Transcript exercise in pregnancy

EXERCISE
FOR
GIRLS
&
WOMEN
Historical Attitudes Towards Women
1875: Hutchingson:
• Women have a sum total of nervous force
equivalent to man
• Women have more organs
• Nervous force is weakened in each organ
• Resistance to disease is weakened
• Women are more sensitive and more liable
to derangement
1875 Dr. King, Obstetrics & Gynecology
Women menstruate because of a failure to conceive
Menstruate occurs because the organ was not used
for it’s intended purpose
When an organ is not used = atrophy & disease
Therefore, once reaching puberty a woman should be
encouraged to marry and immediately impregnated
Continuously impregnated as not to menstruate
Beigel, Physician:
10-14 days of Bed Rest
for Each Menstrual Cycle
International Olympic Committee: Circa 1900
Women should not engage in any activity which
they cannot wear a long dress
Heart Rate Response to Running 540 Yard Run
80
60
40
20
Wearing
Corsets
100
Without
Heart Rate (/min)
120
0
Seargent
Fashion
allowed
more
exercise
1928 Modern Olympics
11 women
First 800 m Race
• 5 collapsed during the Run
• 5 collapsed at the Finish
• Winner collapsed in the Dressing Room
EXERCISE & GYNECOLOGY
10
Normal
Level
Ballet
Sport
Olympic
High School
College
AGE OF MENARCHE
15
5
Type
MATURATION AND SPORT
Does sport delay
maturation?
Is maturation
unsuccessful for
sport?
AGE OF MENARCHE
18
16
High School
College
Olympic
12
10
8
Sport
Ballet
14
6
Normal
Level
Type
LATER AGE OF MENARCHE
FEWER COMPAINTS
IN MENOPAUSE
Jazman, Frontiers of Hormone Research 2:22, 1973.
….AS A
YOUNG WOMAN…
FEMALE ATHLETE TRIAD
AMENORRHEA
INCIDENCE OF ANOREXIA & BULIMA
70
40
30
20
10
0
HS
Specific Sports
50
College
Percent of Athletes
60
Percent of Population (%)
AMENORRHEA
70
60
Athletes
50
40
30
20
10
0
General
35
30
25
20
15
Active
Regular
Cycling
10
5
0
Active
Amenorrhic
Incidence of Bone Fractures (%)
OSTEOPOROSIS
Control
Marcus eat al, Ann Int Med 102:158-163, 1985
ACSM RECOMMENDATIONS
1. Serious Syndrome
2. Unrealistic pressures to lose weight in athletics.
3. Sports Medicine Professionals need more education
4. Screening programs should be developed.
5. Develop prevention strategies
6. Educate parents to have reasonable goals for
children.
7. Educate the girls
8. More research.
EXERCISE IN PREGNANCY
PREGNANCY
EXERCISE
• SKELETAL
• METABOLISM
• RESPIRATORY
• CARDIOVASCULAR
• ENDOCRINE
• THERMOREGULATION
EXERCISE IN PREGNANCY
1. Safe for mother?
2. Safe for fetus
3. Affect on pregnancy outcome?
WEIGHT GAIN DURING PREGANACY
14
12
Weight (kg)
10
8
6
4
2
0
0
13
27
Weeks of Gestation (wks)
40
SKELETAL SYSTEM
Forward
displacement of
the center of
gravity
Increased anterior
flexion of cervical
spine
Lumbar Lordosis
Forward
rotation of
Pelvis & Femur
SKELETAL SYSTEM
PREGNANCY
1. Lumbar Lordosis
2. Cervical Spine
3. Pelvis & Femur
4. Center of Gravity
5. Increased joint mobility
EXERCISE
1. Lumbrosacral Pain
2. Compression Syndromes
1. Carpal Tunnel
2. Ulnar Nerve
3. Posterior Tibial
4. Perennial
5. Overextension Injury
METABOLISM
PREGNANCY
METABOLISM
1. Increased Resting
Metabolism
EXERCISE
1. Increased metabolism
at submaximal work
1. 80,000 cal
2. 300 cal/day
2. Glucose = primary fuel
2. Hypoglycemia
RESPIRATORY
SYSTEM
1. Chest cavity increases
transverse diameter
2. Raised diaphragm
PULMONARY FUNCTIONS
4000
Volume (ml)
3000
Insp Res
2000
1000
0
-1000
Tidal Vol.
Exp Res
RV
-2000
NonPregnant
Pregnant
RESPIRATORY SYSTEM
PREGNANCY
EXERCISE
1. Pulmonary Functions
1. Increased tidal
volume
2. Decreased
Residual Vol
2. Metabolism &
Pulmonary Functions
3. 40% increase in
Resting Minute
Ventilation (VE)
RESTING HEART RATE
90
Heart Rate (/min)
85
80
75
70
65
60
0
8
12
16
20
24
28
Gestation (wks)
32
Wilson et al., Am J Med 68:97, 1980.
