Transcript Special Populations

Pregnancy
Physiological Changes During Pregnancy
• Cardiac output:
– The volume of blood the heart pumps per minute
increases from about 5 liters per minute prepregnancy to about 9 liters per minute at 36 to 39
weeks
• Blood pressure may decrease during the first
two trimesters, returns to baseline in the third
trimester
• Some women may experience edema (fluid
accumulation)
Physiological Changes During Pregnancy
• Nausea and vomiting typically occur
during the first trimester (morning
sickness)
• Center of gravity shifts which may
result in balance problems
• Appetite increases
Medical Clearance
• Pregnant women need to
consult with a physician
before initiating an
exercise program
Pregnant Women
• Women who are pregnant seek out
personal training for numerous reasons:
–Self-conscious about their changing body
–Concerned about having a healthy baby
–Want to stay in shape throughout the
pregnancy
–Want to be able to handle labor and
delivery
Benefits of Exercise During Pregnancy
• Enhanced maternal psychological well being
that may reduce the feelings of stress, anxiety,
and depression often experienced during
pregnancy
• Increased likelihood of adopting permanent
healthy lifestyle habits
• Prevention of gestational diabetes (improving
glucose tolerance)
• Improve physical discomforts, weakness, and
lack of stamina
Benefits of Exercise During Pregnancy
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Improved cardiovascular and muscular fitness
Facilitated recovery from labor
Faster return to pre-pregnancy weight, strength, and
flexibility
Reduced postpartum belly
Reduced back pain during pregnancy
More energy reserve
Fewer Obstetric interventions
Shorter active phase of labor and less pain
Less weight gain
Exercise Concerns During Pregnancy
• Insufficient oxygen or energy
substrates (calories) to the fetus
• Hyperthermia:
–induced fetal distress or birth
abnormalities
• Increased uterine contractions
Exercise Concerns During Pregnancy
• Reduced birth weight in babies whose
mothers performed high-intensity
exercise (300-350 g/10-12 ounces)
• Vigorous exercise during pregnancy is
associated with 5 to 15 beat per minute
increase in fetal heart rate
• No documented adverse affects related
to exercise-induced fetal HR
Exercise Concerns During Pregnancy
• After first trimester, supine positions
results in restricted venous return of
blood to the heart because of an
enlarged uterus
• This position reduces cardiac output
and may cause supine hypotensive
syndrome
Supine Hypotensive Syndrome
• Characterized by :
– Hypotension
(abnormally low blood
pressure) and
bradycardia
(abnormally slow
heartbeat) when a
pregnant women
(especially near term)
lies supine
– This syndrome is the
result of compression
of the aorta
Supine Hypotensive Syndrome
• Exercises performed supine should be
phased out before the second trimester
• These include:
– Crunch, bench press, supine exercises on a
SB, and supine stretching
• Pregnant women can do abdominal
exercises in a side lying position and
upper body exercises on a seated
machine
Exercise Concerns During Pregnancy
• Less oxygen is available for aerobic activity
because the enlarging uterus interferes with
diaphragm movement.
• Avoid training at high levels of fatigue
• Due to center of gravity changes it is advisable
for pregnant women to use machines for
stability and support
– Balance, body control, and movement mechanics
are affected
– Be careful prescribing balance exercises
Exercise Concerns During Pregnancy
• Due to joint laxity in pregnancy, exercises
should be performed slowly and controlled
• High risk exercises like racket sports,
gymnastics, basketball, skiing, bicycling,
horse-back riding, and scuba diving should be
avoided
• Personal trainers should emphasize core
strengthening and pelvic floor exercises to
support the spine and prepare women for
labor
Exercise Concerns During Pregnancy
• Avoid stretching abdominal muscles
(baby is doing that for the mother)
because they cause a widening of the
rectus abdominis
• Avoid weighted squats
• Avoid extreme end ranges of motion
• Avoid prolonged periods of standing
Exercise Guidelines During Pregnancy
• Wear comfortable exercise footwear that gives
strong ankle and arch support
• Take frequent breaks, and drink plenty of fluids
to prevent overheating and dehydrating
• Avoid brisk exercise in hot, humid weather or
when you have a fever
• Wear comfortable clothing that will help you to
remain cool
• Wear a bra that fits well and gives lots of
support to help protect your breasts
Exercise Guidelines During Pregnancy
• Running:
–If you were a runner before
pregnancy, you often can keep
running during pregnancy although
you may have to modify your
routine.
