Exercise during Pregnancy

CASM/ OMA Cutting Edge Sport Medicine 2010 E. Laura Cruz, MD SportCARE, Women’s College Hospital [email protected]

The presenter declares no conflict of interest.

What’s new since 2002?

► ACOG Guidelines 2002 ► SOGC Guidelines (2003) ► CASM Position Paper (2008) ► Exercise in the Active Pregnant Woman ► Evidence based recommendations (2010) ► Available resources

What are the issues?

► Exercise during pregnancy previously restricted ► Now encouraged for all healthy pregnant women ► What are the benefits of exercise seen in pregnant patients?

► Is there a safety threshold? What can athletes do?

► Heart rate changes ► Hyperthermia ► Trauma to uterus ► Hyper/ hypobaric exercise ► Hypotension ► MSK changes

SOGC Guidelines 2003

► Evaluated research of the time ► In conjunction with CSEP ► Used by SportCARE for its North America wide “Exercise and Pregnancy Helpline” ► Ideal for low risk pregnancy in inactive or recreationally exercising women

Purpose of Guidelines

► Standardize care ► Accessible to health care providers ► Protect maternal and fetal health and well being ► Evidence based

SOGC Recommendations 2003

1. All women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy.

(II-1,2B)

SOGC Recommendations 2003

2. Reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level throughout pregnancy without trying to reach peak fitness or train for an athletic competition. (II-1,2C)

SOGC Recommendations 2003

3. Women should choose activities that will minimize the risk of loss of balance and fetal trauma. (III-C)

Table 3 Exercise in Pregnancy

Olson, David; Sikka, Robby S.; Hayman, Jacob; Novak, Melissa; Stavig, Christina Current Sports Medicine Reports. 8(3):147-153, May/June 2009.

doi: 10.1249/JSR.0b013e3181a61d51

TABLE 3. Sports recommendations.

Copyright © 2010 Current Sports Medicine Reports. Published by Lippincott Williams & Wilkins.

14

SOGC Recommendations 2003

4. Women should be advised that adverse pregnancy or neonatal outcomes are not increased for exercising women. (II-1,2B)

SOGC Recommendations 2003

5.Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence. (II 1C)

SOGC Recommendations 2003

6.Women should be advised that moderate exercise during lactation does not affect the quantity or composition of breast milk or impact infant growth. (I-A)

Cochrane Systematic Reviews

► Aerobic Exercise in Pregnancy ► Prevention of Gestational Diabetes ► Decrease risk of Pre Eclampsia

Aerobic exercise for women during pregnancy

Michael S Kramer1, Sheila W McDonald2 1Faculty of Medicine, McGill University, Montreal, Canada. 2Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada Citation: Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3 (reviewed and published in 2009) ►

Authors' conclusions

► Regular aerobic exercise during pregnancy appears to improve (or maintain) physical fitness. Available data are insufficient to infer important risks or benefits for the mother or infant. Larger and better trials are needed before confident recommendations can be made about the benefits and risk of aerobic exercise in pregnancy.

[Note: The 21 citations from 18 separate trials in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

Exercise for Diabetic Pregnant Women

Ceysens G, Rouiller D, Boulvain M. Cochrane Database of Systematic Reviews 2006, Issue 3.

►

Authors' conclusions

► There is insufficient evidence to recommend, or advise against, diabetic pregnant women to enrol in exercise programs. Further trials, with larger sample size, involving women with gestational diabetes, and possibly type 1 and 2 diabetes, are needed to evaluate this intervention. ► [Note: The six citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

Exercise or other physical activity for preventing pre eclampsia and its complications.

Meher S, Duley L.

Cochrane Database of Systematic Reviews 2006, Issue 2. ► MAIN RESULTS: Two small, good quality trials (45 women) were included. Both compared moderate intensity regular aerobic exercise with maintenance of normal physical activity during pregnancy. The confidence intervals were wide and crossed the line of no effect for all reported outcomes including pre-eclampsia (relative risk 0.31, 95% confidence interval 0.01 to 7.09). ► AUTHORS' CONCLUSIONS: There is insufficient evidence for reliable conclusions about the effects of exercise on prevention of pre-eclampsia and its complications

.

