Exercise during Exercise during PregnancyPregnancy

CASM/ OMA Cutting Edge Sport Medicine 2010CASM/ OMA Cutting Edge Sport Medicine 2010E. Laura Cruz, MDE. Laura Cruz, MD

SportCARE, Women’s College HospitalSportCARE, Women’s College Hospitaldrlaura@pivotsmo.comdrlaura@pivotsmo.com

The presenter declares no conflict of The presenter declares no conflict of interest.interest.

What’s new since 2002?What’s new since 2002?

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

(2010)(2010)►Available resourcesAvailable resources

What are the issues?What are the issues?

►Exercise during pregnancy previously Exercise during pregnancy previously restrictedrestricted

►Now encouraged for all healthy Now encouraged for all healthy pregnant womenpregnant women

►What are the benefits of exercise seen What are the benefits of exercise seen in pregnant patients?in pregnant patients?

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

►Heart rate changesHeart rate changes►HyperthermiaHyperthermia►Trauma to uterusTrauma to uterus►Hyper/ hypobaric exerciseHyper/ hypobaric exercise►HypotensionHypotension►MSK changesMSK changes

SOGC Guidelines 2003SOGC Guidelines 2003

►Evaluated research of the timeEvaluated research of the time► In conjunction with CSEPIn conjunction with CSEP►Used by SportCARE for its North Used by SportCARE for its North

America wide “Exercise and Pregnancy America wide “Exercise and Pregnancy Helpline”Helpline”

► Ideal for low risk pregnancy in inactive Ideal for low risk pregnancy in inactive or recreationally exercising womenor recreationally exercising women

Purpose of GuidelinesPurpose of Guidelines

►Standardize careStandardize care►Accessible to health care providersAccessible to health care providers►Protect maternal and fetal health and Protect maternal and fetal health and

well- beingwell- being►Evidence basedEvidence based

SOGC Recommendations SOGC Recommendations 20032003

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 SOGC Recommendations 20032003

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 SOGC Recommendations 20032003

3. Women should choose activities that will minimize the risk of loss of balance and

fetal trauma. (III-C)

Table 3Table 3

TABLE 3. Sports recommendations.TABLE 3. Sports recommendations.

Copyright © 2010 Current Sports Medicine Reports. Published by Lippincott Williams & Wilkins. 14

Exercise in PregnancyExercise in Pregnancy

Olson, David; Sikka, Robby S.; Olson, David; Sikka, Robby S.; Hayman, Jacob; Novak, Melissa; Hayman, Jacob; Novak, Melissa; Stavig, ChristinaStavig, Christina

Current Sports Medicine Reports. Current Sports Medicine Reports. 8(3):147-153, May/June 2009.8(3):147-153, May/June 2009.

doi: 10.1249/JSR.0b013e3181a61d51doi: 10.1249/JSR.0b013e3181a61d51

►

SOGC Recommendations SOGC Recommendations 20032003

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

SOGC Recommendations SOGC Recommendations 20032003

5.Initiation of pelvic floor exercises in the immediate postpartum period may reduce

the risk of future urinary incontinence. (II-1C)

SOGC Recommendations SOGC Recommendations 20032003

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 Cochrane Systematic ReviewsReviews

► Aerobic Exercise in Aerobic Exercise in PregnancyPregnancy

► Prevention of Prevention of Gestational Gestational DiabetesDiabetes

►Decrease risk of Decrease risk of Pre-EclampsiaPre-Eclampsia

Aerobic exercise for women during pregnancyAerobic exercise for women during pregnancy

Michael S Kramer1, Sheila W McDonald2Michael S Kramer1, Sheila W McDonald21Faculty of Medicine, McGill University, Montreal, Canada. 2Department of Epidemiology and Biostatistics, 1Faculty of Medicine, McGill University, Montreal, Canada. 2Department of Epidemiology and Biostatistics,

McGill University, Montreal, CanadaMcGill University, Montreal, Canada

Citation: Citation: Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database of Cochrane Database of Systematic ReviewsSystematic Reviews 2006, Issue 3 2006, Issue 3(reviewed and published in 2009)(reviewed and published in 2009)

► Authors' conclusionsAuthors' conclusions

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

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

Exercise for Diabetic Pregnant WomenExercise for Diabetic Pregnant Women

Ceysens G, Rouiller D, Boulvain M. Ceysens G, Rouiller D, Boulvain M.

Cochrane Database of Systematic Reviews 2006, Issue 3.Cochrane Database of Systematic Reviews 2006, Issue 3.

► Authors' conclusionsAuthors' conclusions

► There is insufficient evidence to recommend, or advise There is insufficient evidence to recommend, or advise against, diabetic pregnant women to enrol in exercise against, diabetic pregnant women to enrol in exercise programs. Further trials, with larger sample size, involving programs. Further trials, with larger sample size, involving women with gestational diabetes, and possibly type 1 and 2 women with gestational diabetes, and possibly type 1 and 2 diabetes, are needed to evaluate this intervention. diabetes, are needed to evaluate this intervention.

► [Note: The six citations in the awaiting classification section of the [Note: The six citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.] review may alter the conclusions of the review once assessed.]

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

Meher S, Duley L.Meher S, Duley L. Cochrane Database of Systematic Reviews 2006, Cochrane Database of Systematic Reviews 2006, Issue 2. Issue 2.

► MAIN RESULTS: MAIN RESULTS: Two small, good quality trials (45 women) were included. Both Two small, good quality trials (45 women) were included. Both

compared moderate intensity regular aerobic exercise with compared moderate intensity regular aerobic exercise with maintenance of normal physical activity during pregnancy. maintenance of normal physical activity during pregnancy. The confidence intervals were wide and crossed the line of no The confidence intervals were wide and crossed the line of no effect for all reported outcomes including pre-eclampsia effect for all reported outcomes including pre-eclampsia (relative risk 0.31, 95% confidence interval 0.01 to 7.09). (relative risk 0.31, 95% confidence interval 0.01 to 7.09).