–Talk to your physician about
whether running during pregnancy
is safe for you
Posture and Pregnancy
Posture and Pregnancy
• During pregnancy the weight of the baby may cause
– Lower Cross Syndrome (Anterior Pelvic Tilt)
• Tightening of the hip flexors and lumbar erectors
• Weakening of gluteus maximus, hamstrings, and
abdominal complex
– Upper Cross Syndrome (Forward Head and
Rounded Shoulders)
• Tightening of pectoralis major and minor, anterior
deltoid, and sternocleidomastoid (neck), upper
trapezius, and levator scapula
• Weakening of rhomboids, serratus anterior, and
lower trapezius
Posture and Pregnancy
• Perform Corrective Exercises
– Stretch the tight muscles and strengthen the weak
muscles
– Posterior pelvic tilts in quadruped or against the
wall
– Drawing-in to engage the core complex
– Chin tucks
– Avoid standing in one position for long periods of
time
Recommended Exercises During Pregnancy
• KEGEL Exercises:
– Strengthens the pelvic floor muscles, which
support the uterus, bladder and bowel
– Provides postural support
– As you are standing, sitting or lying down, try
to contract the muscles you would use to
stop urinating
– You should feel your pelvic muscles contracting
– If your abdominals or glutes tighten, you are not
strengthening the pelvic floor muscles
– Hold the contraction for three seconds then
relax for three seconds. Repeat 10 times
Contraindications for Exercise from International
Federation of Gynecology and Obstetrics
• Pregnancy induced hypertension (high
BP)
• Ruptured membranes (premature labor)
• Persistent bleeding after 12 weeks
• A dilated cervix ahead of schedule
• HR disease or lung disease
• Multiple birth pregnancy that creates a
risk of premature labor
Contraindications for Exercise from International
Federation of Gynecology and Obstetrics
• A placenta that blocks the cervix after 26
weeks
• Cardiac disease
• Pulmonary disease
• Thyroid function abnormality
• Poorly controlled type I diabetes
• Seizures
• Extreme obesity
• Low body weight (BMI less than 12)
Contraindications for Exercise from International
Federation of Gynecology and Obstetrics
• Intrauterine growth retardation
• History of sedentary lifestyle
• Severe anemia:
– lower than normal number of red
blood cells (erythrocytes) in the
blood
• Heavy smoking
• Chronic bronchitis
• Orthopedic limitations
Contraindications for Exercise from International
Federation of Gynecology and Obstetrics
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Sudden swelling of ankles, hands, or face
Persistent headaches, visual disturbance
Elevation of BP that persists after exercise
Unexplained abdominal pain
Insufficient weight gain:
– less than 2 pounds per month during last 2
trimesters
Monitoring Exercise HR During
Pregnancy
• Heart rate is a poor indicator of pregnancy
intensity
• A pregnant women should generally not
exercise above 60% of her maximal oxygen
consumption (VO2 max)
• The heart rate should not go above 140 beats
per minute during exercise
• Personal Trainers can use:
– Rate of Perceived Exertion (RPE) to
prescribe aerobic exercise intensity on a
scale of 12-16
– Talk Test
Exercise Guidelines
• Duration:
–30-60 minutes of low to moderate
exercise
– The two primary concerns in relation to long
durations of exercise (over 45 minutes) are
energy deficit and thermoregulation
• Frequency:
– Could be 7 days a week
Exercise Guidelines
• Avoid exercise in the supine position
after first trimester
• Avoid contact sports
• Emphasize corrective exercises for
upper and lower cross syndromes
• Avoid walking lunges (might increase
connective tissue injury to the pelvic
area)
• Exercise should not continue past the
point of fatigue
Exercise Guidelines
• Non weight bearing exercises are best like
swimming and stationary cycling
• Swimming, Walking, Elliptical Trainer, Prenatal
Pilates, Prenatal yoga and Prenatal low impact
aerobics are recommended
• Large increases in body temp should be
avoided
• Avoid swimming in water temperatures 28-30
degrees Celsius
• Adequate hydration and appropriate clothing
Exercise After Birth
• During the first three months after birth, women
are advised to observe the exercise guidelines
for pregnancy
• Swimming should be avoided until any bleeding
has stopped (usually about four weeks after
delivery).
