연자 및 제목: 김미정 선생님 / Exercise in Pregnancy 대상 : 관심 있는 의료인 및 연구원 일시 : 2016년 7월 19일 AM 7:00 화요일 장소 : 제일병원 수련관 1층 주관 : 마더리스크 프로그램

1. EXERCISE IN PREGNANCY
MF FELLOW
KIM MIJUNG

3. INTRODUCTION
• Physical activity and Exercise
• maintains and improves cardiorespiratory fitnes
• reduces the risk of obesity and associated comorbiditie
• greater longevity
• Physical inactivity is the fourth-leading risk factor for early mortality
worldwide
• Independent risk factors for maternal obesity and related pregnancy
complications, including GDM in pregnancy

4. INTRODUCTION
• Concern!
• regular physical activity during pregnancy may cause miscarriage, poor fetal growth,
musculoskeletal injury, or premature delivery.
• For uncomplicated pregnancies, these concerns have not been substantiated.
• maintain or improve fitness Obstet Gynecol. 2012
• prevent excessive gestational weight gain Cochrane Database Syst Rev. 2012
• prevent or reduce low back pain Int J Gynaecol Obstet. 2011
• reduce the risk of developing GDM and preeclampsia
• reduce having a cesarean delivery

5. ANATOMIC AND PHYSIOLOGIC ASPECTS
• Pregnancy ➩ Anatomic, physiologic changes
• Increased weight gain
• Shift in the point of gravity
• results in progressive lordosis
Increase in the forces across joints and the spine
• More than 60% experience low back pain
• Strengthening of abdominal and back muscles
minimize risk
• Lower extremities edema and joint laxity
The most common sports-related injuries
in pregnancy are musculoskeletal

6. PHYSIOLOGIC CHANGE DURING PREGNANCY
• Hemodynamic changes
• Blood volume, heart rate, stroke volume,
cardiac output ⇑
• Systemic vascular resistance ⇓
• Respiratory changes
• Minute ventilation up to 50% ⇑
• Tidal volume ⇑
• Pulmonary reserve ⇓
• Physiologic respiratory alkalosis
Motionless postures
(certain yoga positions, supine position)
⇒ decreased venous return, hypotension
⇒ should be avoided as much as possible
Short of breath
Ability to exercise anaerobically ⇓
O2 availability for strenuous aerobic
exercise ⇓ (esp. obese women)

7. TEMPERATURE REGULATION
• Highly dependent on hydration and environmental condition
• During exercise, pregnant women should stay well-hydrated, wear loose-
fitting clothing, and avoid high heat and humidity to protect against heat
stress, particularly during the first trimester
• Exposure to heat from sources like hot tubs, saunas, or fever has been
associated with an increased risk of neural tube defects.
• Exercise would not be expected to increase core body temperature into the
range of concern.
Despite pregnancy is associated with
profound anatomic and physiologic changes,
Exercise has minimal risks
and has been shown to benefit most women.

8. FETAL RESPONSE TO MATERNAL EXERCISE
• Minimum-to-moderate increases in fetal heart rate by 10–30 beats per
minute over the baseline during or after exercise
• Three meta-analyses concluded : differences in birth weight were minimal to
none in women who exercised during pregnancy compared with controls
• However, exercise vigorouse group during the third trimester were more likely
to deliver infants weighing 200–400 g less, although there was not an
increased risk of fetal growth restriction
Am J Obstet Gynecol. 1986

9. FETAL RESPONSE TO MATERNAL EXERCISE
• UA blood flow, fetal heart rates, and ,
NST, biophysical profiles before and
after strenuous exercise in 2nd trimester
• The increase in rate may be
accompanied by a reactive FHR pattern
(ie, FHR accelerations); postexercise
reactivity is generally achieved
within 20 minutes. Biophysical profile
scores were reassuring.
Szymanski LM, Satin AJ., Obstet Gynecol
2012;119:603–10
30 minutes of strenuous exercise was
well tolerated by women and fetuses
in active and inactive pregnant women

10. BENEFITS OF EXERCISE DURING PREGNANCY
• Women who exercise during pregnancy
• Decreased GDM
• Decreased cesarean and operative vaginal delivery
• Decreased postpartum recovery time
• Lower glucose levels in women with GDM
• Help prevent preeclampsia
Obstet Gynecol. 2015
Med Sci Sports Exerc. 2005