► AUTHORS' CONCLUSIONS: AUTHORS' CONCLUSIONS:

There is insufficient evidence for reliable conclusions about There is insufficient evidence for reliable conclusions about the effects of exercise on prevention of pre-eclampsia and its the effects of exercise on prevention of pre-eclampsia and its

complicationscomplications..

CASM Position Paper 2008CASM Position Paper 2008

► Previously active women may continue in T1 Previously active women may continue in T1 ► Mild core temp changes are toleratedMild core temp changes are tolerated► No affect birth weightNo affect birth weight► No known threshold for maternal exercise, No known threshold for maternal exercise,

and fetal stress: ongoing research neededand fetal stress: ongoing research needed► Psychological benefits can be achieved by Psychological benefits can be achieved by

moderate exercisemoderate exercise► Post Partum exercise is supported as Post Partum exercise is supported as

intervention for healthy lifestyle without intervention for healthy lifestyle without adverse effectsadverse effects

Exercise in the Active Pregnant Exercise in the Active Pregnant WomanWoman

Evidence- based Evidence- based Recommendations for Active Recommendations for Active

Women in 2010Women in 2010►Paucity of new research about Paucity of new research about

pregnant elite athletespregnant elite athletes►Many anecdotes (AKA case reports?)Many anecdotes (AKA case reports?)►Some advances in role of exercise and Some advances in role of exercise and

GDMGDM►Little if any data on elite pregnant Little if any data on elite pregnant

athletesathletes►One comprehensive review (level III)One comprehensive review (level III)

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

Wolfe, L A. FACSM; Mottola, M F.Wolfe, L A. FACSM; Mottola, M F.MSSE 2002; 34 (5): S46 B5 Mini-SymposiumMSSE 2002; 34 (5): S46 B5 Mini-Symposium

► In summary, information presented in In summary, information presented in this mini-symposium supports the this mini-symposium supports the hypothesis that healthy, fit pregnant hypothesis that healthy, fit pregnant women are well-adapted to perform women are well-adapted to perform acute bouts of high-intensity, short acute bouts of high-intensity, short duration as well as prolonged exercise duration as well as prolonged exercise at moderate intensities at moderate intensities

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

Kristin Reimers KardelScand 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 Retrospective questionnaire and review of pregnancy diaries in 30 elite Finnish endurance athletesin 30 elite Finnish endurance athletes

► Compared to 30 control womenCompared to 30 control women► No information about training regimenNo information about training regimen► 23 athletes continued to train (GA 7-39 wk)23 athletes continued to train (GA 7-39 wk)► 18 continued to compete (GA 0-25 wk)18 continued to compete (GA 0-25 wk)► Results: Results:

No significant differences in fetal well being, labour, No significant differences in fetal well being, labour, complicationscomplications

► Authors concluded endurance training was safe and effect of Authors concluded endurance training was safe and effect of pregnancy on performance was individualpregnancy on performance was individual

Exercise in PregnancyExercise in Pregnancy

Olson, David; Sikka, Robby S.; Hayman, Jacob; Novak, Melissa; Stavig, Olson, David; Sikka, Robby S.; Hayman, Jacob; Novak, Melissa; Stavig, ChristinaChristina

Current Sports Medicine Reports: Current Sports Medicine Reports: May/June 2009 - Volume 8 - Issue 3 - pp 147-153May/June 2009 - Volume 8 - Issue 3 - pp 147-153

► The 2006 “Cochrane review highlights the need for more studies The 2006 “Cochrane review highlights the need for more studies examining the impact of exercise upon pregnancy (35). examining the impact of exercise upon pregnancy (35).

► However, recent research suggests that positive effects include However, recent research suggests that positive effects include

potential risk reduction for development of gestational diabetespotential risk reduction for development of gestational diabetes pregnancy-induced hypertension, pregnancy-induced hypertension, decrease in postpartum depression symptoms, and decrease in postpartum depression symptoms, and a decreased incidence of urinary incontinence and preeclampsia, a decreased incidence of urinary incontinence and preeclampsia,

and and no increased risk of preterm birth (1,8,13,28,29,31,36).” no increased risk of preterm birth (1,8,13,28,29,31,36).”

““Despite methodological pitfalls in the studies published, the Despite methodological pitfalls in the studies published, the evidence does suggest a benefit of exercise in pregnancy” evidence does suggest a benefit of exercise in pregnancy”

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

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

Available ResourcesAvailable Resources

► PARmed- X for PARmed- X for PregnancyPregnancy

► Cochrane Reviews?Cochrane Reviews?► SportCARE Exercise SportCARE Exercise

and Pregnancy and Pregnancy HelplineHelpline

► SportCARE Active SportCARE Active Pregnancy ClinicPregnancy Clinic

PARmed-X for PregnancyPARmed-X for Pregnancy

SportCARE ResourcesSportCARE Resources

►Exercise and Pregnancy Helpline Exercise and Pregnancy Helpline 1-866-937-76781-866-937-7678

►Active Pregnancy Clinic Active Pregnancy Clinic 416-323-6479416-323-6479 MSK; pelvic floor; metabolic conditions of MSK; pelvic floor; metabolic conditions of

pregnancy (e.g. uncomplicated GDM; pregnancy (e.g. uncomplicated GDM; obese patients)obese patients)

Pregnant athletesPregnant athletes

Thank you!Thank you!