• Women who do strenuous exercise while
breastfeeding should ensure that they have
adequate rest, fluids and food intake
• A woman who has had a cesarean delivery
should not exercise until her physician
gives her the go-ahead (usually six weeks)
Nutrition and Pregnancy
• National standards are an increase of 340
kcal/day during the second trimester and
450 kcal/day during the third trimester for a
total of 2200-2800 kcal per day
• Weight gain within pregnancy is generally within
the range of 25-35 pounds
• Rate of Weight Gain:
– 2-4 pounds during the first trimester
– 1 pound per week during the remainder of the
pregnancy
How Much Weight Women Should Gain During
Pregnancy
• Average weight gain (BMI 19.8 to 26):
– 25-35 pounds
• Underweight women (BMI less than 19.8):
– 28-40 pounds of weight gain
• Overweight women (BMI of 26-29):
– 15-25 pounds of weight gain
• Obese women (BMI greater than 29):
– 15 pounds of weight gain
• Teenage girls:
– 35 to 40 pounds of weight gain
• Women carrying twins:
– 35-45 pounds of weight gain
Where Does the Weight Go During
Pregnancy?
Protein Needs
• Pregnant women require about 60 grams of
protein per day
• Good sources of protein include:
– Lean meats
– Poultry
– Fish (Avoid eating shark, swordfish, king mackerel,
tilefish-they contain high levels of mercury)
– Dried beans
– Lentils
– Nuts
– Eggs
– Cheese
Calcium Needs
• The recommended amount of calcium for women ages
19 to 50, pregnant or not, is 1,000 milligrams (mg) per
day. (For teenage girls up to age 18, it is 1,300 mg
daily.) That's right—the amount of calcium you need
each day remains the same before, during and after
pregnancy.
You can get your calcium from:
– Green leafy vegetables
– Orange juice
– Milk
– Yogurt
– Cheese
Iron
• As maternal blood supply increases the need for iron
also increases
• Essential for hemoglobin synthesis
– red, iron-based protein pigment in red blood cells
that enables them to transport oxygen
• Pregnant women need 27 mg of iron per day
• Good sources of iron:
– Fish, poultry, whole grain breads and cereals, green
leafy vegetables, legumes, dried fruits, eggs, liver,
and red meat
• Coffee and tea interfere with iron absorption
Folate(Vitamin B)
• Promotes normal growth of the fetus and
placenta
• Necessary for the prevention of neural tube
defects (child is born with an underdeveloped
brain or no brain at all) or spina bifida (spinal
cord does not completely close)
• Recommendation is 600 mcg/day
• Good sources of folate include:
– Fortified cereals, lentils, peanut butter, corn,
cantaloupe, beets, asparagus, broccoli, spinach,
citrus fruits, and most berries
Foods to Avoid During Pregnancy
• Some infections can be picked up by pregnant women
and transferred to the developing baby via the
placenta
• Examples include toxoplasmosis, listeria and
salmonella
• Pregnant women are therefore advised to avoid the
following foods:
– Unpasteurized dairy products
– Soft or blue-veined cheeses
– Soft-whipped ice-cream
– Raw or undercooked eggs or shellfish
– Undercooked chicken
– Undercooked meat products in general (deli meats)
Alcohol, Cigarettes, and Caffeine
• Fetal Alcohol Syndrome:
– leading cause of mental retardation
• Small doses of alcohol may cause brain
damage, delayed growth, facial and vision
abnormalities
• Cigarette smoking causes low birth weight and