CASM Position Paper 2008

► Previously active women may continue in T1 ► Mild core temp changes are tolerated ► No affect birth weight ► No known threshold for maternal exercise, and fetal stress: ongoing research needed ► Psychological benefits can be achieved by moderate exercise ► Post Partum exercise is supported as intervention for healthy lifestyle without adverse effects

Exercise in the Active Pregnant Woman

Evidence- based Recommendations for Active Women in 2010

► Paucity of new research about pregnant elite athletes ► Many anecdotes (AKA case reports?) ► Some advances in role of exercise and GDM ► Little if any data on elite pregnant athletes ► One comprehensive review (level III)

Strenuous Exercise During Pregnancy: Is It Safe for Fit, Healthy Women?

Wolfe, L A. FACSM; Mottola, M F.

MSSE 2002; 34 (5): S46 B5 Mini-Symposium ► In summary, information presented in this mini-symposium supports the hypothesis that healthy, fit pregnant women are well adapted to perform acute bouts of high intensity, short duration as well as prolonged exercise at moderate intensities

Effects of intense training during and after pregnancy in top-level athletes

Kristin Reimers Kardel Scand J Med Sci Sports 2005: 15: 79–86 ► “The overall aim of the study was to define a safe training regime for the maintenance of fitness in top-level female athletes during pregnancy” ► ► Cohort study with 41 pregnant elite athletes (from 17 wk GA) High intensity exercise (n=20) and medium intensity exercise (n-21)  Strength training- 1 hr 12 min 2X wkly   Interval training-10 or 15 min sprints (mean HR 170-180 bpm) 2X wkly Endurance training-1.5 or 2.5 hr (mean HR 120- 140 bpm) 2X wkly ► ► Measured parameters demonstrated maintenance of fitness levels Interval and endurance training exceeded guidelines-no effect on fetal health

Pregnancy in endurance athletes.

Penttinen J, Erkkola R. Scand J Med Sci Sports 1997: 7: 226228 ► ► ► ► ► ► ► Retrospective questionnaire and review of pregnancy diaries in 30 elite Finnish endurance athletes Compared to 30 control women No information about training regimen 23 athletes continued to train (GA 7-39 wk) 18 continued to compete (GA 0-25 wk) Results:  No significant differences in fetal well being, labour, complications Authors concluded endurance training was safe and effect of pregnancy on performance was individual

Exercise in Pregnancy

Olson, David; Sikka, Robby S.; Hayman, Jacob; Novak, Melissa; Stavig, Christina Current Sports Medicine Reports: May/June 2009 - Volume 8 - Issue 3 - pp 147-153 ► ► The 2006 “Cochrane review highlights the need for more studies examining the impact of exercise upon pregnancy ( 35 ). However, recent research suggests that positive effects include      potential risk reduction for development of gestational diabetes pregnancy-induced hypertension, decrease in postpartum depression symptoms, and a decreased incidence of urinary incontinence and preeclampsia, and no increased risk of preterm birth ( 1,8,13,28,29,31,36 ).” “Despite methodological pitfalls in the studies published, the evidence does suggest a benefit of exercise in pregnancy”

“In the absence of contraindications, the authors believe that physicians should help to develop a reasonable exercise protocol for women based upon their previous activity levels.”

Olson et al, Exercise and Pregnancy 2009 Curr Sports Med Rep ; 8(3): 147-153

Available Resources

► PARmed- X for Pregnancy ► Cochrane Reviews?

► SportCARE Exercise and Pregnancy Helpline ► SportCARE Active Pregnancy Clinic

PARmed-X for Pregnancy

SportCARE Resources

► Exercise and Pregnancy Helpline 

1-866-937-7678

► Active Pregnancy Clinic   

416-323-6479

MSK; pelvic floor; metabolic conditions of pregnancy (e.g. uncomplicated GDM; obese patients) Pregnant athletes

Thank you!