Exercise in pregnancy

전임의 채용화

Effects of Physical Activity, Traditionally

• Raising core body temperature • Increasing the risk of maternal musculoskeletal injury

• Moving transport of oxygen and nutrients to maternal skeletal

muscle rather than to the developing fetus.

• Prevalance of active pregnant women, as well as duration, frequency and intensity : lower than that of adult woman

Evenson et al. 2004Domingues et al . 2007

US Ireland Brazil Danish0

102030405060708090

100

Prevalence

Prevalence

Evenson et al,2004Walsh et al, 2011

Domingues et al, 2004

Exercise guideline for pregnant women

Exercise guideline for pregnant women

• In the absence of medical or obstetric complications, • 30 minutes or more of moderate exercise a day on most, if not all, days of the week.

• Women who were active before pregnancy may continue their activities but change intensity and frequency over the

course of pregnancy.

2002, the American College of Obstetricians and Gynecolo-gists (ACOG)

Med Sci Sports Exerc 2007ACOG 2002

not define ‘moderate intensity’ or the specific amount of weekly caloric expenditure from physical activity required

Absolute Contraindications

• Hemodynamically significant heart disease• Restrictive lung disease• Incompetent cervix/cerclage• Multiple gestation at risk for premature labor• Persistent second- or third-trimester bleeding• Placenta previa after 26 weeks of gestation• Premature labor during the current pregnancy• Ruptured membranes• Preeclampsia/pregnancy-induced hypertension

2002, ACOG

Relatively Contraindications

• Severe anemia• Unevaluated maternal cardiac arrhythmia• Chronic bronchitis• Poorly controlled type 1 diabetes• Extreme morbid obesity• Extreme underweight (BMI <12)• History of extremely sedentary lifestyle• Intrauterine growth restriction in current pregnancy• Pooly controlled hypertention• Orthopedic limitations• Poorly controlled seizure disorder• Poorly controlled hyperthyroidism• Heavy smoker

2002, ACOG

Warning Signs to Terminate Exercise While Pregnant

• Vaginal bleeding• Dyspnea prior to exertion• Dizziness• Headache• Chest pain• Muscle weakness• Calf pain or swelling (need to rule out thrombophlebitis)• Preterm labor• Decreased fetal movement• Amniotic fluid leakage

2002, ACOG

Type of exercise

• Aerobic exercise maintain cardiovascular fitness prevent chronic diseases involve large muscle groups in activities

,

Aerobic exercise Contraindication

walking or jogging gymnastics

using stationary bicycle Horseback riding

treadmill skiing

swimming Racquet sports

water aerobics exercises Contact sports

aerobic dance Suba diving

• Muscle strengthening

Use lighter weights, more reps

Try not to lift while flat on your back.

Try to avoid the valsalva manoeuver

Listen to your body

Sports Med 2011

• Strength training for pregnant women: once or twice per week on nonconsecutive days 8 to 10 muscular strength exercises per session.

• These effects have been rarely studied. : muscle conditioning practices such as Pilates, yoga, and weight training.

Zavorsky GS, 2011

to be careful with overexertion and over-stretch

Intensity of exercise

Maternal age(years)

Heart rate target zone(beats/min)

Heart rate target zone(beats/10sec)

<20 140-155 23-26

20-29 135-150 22-25

30-39 130-145 21-24

>=40 125-140 20-23

Artal et al 2003 Br J Sports Med

Modified heart rate target zones for aerobic exercise in preg-nancy

Davies et al, J Obstet Gynaecol Can, 2003

Correpond to 60-80% aerobic capacity

Modified heart rate target zones for overweight and obese pregnant woman

Boring's rating of perceived exertion6　 　 　 　7 Very,very light

8

9 Somewhat light

10

11 Fairly light

12

13 Somewhat hard

14

15 Hard

16

17 Very hard

18

19 Very,very hard

20　 　 　 　

A rating of 12-14( light), 15-16(vigorous) : appropriate for pregnant women

Borg et al, 1998

Frequency of exercise and rate of pro-gression

• Previously sedentary women start with 15min of exercise three times a week gradually increase to 30min four times a week at low to moderate intensity

• Active women keep their routine exercise or perform at least moderate-to-

vigorous exercise four times a week in sessions of 30min or more

• Athletes or women who have higher fitness status evaluated individually the intensity of exercise like running should be reduced

Davies et al 2003 J Obstet Gynaecol Can

American College of Sports Medicine(ASCM) and the American Heart Association (AHA) recommendations in 2007

: the amount of Physical-activity expenditure needed the intensity of exercise needed

Quantified physical activity using absolute intensity measurements

• Metabolic equivalent task(MET) (1 MET:energy used by the body while sitting) (1 MET = resting VO2 ~3.5mLO2/kg/min) = about 1 kcal/kgxh

• Vigorous physical activity :6METs 이상 (bicycling uphill or swimming continuous laps bicycling on a stationary bike)• Moderate physical activity : 3~6 METs (brisk walking at ~5-7km/h(3-4mph)