impaired oxygen transport
• Caffeine:
– Does cross the placenta and stays in the blood
stream
– Extensive caffeine use may cause low birth weight
– Consult physician about how much can be
consumed
Lactation
• Milk production requires an additional 330 kcal/day in
the first six months and 400 kcal/day in the second
six months
• Protein needs are 71 g/day or 1.1g/kg of BW per day
• Advantages of Breast Feeding
– Fewer infections
– Fewer allergies and intolerances
– Ease of digestion
– Improved cognitive development
– Decreases in the risk of childhood obesity and heart
disease
• Advised for women to breast feed for at least 12
Benefits of Breastfeeding for Mother
• Promotes faster shrinking of uterus
• Reduces postpartum bleeding
• Decreases risk of ovarian and breast
cancer
• Improves glucose profile in those with
gestational diabetes
• Strengthens bond with infant
• Saves money not spent on formula
Gestational Diabetes
• Pregnancy diabetes
• If a woman gets high blood sugar when she's
pregnant, but she never had high blood sugar before,
she has gestational diabetes.
• Usually diagnosed between the 24th and 28th week of
pregnancy when insulin resistance usually begins
• Diagnostic Criteria:
– Random blood glucose level greater than 200
mg/dL
– Fasting blood glucose level greater than 126 mg/dL
– Fail to clear glucose from the blood stream within
the specified time after an oral glucose tolerance
test
Gestational Diabetes
• The placenta supports the baby as it grows
• Hormones from the placenta help the baby
develop.
• But these hormones also block the action of the
mother's insulin in her body.
• Insulin resistance makes it hard for the mother's
body to use insulin.
• She may need up to three times as much
insulin.
Risk for Developing Gestational Diabetes
• A family history of diabetes in parents or brothers and
sisters
• Gestational diabetes in a previous pregnancy
• The presence of a birth defect in a previous pregnancy
• Obesity
• BMI greater than 29
• Older maternal age (over the age of 30)
• Previous stillbirth or spontaneous miscarriage
• A previous delivery of a large baby (greater than 9
pounds).
• A history of pregnancy induced high blood pressure
• Women of Hispanic, American Indian, or of AfricanAmerican decent.
Gestational Diabetes
• Treatment:
– Special meal plans
– Exercise
– Daily blood glucose testing and insulin
injections
• Usually goes away after pregnancy
• Once you've had gestational diabetes,
your chances increase in that it will return
in future pregnancies
Gestational Diabetes
• Risk for babies born to mothers with gestational
diabetes:
– Macrosomia (large, fat baby weighing 9 pounds or
more)
– Shoulder dystocia (birth trauma)
– Neonatal hypoglycemia (low blood sugar in the
newborn)
– Prolonged newborn jaundice (yellowing of the skin,
eyes, and mouth)
– Low blood calcium
– Respiratory distress syndrome.
Toxoplasmosis
• Can be caught from cat feces or ingesting
contaminated meat or soil
• Pregnant women should avoid handling cat
litter, wear gloves when gardening and wash
hands afterwards
Travel
• Avoid flying after 34-36 weeks of
pregnancy
• The main hazard is the risk of
developing deep vein thrombosis
(DVT)
–A clot in a deep vein, usually the leg
• The risk of getting a DVT is already
increased by pregnancy and the
individual risk could be higher for
some pregnant women