretic increased risk for strains/sprainsfor strains/sprains
    18. 18. Risks and Benefits
    19. 19. RisksRisks • Theoretical risks:Theoretical risks: – Hypoxemia/HypoglycemiaHypoxemia/Hypoglycemia – Fetal teratogenesisFetal teratogenesis – Preterm laborPreterm labor – Low birth weightsLow birth weights – Sprains/strainsSprains/strains
    20. 20. RisksRisks • Theoretical risks:Theoretical risks: – Hypoxemia/HypoglycemiaHypoxemia/Hypoglycemia – Fetal teratogenesisFetal teratogenesis – Preterm laborPreterm labor – Low birth weightsLow birth weights – Sprains/strainsSprains/strains • Negative outcomes haveNegative outcomes have notnot been identified:been identified: – SABSAB – Pregnancy complicationsPregnancy complications – PTL/preterm birthPTL/preterm birth – Altered birth weightAltered birth weight – Higher injury ratesHigher injury rates
    21. 21. Sour Milk?Sour Milk? • NeitherNeither quantityquantity nornor qualityquality of breast milkof breast milk produced appears to beproduced appears to be affected by moderateaffected by moderate exerciseexercise
    22. 22. BenefitsBenefits • Improved cardiovascular fitnessImproved cardiovascular fitness • Control of maternal weight gainControl of maternal weight gain • Reduced subjective discomforts of pregnancyReduced subjective discomforts of pregnancy – Swelling, leg cramps, fatigue, SOBSwelling, leg cramps, fatigue, SOB • Positive influence of labor & deliveryPositive influence of labor & delivery (Clapp et al)(Clapp et al) – Decreased risk of operative or assisted deliveriesDecreased risk of operative or assisted deliveries – Shorter active laborShorter active labor – Increased fetal tolerance of laborIncreased fetal tolerance of labor • Possible reduced risk of preeclampsia, GDMPossible reduced risk of preeclampsia, GDM
    23. 23. Course of Labor after EnduranceCourse of Labor after Endurance Exercise in PregnancyExercise in Pregnancy ExerciseExercise (n=87)(n=87) ControlControl (n=44)(n=44) Incidence of PTLIncidence of PTL 9%9% 9%9% Length of GestationLength of Gestation 277 d277 d 282 d282 d Incidence of c-sectionIncidence of c-section 6%6% 30%30% Incidence of operative vaginal deliveryIncidence of operative vaginal delivery 6%6% 20%20% Duration of laborDuration of labor 264 min264 min 382 min382 min Clinical evidence of fetal distressClinical evidence of fetal distress 26%26% 50%50% Am J Obstet Gynecol 163: 1799-1805, 1990.
    24. 24. Psychological Well-BeingPsychological Well-Being • Improved moodImproved mood • Decreased stressDecreased stress • Improved self-imageImproved self-image • Increased sense ofIncreased sense of control and relief ofcontrol and relief of tensiontension Semin Perinatol 20: 70-76, 1996.
    25. 25. Postpartum Well-BeingPostpartum Well-Being • Improved weight lossImproved weight loss • Improved psychological well-beingImproved psychological well-being • No adverse impact on breastfeeding.No adverse impact on breastfeeding.
    26. 26. Neonatal & Childhood BenefitsNeonatal & Childhood Benefits • Clapp JF: Morphometric andClapp JF: Morphometric and neurodevelopment outcomes at ageneurodevelopment outcomes at age 5 years of offspring of women who5 years of offspring of women who continued to exercise regularlycontinued to exercise regularly throughout pregnancy.throughout pregnancy. – Less body fat at birth and 5 yrsLess body fat at birth and 5 yrs – Similar motor, integrative &Similar motor, integrative & academic readiness as controlacademic readiness as control groupsgroups – Higher scores on Wechsler scalesHigher scores on Wechsler scales and tests of oral language skills.and tests of oral language skills. J. Pediatr 129: 856-863, 1996.
    27. 27. Preventing & Treating GDMPreventing & Treating GDM • Exercise may be beneficial in the primaryExercise may be beneficial in the primary prevention of GDM, especially in morbidlyprevention of GDM, especially in morbidly obese women (BMI > 33)obese women (BMI > 33) • Resistance training may reduce need for insulinResistance training may reduce need for insulin therapy in overweight women (BMI > 25)therapy in overweight women (BMI > 25) • ADA endorsed exercise as helpful adjunctiveADA endorsed exercise as helpful adjunctive therapy with GDM when euglycemia is nottherapy with GDM when euglycemia is not achieved by diet alone.achieved by diet alone.