• Light physical activity

:2.5METs (walking at 3.2km/h (2.0mph)

Recommended Energy Expenditure per Week During Pregnancy According to Body Weight at Start of Preg-nancy

For 4.5kg increase in bodyweight76kcal/wk for 16 MET h/wk 133kcal/wk for 28 MET h/wk increase

Sports Medicine 2011Zavorsky et al, Obstetric Gynecology 2011

Exercise in Postpartum

• Prepregnancy exercise routines

gradually resume

within days of delivery ( vary from individual )

• No known maternal complications are assiociated with re-sumption of training

• Decreased incidence of postartum depression amd stress relieving

Koltyn et al, 1997

Hale et al, 1996

ACOG 2002

Physical exercise on maternal outcome

Musculoskeletal discomforts

• Lower back, pelvic, and/or joint pain • A 10-week exercise program back pain intensity functional ability during pregnancy

• Tailored strengthening exercise, • Sitting pelvic tilt exercise programs• Water gymnastics All had beneficial, although small, effects when compared with standard prenatal care

Kluge J et al 2011

Pennick V et al 2007

Stress urinary incontinence

• The best way to prevent incontinence to exercise pelvic floor muscles every day

following a vaginal assessment of correct contraction.

Mason L et al 2010

higher intensity exercise

to improve oxida-tive capacity

To increase post-exercise oxygen

consumption (VO2)

body fat percentage is reduced to a greater

extent

weight gain is limited in overweight and obese pregnant women.

Sports Med 2011

Prevent excessive weight gain.

Gestational diabetes control

• Moderate physical exercise performed during the entire pregnancy improved levels of maternal glucose tolerance (50 g maternal glucose screen 24–28 weeks) with no cases of ges-tational diabetes.

•Improving glycemic control in women who required insulin

Barakat et al 2012

Zhang et al 2006

•16 MET hours per week showed a 17% reduction in GDM risk, •56 MET hours per week showed a ~30% reduction in GDM risk, compared with subjects who did not exer-cise.

Preeclampsia

• Recent trend toward a protective effect of physical activity in the

prevention of preeclampsia. Dempsey et al 2005Kasawara et al 2012

the psychological impact

• Clinical trials find positive effects of physical exercise on depressive symptoms during pregnancy and postpartum

• Quality of life mainly with regards to physical and pain com-

ponents.• A greater sense of well-being• Improved sleep

Robledo-Colonia et al 2012Songoyard et al 2012

Nascimento 2011Vallim et al 2011

Barakat et al 2011

Maternal hyperthermia

No reports indicating that hyperthermia occurs during ex-ercise among prengnat women

Physical exercise on fetal or neona-tal outcome

Exercise and Miscarriage

• Few studies association between exercise and early preg-nancy loss :mixed results

Fetal health

• Exercise intensity and duration

Uterine blood flow decrease progressively (by up to ~20%). Compensatory mechanisms act to preserve fetal VO2 re-mains unaltered.

Lotgering et al, 1983

Fetal distress

• FHR is increased by about 20 beats/minute within 30 sec-onds of strenuous exercise stoppage.

• By 10 minutes post-exercise, FHR is 0–10 beats/minute higher, compared with pre-exercise after a bicycle test to maximal or near maximal exertion.

• brief intense exercise does not cause fetal distress.

• Regular exercise training does not alter the fetal response.

Kennelly et al, 2002Van Doorn et al, 1992

Barakat et al,2010

Neonatal birth weight

• Aerobic dance exercise and strength twice a week, per-formed by sedentary pregnant women for a minimum 12 weeks

not associated with reduction in birth weight, preterm birth rate, or neonatal well being measured with Apgar score.

Haakstad et al, 2011

• Vigorous exerciseno evidence of adverse results for fetal growth.

Kramer et al, 2006

Maternal assessment

Maternal assessment before exercise recommendation

• Assessing the quantity and quality of dietary intake• Maternal medical history and contraindications to exer-

cise• Exercise history both before and during the present

pregnancy (intensity, type, and duration)

• Prepregnant BMI

IOM (2009) WHO 아시아 - 태평양 지역

대한 비만학회Total weight

Gain (Kg)

Underweight < 18.5 < 18.5 12.5 – 18.0

Normal 18.5 - 24.9 18.5 - 22.9 11.5 – 16.0

Overweight 25.0 - 29.9 23.0 - 24.9 7.0 – 11.5

obese > 30.0 > 25.0 5.0 – 9.0

BMI ( 체질량지수 )= 체중 (kg)/ 키(m)2

Maternal adviceafter exercise recommendation

• Should be aware of uterine contractions.

• No longer suggest the routine counting of fetal movements in the second half of a woman’s pregnancy.

– Less than ten fetal movements in 12 hours is an indication that further investigation at a hospital is warranted.

NICE guidline, 2004

Conclusion

The aim of exercising during pregnancy

to maintain a good condition without trying to reach a peak fitness level

Thanks you for your attention