High Yield Topics

Pregnancy

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Ovid: 5-Minute Sports Medicine Consult, The


Pregnancy
Suzanne Hecht
David Olson
Ronald Yee
Robby S. Sikka
Basics
American College of Obstetricians and Gynecologists (ACOG) 2002 recommendations for exercise in pregnancy:
  • In the absence of either medical or obstetrical complications pregnant women should participate in 30 min or more of moderate intensity exercise on most, if not all days of the week.
  • Thorough clinical evaluation required for recommendation of exercise program. In the absence of contraindications regular, moderate intensity exercise is advised. Women should be counseled for warning signs of when to stop exercise.
  • Avoid the following:
    • Activities with a high risk of falling or trauma.
  • Hockey, soccer, basketball, gymnastics, horseback riding, downhill skiing, and vigorous racquet sports, scuba diving
  • Women should avoid exercises where they will be in the supine position or exposed to prolonged motionless standing.
  • Women who plan to exercise at altitudes of >6,000 feet should be made aware of signs of altitude sickness.
  • Recommended exercises include walking, hiking, jogging/running, aerobic dance, swimming, cycling, rowing, cross-country skiing, and dancing.
  • Athletes participating in NCAA or professional sports may continue to participate in sports during the early phases of pregnancy, but should be made aware of the risks and benefits of continued participation in high-level sports and should be monitored more closely.
  • As pregnancy progresses athletic performance tends to decline. The physical demands of high intensity training should be balanced with close monitoring of body temperature, hydration status, and weight. These patients should be seen more frequently than their routine prenatal visits.
  • Gradual resumption of exercise in the post partum period is advised.
  • Return to physical activity after pregnancy has been associated with decreased incidence of postpartum depression if the exercise is felt to be stress relieving (1,2,3).
General Prevention
  • Warning signs to terminate exercise while pregnant (1,3,4):
    • Vaginal bleeding
    • Dyspnea prior to exertion
    • Dizziness
    • Headache
    • Chest pain
    • Muscle weakness
    • Calf pain or swelling
    • Preterm labor
    • Decreased fetal movements
    • Amniotic fluid leakage
  • Absolute contraindications to exercise in pregnancy (1,3,4):
    • Incompetent cervix
    • Intrauterine growth restriction
    • Multiple gestations (>triplets)
    • Persistent 2nd or 3rd trimester bleeding
    • Placenta previa after 25–28 wks of gestation
    • Preeclampsia
    • Pregnancy-induced HTN
    • Premature labor during current or prior pregnancy
    • Premature rupture of membranes
    • Risk of premature labor
Etiology
  • Thermoregulation:
    • In active nonpregnant women, exercise can elevate body temperature >103°F (39.2°C). Current recommendations are that core body temperature should not rise more than 1.5°C above resting temperature or >38.9°C during exercise in pregnancy (4,5).
    • Studies show that women appear well protected against hyperthermia even during prolonged exercise when the intensity is low. However, nearly all studies have been performed in women who trained prior to the study, and no prospective trials exist evaluating the risk of elevated temperatures. Nonetheless, no human study has elicited an increase of more than 1.1°C in maternal core temperature during pregnancy in response to exercise (4,6,7,8).
    • Metabolic changes:
      • Utilization of glucose is potential concern for the fetus. However, no studies have shown an actual decrease in fetal growth during exercise as there is likely increased glucose delivery after exercise, and women who exercise may have an increased placental size. Regular aerobic exercise has been shown to lower fasting and postprandial glucose concentrations in several small studies of previously sedentary individuals with GDM (2,7,9,10).
  • Lower back pain and pelvic pain:
    • Commonly associated with hormonal change. Increased ligamentous laxity is commonly seen in pregnancy and is thought to be related to the effects of estrogen and relaxin.
    • Exacerbated with weight bearing and activity.
    • Sitting, rest, and recumbency often ameliorate symptoms, and good results have been seen following acupuncture and use of a pelvic binder.
    • Hyperlordosis of pregnancy is associated with ligamentous laxity and pubic symphysis pain is caused by widening of the pubic symphysis caused in part by the effects of relaxin and can cause tenderness and pain over the pubic symphysis.
      • Rupture of the pubic symphysis is a rare complication.
      • Treatment of this is generally conservative.