    28. 28. Expert Guidance
    29. 29. Guidelines for Exercise in PregnancyGuidelines for Exercise in Pregnancy • ACOG in evolutionACOG in evolution – 19851985: HR: HR <<140 BPM with maximum duration of exercise =140 BPM with maximum duration of exercise = 15 minutes15 minutes – 19941994: Less cautious and began to stress the health benefits of: Less cautious and began to stress the health benefits of exerciseexercise – 20022002: 30 minutes or more of moderate exercise a day: 30 minutes or more of moderate exercise a day recommendedrecommended • SOGC/CSEPSOGC/CSEP – 2003:2003: All women without contraindications shouldAll women without contraindications should participate in aerobic & strength-conditioning exercise.participate in aerobic & strength-conditioning exercise.
    30. 30. ACOG 2002ACOG 2002 • Recognition that regularRecognition that regular exercise is beneficial toexercise is beneficial to even pregnant womeneven pregnant women and should beand should be encouraged.encouraged. • All women should beAll women should be evaluated clinicallyevaluated clinically before recommendationsbefore recommendations made.made. Obstet Gynecol 2002; 99: 171-173.
    31. 31. Absolute ContraindicationsAbsolute Contraindications • Hemodynamically significant heart diseaseHemodynamically significant heart disease • Restrictive lung diseaseRestrictive lung disease • Incompetent cervix/cerclageIncompetent cervix/cerclage • Multiple gestation at risk for premature laborMultiple gestation at risk for premature labor • Persistent second- or third-trimester bleedingPersistent second- or third-trimester bleeding • Placenta previa after 26 weeksPlacenta previa after 26 weeks • Premature labor during current pregnancyPremature labor during current pregnancy • Ruptured membranesRuptured membranes • Preeclampsia/pregnancy induced hypertensionPreeclampsia/pregnancy induced hypertension Obstet Gynecol 2002; 99: 171-173
    32. 32. Relative ContraindicationsRelative Contraindications • Severe anemiaSevere anemia • Unevaluated maternal cardiacUnevaluated maternal cardiac arrhythmiaarrhythmia • Chronic bronchitisChronic bronchitis • Poorly controlled type 1Poorly controlled type 1 diabetesdiabetes • Extreme morbid obesityExtreme morbid obesity • Extreme underweight (BMIExtreme underweight (BMI < 12)< 12) • Heavy smokerHeavy smoker • History of extremelyHistory of extremely sedentary lifestylesedentary lifestyle • IUGR in current pregnancyIUGR in current pregnancy • Poorly controlledPoorly controlled hypertensionhypertension • Orthopedic limitationsOrthopedic limitations • Poorly controlled seizurePoorly controlled seizure disorderdisorder • Poorly controlledPoorly controlled hyperthyroidismhyperthyroidism Obstet Gynecol 2002; 99: 171-173
    33. 33. ACOG 2002ACOG 2002 • Acknowledges the potential of exercise toAcknowledges the potential of exercise to prevent & treat gestational diabetes mellitusprevent & treat gestational diabetes mellitus • Recommends avoiding exercise involvingRecommends avoiding exercise involving bothboth – the supine position “as much as possible”the supine position “as much as possible” – prolonged periods of motionless standingprolonged periods of motionless standing • Notes that strenuous activity has not beenNotes that strenuous activity has not been linked to poor fetal growth or outcomeslinked to poor fetal growth or outcomes Obstet Gynecol 2002; 99: 171-173
    34. 34. ACOG & SafetyACOG & Safety • Safety of each sport determined by the “specificSafety of each sport determined by the “specific movements required by that sport.”movements required by that sport.” • Scuba diving is contraindicatedScuba diving is contraindicated • Exertion above 6000 feet carries risks.Exertion above 6000 feet carries risks. • Hyperthermia associated with exercise has notHyperthermia associated with exercise has not be shown to be teratogenicbe shown to be teratogenic Obstet Gynecol 2002; 99: 171-173