36
40
Post
60
CARDIOVASCULAR SYSTEM
Percent Increase (%)
50
40
Cardiac Output
30
Blood Volume
20
10
0
0
12
20
Gestation (wks)
28
36
CARDIOVASCULAR SYSTEM
PREGNANCY
1. Cardiac Output
1. Heart Rate
2. Stroke Volume
EXERCISE
1. Decreased
Physical Work
Capacity
2. Increased Submaximal work
1. Heart Rate
2. Stroke Volume
3. Cardiac Output
140
CARDIOVASCULAR SYSTEM
Heart Rate (/min)
130
Non
<19 wks
120
20-28 wks
29-35 wks
110
36-40 wk
100
150
250
Workrate (kpm/min)
300
CARDIOVASCULAR SYSTEM
Stroke Volume (cc)
90
80
Non
<19 wks
70
20-28 wks
60
29-35 wks
36-40 wk
50
40
150
250
Workrate (kpm/min)
300
12
CARDIOVASCULAR SYSTEM
Cardiac Output (L/min)
10
Non
<19 wks
8
20-28 wks
6
29-35 wks
36-40 wk
4
2
150
250
300
Workrate (kpm/min)
120
CARDIOVASCULAR SYSTEM
Non
C(a-v)O2 (ml/L)
100
<19 wks
20-28 wks
29-35 wks
80
36-40 wk
60
150
250
300
Workrate (kpm/min)
PHYSICAL WORK CAPACITY
• Lowest PWC in First Trimester
• Highest PWC in Second Trimester
• Decreases as Body Weight Increases
in Third Trimester
Concentration (iu/1000ml urine)
ENDOCRINE SYSTEM
40
HCG
35
30
25
Estriol
20
HSC
15
Pregnanediol
10
5
0
0
70
140
210
Gestation (days)
280
ENDOCRINE SYSTEM
PREGNANCY
1. Hormone Changes
EXERCISE
1. Physical Work
Capacity
2. Joint Injury
3. Gestational
Diabetes
THERMOREGULATION
PREGNANCY
1. Increased Sweat
Gland Activity
2. Shunt blood to
Periphery
3. Fetus >1oC
EXERCISE
1. Dehydration
2. Heat Related
Injury
3. Spinal Cord
Growth
Retardation
(1st trimester)
EXERCISE IN PREGNANCY
1. Safe for mother?
2. Safe for fetus
3. Affect on pregnancy outcome?
FOR THE MOTHER?
Exercise Training during Pregnancy
1. Physical Work Capacity
1. Increases during pregnancy
2. Not above Pre-Pregnant Values
2. Lower Exercise Heart Rates*
1. At same workrate
3. Increased Heart Volume*
* Not all studies agree
FOR THE MOTHER?
1. Skinfold thickness
2. Maternal Weight Gain
3. Resting Heart Rate
4. Maximal Heart Rate
5. Exercising Heart Rates*
6. Cardiac Output at Submax
7. Stroke Volume at Submax
8. Resting & Orthostatic Blood Pressures
9. VO2 at submax
10. Resting Metabolism
11. VEmax
12. VEsubmax
FOR THE FETUS?
FETAL HEART RATES
Deceleration
>15 /min
Normal response to mild
or transient hypoxia
Moderate
100-120/min
Initial response to
Bradycardia
hypoxia
Profound
Bradycardia
<100/min
Normal response to
prolonged hypoxia
Tachycardia
>160/min
Compensatory adaptation
during hypoxic recovery
FETAL HEART RATES
1. During Exercise
1. Slight Increase
2. Slight Decrease
3. No change
2. Recovery from Exercise
1. Slight Increase
2. Slight Decrease
3. No change
FETAL HEART RATES
6/40 Exercise Studies
• Bradycardia
• Irregularity
• Tachycardia
• Cord tightly wrapped around neck (3x)
• Loop of umbilical cord prolapsed by head
• Flattened umbilical cord (4”)
• Fetal distress at birth
Hon & Wohlgemuth, Am J Obstet Gynecol 81:361-371, 1961.