      • Consideration of operative intervention is needed if diastasis is >4 cm. Careful monitoring of women who become pregnant within a few months of ACL reconstruction is recommended (11,12).
  • Cardiopulmonary changes:
    • Cardiac output may increase up to 40% by as early as 24 wks' gestation.
    • After 30 wks gestation, cardiac output is greatly influenced by body position; specifically recumbent position may decrease the cardiac output.
    • Decreased splanchnic blood flow may result from exercise potentially compromising uterine or umbilical artery blood flow.
      • Doppler US has shown no change in either arteries perfusion.
      • Increase in fetal heart rate may occur during maternal exercise.
      • Small percentage of fetuses that have bradycardia or decelerations in response to maternal exercise. Episodes of bradycardia resolved within 2 min and were not thought to be substantial enough to result in fetal hypoxia, and there were no adverse birth outcomes (13).
      • Iron supplementation is advised. It is not uncommon for a pregnant female to have a hemoglobin of 12.5 m/dL (2,7).
Commonly Associated Conditions
  • Orthopedic considerations during pregnancy include:
    • Soft tissue swelling in the 2nd and 3rd trimesters; may manifest as carpal tunnel syndrome (CTS).
      • Elevated prolactin, fluid retention, and hand positioning during nursing may worsen symptoms.
    • De Quervain's tenosynovitis and Meralgia paresthetica, neuropathy of the lateral femoral cutaneous nerve, are often seen.
    • Symptoms from nerve compression syndromes typically resolve after pregnancy and are treated conservatively.
    • Night splints can relieve CTS and steroid injections are useful in patients with recalcitrant symptoms. Similar treatments are recommended for de Quervain's patients. For patients with meralgia paresthetica, loose-fitting clothes, positional changes, and activity modification often relieve symptoms (11).
  • In late pregnancy and after delivery, transient changes in cortisol and clotting factors can lead to femoral head osteonecrosis:
    • Symptoms include antalgic gait, pain at rest, and painful range of motion.
    • Treatment: Restricted weight bearing; avoid surgery until after delivery.
  • Transient osteoporosis of pregnancy should be suspected in any patient with an antalgic gait and complaints of pain with activity, with minimal pain at rest (5,6,9,14).
    • Diagnosis: Usually presents in the 3rd trimester and plain AP radiographs with appropriate shielding often show diffuse osteopenia of the pelvis.
      • MRI may show high-intensity signal in the bone marrow on T2 images.

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    • Treatment: Protected weight bearing; Use of calcitonin is controversial but may shorten the duration of symptoms; bisphosphonate exposure during gestation may lead to decreased fetal bone growth.
    • Outcomes and follow-up:
      • Usually results in a self-limited course with no long-term sequelae; failure to diagnose transient osteoporosis could lead to fracture.
      • Serial exams are important to distinguish between these conditions. The clinician should try to avoid unnecessary radiographs, as hip pain is common in pregnancy.
Ongoing Care
Specific sport recommendations include (13):
  • Stationary upright cycling is recommended by the Society of Obstetricians and Gynecologists of Canada (SOGC) and American College of Sports Medicine (ACSM).
    • Fetal heart rate (FHR) and maternal temperature are not negatively affected. However there may be more variability of FHR and maternal temperature with higher intensity and longer duration exercise.
    • No negative fetal outcomes have been reported.
    • Recommended: Cycling for 30 min at a maternal heart rate around 140 beats per min (bpm), or exercising for 15 min at a rate of 155 bpm.
  • Swimming is an optimal exercise during pregnancy due to buoyant effects and the thermally conductive properties of water; recommended by ACOG, SOGC, and ACSM.
    • Baseline fetal heart rate may be less affected by swimming than cycling (1,3,10).
  • Walking: Many women use walking as a primary means of exercise throughout pregnancy.
    • Recommended by ACOG, SCOG and ACSM.
    • Increases maternal sense of well-being and decreases physical complaints.
    • Has not been shown to have a negative effect on maternal weight gain or on labor outcomes (13).
  • Weight training: Conditioning exercises and physical therapy to help maintain posture and prevent low back pain have been recommended by ACOG.
    • No reports of adverse effects with light to moderate weight training with free weights or weight machines.
    • Moderate strength conditioning has been shown to be safe in a healthy pregnancy with no obvious positive or negative effects; minimal fetal heart rate changes from baseline and fetal wakefulness is increased.