    35. 35. Higher Risk ActivitiesHigher Risk Activities • Contact sports with riskContact sports with risk of abdominal traumaof abdominal trauma – HockeyHockey – BasketballBasketball – SoccerSoccer • High Risk Sports withHigh Risk Sports with risk of both falls andrisk of both falls and traumatrauma – GymnasticsGymnastics – Horseback ridingHorseback riding – Downhill SkiingDownhill Skiing – Vigorous racquet sportVigorous racquet sport Obstet Gynecol 2002; 99: 171-173
    36. 36. Warning Signs to TerminateWarning Signs to Terminate ExerciseExercise • Vaginal bleedingVaginal bleeding • Dyspnea prior to exertionDyspnea prior to exertion • DizzinessDizziness • HeadacheHeadache • Chest painChest pain • Muscle weaknessMuscle weakness • Calf pain or swellingCalf pain or swelling • Preterm laborPreterm labor • Decreased fetal movementDecreased fetal movement • Amniotic fluid leakageAmniotic fluid leakage Obstet Gynecol 2002; 99: 171-173
    37. 37. Postpartum ExercisePostpartum Exercise • ““Prepregancy exercise routines may be resumedPrepregancy exercise routines may be resumed gradually as soon as it is physically and medicallygradually as soon as it is physically and medically safe.”safe.” • No adverse effects noted for even rapid returnNo adverse effects noted for even rapid return to activity.to activity. • Moderate weight reduction while nursing doesModerate weight reduction while nursing does not compromise infant weight gain.not compromise infant weight gain. • Associated with decreased incidence ofAssociated with decreased incidence of postpartum depression.postpartum depression. Obstet Gynecol 2002; 99: 171-173
    38. 38. Advising the Pregnant AthleteAdvising the Pregnant Athlete • Will her athletic performance suffer?Will her athletic performance suffer? – Will she lose a significant amount of aerobic fitness?Will she lose a significant amount of aerobic fitness? – Will her submaximal performance be affected?Will her submaximal performance be affected? • Can she safely continue resistance exercises?Can she safely continue resistance exercises? • Should she stop competing?Should she stop competing? • How soon can she return to competition?How soon can she return to competition? • Are breastfeeding and competitive athleticsAre breastfeeding and competitive athletics mutually exclusive?mutually exclusive?
    39. 39. Orthopedic Considerations for the Pregnant Athlete
    40. 40. Orthopedic ConcernsOrthopedic Concerns • No injury pattern hasNo injury pattern has been definitely associatedbeen definitely associated with exercise inwith exercise in pregnancypregnancy • Increased joint laxity +Increased joint laxity + weight gain = increasedweight gain = increased risk of joint discomfortrisk of joint discomfort
    41. 41. Common Orthopedic ConditionsCommon Orthopedic Conditions • Low back painLow back pain
    42. 42. Common Orthopedic ConditionsCommon Orthopedic Conditions • Low back painLow back pain • Pelvic/hip painPelvic/hip pain
    43. 43. Common Orthopedic ConditionsCommon Orthopedic Conditions • Low back painLow back pain • Pelvic/hip painPelvic/hip pain • Pubic painPubic pain
    44. 44. Common Orthopedic ConditionsCommon Orthopedic Conditions • Low back painLow back pain • Pelvic/hip painPelvic/hip pain • Pubic painPubic pain • Knee painKnee pain • Leg crampsLeg cramps
    45. 45. Common Orthopedic ConditionsCommon Orthopedic Conditions • Low back painLow back pain • Pelvic/hip painPelvic/hip pain • Pubic painPubic pain • Knee painKnee pain • Leg crampsLeg cramps • Carpal TunnelCarpal Tunnel SyndromeSyndrome • DeQuervain’sDeQuervain’s TenosynovitisTenosynovitis
    46. 46. Exercise PrescriptionExercise Prescription • Goal: Maintain maternalGoal: Maintain maternal fitness levels and minimizefitness levels and minimize risk to fetus.risk to fetus. • Points to considerPoints to consider – Current fitness levelCurrent fitness level – Goals for exerciseGoals for exercise – Job/occupational requirementsJob/occupational requirements – Gestational ageGestational age • Intensity: Perceived exertionIntensity: Perceived exertion • Safety is key!Safety is key!