11. RISK FOR FETAL GROWTH RESTRICTION
• Modest decrease in overall weight gain (1–2 kg) in normal weight,
overweight, and obese women
• Low risk women (2015 systematic review of randomized trials )
: regular participation in a supervised prenatal exercise program resulted
in a clinically insignificant reduction in birthweight compared with usual
care and no increase in small for gestational age newborns
Obstet Gynecol. 2015

12. RECOMMENDING AN EXERCISE PROGRAM

13. MOTIVATIONAL COUNSELING
• Pregnancy is an ideal time for behavior modification, adopting a
healthy lifestyle.
• Patients are more likely to control weight, increase physical activity,
and improve their diet if their physician recommends.
• Motivational counseling tools such as
the Five A’s (Ask, Advise, Assess, Assist, and Arrange) approach.
Serdula MK et al., JAMA 2003;289:1747–
50

14. PRESCRIBING AN INDIVIDUALIZED EXERCISE PROGRAM
A.A thorough clinical evaluation to ensure the patient does not have medical reasons to
avoid exercise.
Committee Opinion No. 650. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015

15. B. Exercise program
• Eventual goal of moderate-intensity exercise for at least 20–30
minutes per day on most or all days of the week
Committee Opinion No. 650. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015
1) Physical activities

16. • Ratings of perceived exertion may be a more effective means to monitor exercise intensity during
pregnancy than heart-rate parameters
Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982
• For moderate-intensity exercise, ratings of perceived exertion
13–14 on the 6–20 Borg scale of perceived exertion
• “Talk test”
As long as a woman can carry on a conversation while exercising,
she is likely not overexerting herself
2) Exercise Intensity

17. • Women should be well hydrated, avoid long
periods of lying flat on their backs, and stop
exercising if they have any of the warning signs
C. Environmental Control
• High-intensity or prolonged exercise in excess
of 45 minutes can lead to hypoglycemia;
• Adequate caloric intake before exercise, or
limiting the exercise session
• Prolonged exercise : in a thermoneutral environment or in controlled environmental
conditions (air conditioning) with proper hydration
• Core body temperatures rose less than 1.5°C and stayed within safe limits

18. SPECIAL POPULATIONS
• Pregnant women who were sedentary before pregnancy
• more gradual progression of exercise
• ACOG guideline : “bed rest is not effective for the prevention of preterm birth and
should not be routinely recommended”
• at risk of venous thromboembolism, bone demineralization, and deconditioning.
• Obese women should start with low-intensity, short periods of exercise and
gradually increase as able.
• modest reductions in weight gain and no adverse outcomes
• Competitive athletes frequent and closer supervision
• particular attention to avoiding hyperthermia and prevent weight loss

19. EXERCISE IN THE POSTPARTUM PERIOD
Resuming exercise activities
• Incorporating new exercise routines after delivery is important in supporting lifelong
healthy habits.
• Exercise and a healthy diet postpartum promote weight loss
• Participation in exercise programs diminishes after childbirth
• frequently leading to overweight and obesity
• In the absence of medical or surgical complications, rapid resumption
• Pelvic floor exercises could be initiated in the immediate postpartum period.

20. EXERCISE IN THE POSTPARTUM PERIOD
Nursing women should consider …
• Regular aerobic exercise
• improve maternal cardiovascular fitness without affecting milk production,
composition, or infant growth
• Ensure adequate hydration before commencing physical activity
• Feeding their infants before exercising
• Brest engorgement
• Increased acidity of milk secondary to any build-up of lactic acid.

21. SUMMARY
• Despite, pregnancy is associated with profound anatomic and physiologic changes,
exercise has minimal risks and has been shown to benefit most women.
• Women with uncomplicated pregnancies should be encouraged to engage in physical
activities before, during, and after pregnancy.
• Obstetrician–gynecologists and other care providers should carefully evaluate women
with medical or obstetric complications before making recommendations on physical
activity during pregnancy.
• Physical activity and exercise during pregnancy promotes physical fitness and may
prevent excessive gestational weight gain. Exercise may reduce the risk of gestational
diabetes, preeclampsia, and cesarean deliveries.
• Additional research is needed to further clarify effective behavioral counseling
methods and optimal type, frequency, and intensity of exercise.
Eventual goal of moderate-intensity exercise for at least
20–30 minutes per day on most or all days of the week

22. Thank you for your attention !!