UTERINE BLOOD FLOW
10
• Human
•26 normal
•29 Pre-Ec
• Supine Ex
• Radioactive
Na+
Clearance Times (min)
8
6
Rest
Exercise
4
Recovery
2
0
Normal
Pre-Eclaptic
Morris, et al., Lancet 8 Sept 1956; pg 481-484
• 6 Pregnant
Percent Change from Rest (%)
UTERINE BLOOD FLOW
80
70
60
50
Pregnant
40
• 2 Non-Pregnant
30
• Flow of Uterine
Artery
10
Non-Pregnant
20
0
Rest
2
3
Max
Orr, et al., Am J Obstet Gynecol 114:213-217, 1972
• 3 mph 10%
• Exhaustion
• n=10
• Cath
Percent of Uterine Blood Flow (%)
UTERINE BLOOD FLOW
100
80
60
Pre
40
Post
20
0
Endometrium
Placenta
Curet, et al., J Appl Physiol 40:725-728, 1976
UTERINE BLOOD FLOW
90
PO2 (mmHg)
80
70
60
50
Rest
40
Exercise
30
Recovery
20
10
0
Maternal
Fetal
Emmanouilides et al. Am J Obstet Gynecol 122:130-137, 1972
PCO2 (mmHg)
UTERINE BLOOD FLOW
50
45
40
35
30
25
20
15
10
5
0
Rest
Exercise
Recovery
Maternal
Fetal
Emmanouilides et al. Am J Obstet Gynecol 122:130-137, 1972
UTERINE BLOOD FLOW
8
pH
7.8
7.6
Rest
Exercise
7.4
Recovery
7.2
7
Maternal
Fetal
Emmanouilides et al. Am J Obstet Gynecol 122:130-137, 1972
40
FETAL GLUCOSE
Glucose (mg/dl)
35
30
25
20
NonPregnant
Pregnant
15
10
0
15
30
45
60
Rec
Time (min)
Soultanakis, et al., Seminars in Perinatology. 20(4):315-27, 1996
Core Temperature (Co)
40
FETAL TEMPERATURES
39
38
37
36
NonPregnant
Pregnant
35
0
15
30
45
60
Rec
Time (min)
Soultanakis, et al., Seminars in Perinatology. 20(4):315-27, 1996
PREGNANCY OUTCOME
1.
Stages of Labor
2.
Complications of Labor &
Delivery
3.
Health of Infant
PREGNANCY OUTCOME
STAGES OF LABOR
1. Progressive Cervical Dilation
8 to 24 hrs
2. Head moves into birth canal
to birth
1 – 30 min
(same as head)
3. Passing of the Placenta
PREGNANCY OUTCOME
STAGES OF LABOR
1.
Duration of Labor
1. Primi- or Multi-parous
2.
Mode of Delivery
3.
Work of Labor & Delivery
Complications of
Labor & Delivery
1.
Pre-Mature
2. Caesarean Section
3. Rupture
4. Perineotomy
5. Episiotomy
6. Forceps Delivery
PREGNANCY OUTCOME
Health of Infant
1. Apgar Scores
2. Neonatal Complications
3. Infant Birth Weight
4. Infant Head Circumference
APGAR SCORES
0
1
2
Heart Rate
Absent
<100
>100
Respiratory
Effort
Absent
Weak
Strong Cry
Muscle Tone
Limp
Some Fl
Flex
Extremities
Reflex (feet)
Irritability
Absent
Some
Motion
Cry
Color
Blue
Body Pink Completely
Limbs blue
Pink
Neonatal Complications
1. Asphyxiated Infants
2. Neonatal Morbidity
PREGNANCY OUTCOME
Lamasze
• 276 Exercise
• 281 Control
Minutes
1500
100
80
60
1000
40
500
0
20
0
First
Control
Total
Exercise
Second
Third
Rodway et al. J Obstet Gynec Brt Comm
54:77-85, 1947.
3600
Sitting Work
3400
Standing Work
Other Children
3200
wk
s
>3
8
wk
s
34
-3
8
wk
s
29
-3
0
wk
s
20
-2
8
wk
s
3000
<2
0
Infant Birth Weight (gms)
3800
BIRTH WEIGHT
Naeye & Peters, Pediatrics 69:724-727, 1982.
ATHLETIC TRAINING
• 729 athletes
• General
population
Percent of Sample (%)
80
ATHLETIC TRAINING
60
40
20
0
• Disturbances with Pregnancy
• Competing during Pregnancy
• Good Pregnancy Outcome
• Improved Performance after
Preg
Compete
Outcome
Perform
First Grade
Masters
Olympic
n=64
n=59
n=27
EXERCISE IN PREGNANCY
• Not Unsafe for Mother or Fetus
• In moderation
• No Athletic Competition or Sport
1. Physical conditioning during pregnancy results in no detrimental
effect on pregnancy outcome.
2. Physical conditioning during pregnancy does not appear to result in
the same physiological changes as physical conditioning in the
non-pregnant state.
3. Continued athletic training during pregnancy may result in obstetric
complications.
4. Athletic training, if discontinued during pregnancy results in no
detrimental effects on pregnancy.
5. Pregnancy may improve athletic performance following pregnancy.
1. Continued occupational activity during the last weeks of
pregnancy can result in lower infant birth weight which in some
cases, is related to poorer infant health.