    47. 47. NutritionNutrition • Energy intake needs toEnergy intake needs to be sufficient to meetbe sufficient to meet energy expenditure andenergy expenditure and promote weight gain.promote weight gain. • Gestational weight gainGestational weight gain (total & rate) good(total & rate) good indicator of adequateindicator of adequate nutritionnutrition • Quality of diet should beQuality of diet should be assessed periodicallyassessed periodically
    48. 48. Practical AdvicePractical Advice
    49. 49. Practical AdvicePractical Advice • Begin discussions at the first visitBegin discussions at the first visit • Structure each regimen individuallyStructure each regimen individually – safe upper limit of exercise will be dictated by asafe upper limit of exercise will be dictated by a women’s fitness status prior to entering pregnancywomen’s fitness status prior to entering pregnancy • Encourage rest-activity cyclesEncourage rest-activity cycles • Promote exercise as relaxationPromote exercise as relaxation
    50. 50. More Practical AdviceMore Practical Advice • Assure adequateAssure adequate hydration and calories tohydration and calories to support activitysupport activity • In mid to late pregnancy,In mid to late pregnancy, monitor for 2-3 fetalmonitor for 2-3 fetal movements in first 30movements in first 30 minutes after exerciseminutes after exercise • Do not ignore pain orDo not ignore pain or fatiguefatigue • Routine prenatal careRoutine prenatal care key!key! Maternity Support Binder
    51. 51. ACOG & the Competitive AthleteACOG & the Competitive Athlete • First opinion statement to acknowledge theFirst opinion statement to acknowledge the competitive athlete & pregnancycompetitive athlete & pregnancy • Highlighted concerns:Highlighted concerns: – The potential effect of pregnancy on competitiveThe potential effect of pregnancy on competitive abilityability – The effects of strenuous training and competition onThe effects of strenuous training and competition on pregnancy and the fetuspregnancy and the fetus • ““Such athletes may require close obstetricSuch athletes may require close obstetric supervision.”supervision.” Obstet Gynecol 2002; 99: 171-173
    52. 52. NCAA & PregnancyNCAA & Pregnancy • Guideline published 2002Guideline published 2002 • Acknowledges lack of research addressing intenseAcknowledges lack of research addressing intense physical exercise & pregnancyphysical exercise & pregnancy • Cite expert opinion recommending avoid participationCite expert opinion recommending avoid participation in contact sports after 14 wks EGAin contact sports after 14 wks EGA • Team physician job is to advise student-athlete:Team physician job is to advise student-athlete: – Risk, benefits, effects on competitive abilityRisk, benefits, effects on competitive ability – One-year extension of 5 yr eligibility period for reasons ofOne-year extension of 5 yr eligibility period for reasons of pregnancy ??pregnancy ?? • Signed informed consent recommended if athleteSigned informed consent recommended if athlete chooses to compete. May or may not protect thechooses to compete. May or may not protect the universityuniversity
    53. 53. College athlete dilemmasCollege athlete dilemmas • Athletes required to notify athletic departmentAthletes required to notify athletic department when they become pregnant?when they become pregnant? • Allowed to play while pregnant and for howAllowed to play while pregnant and for how long?long? • Should pregnancy be protected medicalShould pregnancy be protected medical condition protected from scholarshipcondition protected from scholarship revocation?revocation? • Should colleges develop programs for pregnantShould colleges develop programs for pregnant athletes?athletes?
    54. 54. College athlete dilemmasCollege athlete dilemmas • Athletes may:Athletes may: – Hide pregnancyHide pregnancy – Drop out of schoolDrop out of school – Elect to have an abortionElect to have an abortion – Delay prenatal careDelay prenatal care • Many colleges have no written policiesMany colleges have no written policies • Need safe environmentNeed safe environment • NCAA: “Stand up” to prevent revocation ofNCAA: “Stand up” to prevent revocation of scholarshipsscholarships
    55. 55. Take Home PointsTake Home Points • Healthy women should be encouraged toHealthy women should be encouraged to exercise before, during, and after pregnancyexercise before, during, and after pregnancy • Knowledge of theoretical risks and knownKnowledge of theoretical risks and known benefits are key to advising womenbenefits are key to advising women • Individualized exercise prescription promotes aIndividualized exercise prescription promotes a safe, healthy pregnancysafe, healthy pregnancy • Potential benefits typically outweigh any risksPotential benefits typically outweigh any risks • Colleges need to adopt written “athlete friendly”Colleges need to adopt written “athlete friendly” policies to “assist” pregnant athletespolicies to “assist” pregnant athletes
    56. 56. Questions?
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