ABSOLUTE CONTRAINDICATIONS FOR
EXERICSE IN PREGNANCY
•
•
•
•
•
•
•
•
•
Heart Disease
Restrictive lung disease
Pregnancy induced hypertension
Incompetent Cervix
Multiple Gestation
Hx: Placenta Previa
Hx: Breech Presentation
Hx: Ruptured Membranes
Hx: Premature Labor
RELATIVE
CONTRAINDICATIONS
FOR EXERICSE IN
PREGNANCY
•
•
•
•
•
•
•
•
Anemia
Maternal cardiac arrhythmia
Chronic bronchitis
Extreme Morbid Obesity
Extreme Underweight (BMI <12)
Orthopedic limitations
Heavy Smoker
Poorly controlled
•
•
•
•
Thyroid Disease
Type 1 diabetes
Hypertension/pre eclampsia
Seizure disorder
EXRX: Pregnancy
MODE
CV; non-wt bearing as weight increases
Discontinue Athletic Training
Flexibility for Muscle Soreness
Muscle Endurance is OK
FREQUENCY
3-4/wk (resistance 2/wk)
DURATION
20-30 min up to 60 min
INTENSITY
Moderate 50-85%
(< Ventilatory threshold)
Not guided by Heart Rates
EXRX: Pregnancy
PRECAUTIONS
1. Thermoregulation
2. Injury
3. Supine Exercise (>4 months)
4. As pregnancy progresses
1.
Move to non-weight bearing
2. Decrease intensity increase frequency
EXRX: Pregnancy
DISCONTINUE:
1. Pain or Bleeding
2.
3.
4.
5.
6.
7.
Dizziness or Faintness
Pubic Pain
Palpitations
Back Pain
Shortness of Breath
Difficulty Walking
EXERCISE IN POST-PARTUM
• Beginning In 1974
• Infants Refused to Nurse
following Maternal Exercise
• 7%
Concentrations of Lactic Acid in Blood and
Milk following Maximal Exercise
Lactic Acid (mM/L)
8
6
Blood
4
Milk
2
0
Rest
10 min Post
30 min Post
Wallace & Rabin, Int J Sports Med 12:328-331, 1991
Concentrations of Lactic Acid in Milk following
a Normal Workout & Maximal Exercise
Lactic Acid (mM/L)
3
2.5
2
Pre
1.5
Post
1
0.5
0
Workout Aerobics Walk/Jog Maximal
Wallace et al, J Women’s Health 3:91-96, 1994
SOUR MILK?
10
Accept
8
6
4
2
Reject
0
1
2
3
4
5
THE RELATIOSHIP BETWEEN TASTE AND LACTIC
ACID CONENTRATIONS IN MOTHER’S MILK
Detect
Recognize
EXERCISE GUIDELINES FOR
LACTATION
Only for Women who have
Problems
1. Nurse before Exercise
2. Collect Milk before Exercise
3. Discard first 30-60 min post exercise
milk production
4. Exercise below Ventilatory Threshold
IN MENOPAUSE
• Increased Risk of Disease
• Heart Disease
• Hypertension
• Hyperlipidemia
• Breast Cancer
• Symptoms of Menopause
•
•
•
•
Hot Flash
Insomnia
Fatigue
Nervousness/Depression
STUDIES ON MENOPAUSAL SYMPTOMS
PENN STATE
• Subjects
• 11 Pre
• 7 Peri• 11 Post
• Exercise
• Walk/Jog
• Swim
• Dance
• Aerobic Games
• 4/wk for 6 wks
• Moderate
SAN DIEGO STATE
IU
• Subjects
• 9 Post
• 4 Control
•Subjects
• 10 Post
• 10 Control
• Exercise
• Walk/Jog
• 3/wk for 12 wks
• Moderate
• Exercise
• Walk/Jog
• 3/wk for 12 wks
• Moderate
CHANGES IN POSTMENOPAUSAL
SYMPTOMS WITH TRAIING
Changes with Training (%)
60
40
20
0
Exercise
-20
Control
-40
-60
-80
Penn State
San Diego
IU
IN OLD AGE
IMMERSION EXERCISE
• 12 pregnant women
• 15, 25, 35 weeks
• 8-10 wks postpartum
• 20 min of immersion
• 30oC
• 20 min of exercise @ 60% VO2max (bike)
• 20 min supine recovery
McMurray, R.G., et al. American Journal of Obstetrics & Gynecology. 158(3 Pt
1):481-6, 1988
IMMERSION EXERCISE
• HRwater <HRland
• Qwater>Qpostpartum
• PVRwater<PVRpostpartum
Pregnancy has increased demand, yet water
reduces those demands
McMurray, R.G., et al., International Journal of Sports Medicine. 9(6):443-7, 1988