    • Avoid weight training in the supine position late in gestation (10,13).
  • Scuba diving is not endorsed by the ACOG.
    • Those who dive frequently and professionally are at 3–6 times greater risk for spontaneous abortion, IUGR, and fetal malformation (1,13).
  • High altitude exercise: Few reported cases of injury with high altitude exercise such as skiing, hiking, mountain biking, and running.
    • Pregnancy complications such as low birth weight occur at a higher rate at altitudes above 10,000 ft. SOGC has suggested women modify or avoid mountain climbing all together. Cycling with short bursts of moderate to high intensity at altitude levels of 6,000 and 7,300 ft have been reported without injury to mother or fetus (10,13).
  • Sports with abdominal trauma risk from contact or falling are discouraged (eg, downhill skiing, waterskiing, horseback riding, road cycling, surfing, basketball, racquet sports, ice hockey, soccer, and gymnastics) (3,13).
  • Running:
    • Can become uncomfortable later in gestation.
    • Jogging is supported by ACOG; may enhance placental growth, indicating a healthy pregnancy outcome (12).
  • Women who continue to exercise throughout pregnancy generally maintain their training regimens and level of fitness; cardiovascular risk level is well below those of the general populace and women who temporarily stopped exercise during pregnancy (10,12).
References
1. American College of Obstetricians and Gynecologists Committee Opinion Number 267. Exercise during pregnancy and the postpartum period. Washington, DC: The American College of Obstetricians and Gynecologists; January 2002.
2. Artal R, O'Toole M, White S. Guidelines of the American College of Obstetrics and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med. 2003;37:6–12.
3. Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2006;(1):CD000180.
4. Olson DA, Sikka RS, et al. Exercise in Pregnancy. Curr Sport Med Rep. 2009;8(3):147–153.
5. Ritchie JR, et al. Orthopaedic considerations during pregnancy. Clin Obstet Gynec. 2003;46:456–466.
6. Artal R, Fortunato V, et al. A comparison of cardiopulmonary adaptations to exercise in pregnancy at sea level and altitiude. Am J Obstet Gynecol. 1995;172:1170–1178.
7. Clapp JF. Exercise during pregnancy: An Update. Clin Sports Med. 2000;19:273–286.
8. Soultanakis-Aligianni HN. Thermoregulation during exercise in pregnancy. Clin Obstet Gynec. 2003;46:442–455.
9. Borg-Stein J, Dugan S, et al. Musculoskeletal aspects of pregnancy. Am J Phys Med Rehab. 2005;84:180–192.
10. Clapp JF. Long-term outcome after exercising throughout pregnancy: fitness and cardiovascular risk. Am J Obstet Gynecol. 2008;199:489.e1–489.e6.
11. Artal R, Wiswell RA, et al. Exercise in pregnancy: heat stress and pregnancy. Phiadelphia: Lippincott Williams & Wilkins, 1991.
12. Guerra JJ, Steinberg ME. Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg. 1995;77:616–624.
13. Blecher AM, Richmond JC. Transient laxity of an anterior cruciate ligament reconstructed knee related to pregnancy. Arthros. 1998;14:77–79.
14. Cunningham F, et al. Williams obstetrics 21st ed. McGraw-Hill: Medical Publishing Division. 2001:109–195.
Codes
ICD9
  • V22.0 Supervision of normal first pregnancy
  • V22.1 Supervision of other normal pregnancies
Clinical Pearls
  • Positive effects include potential risk reduction for development of gestational diabetes and pregnancy-induced HTN, decrease in post partum depression symptoms, and a decreased incidence of urinary incontinence, preeclampsia; no increased risk of pre-term birth.
  • The cardiovascular benefits of exercise are the same for pregnant women as they are for nonpregnant women.
  • Exercise in morbidly obese women may have a preventative effect on development of gestational diabetes.
  • All pregnant women should be evaluated for medical and/or obstetrical contraindications prior to beginning an exercise regimen.
  • Recreational and competitive athletes with uncomplicated pregnancies should remain active. They should be monitored by regular prenatal visits unless participating in high-intensity exercise.
  • Sedentary individuals without contraindications should be encouraged to begin exercising for the health benefits.
  • Women with a history of or risk for preterm labor or fetal growth restriction should be advised to reduce their activity in the 2nd and 3rd trimesters.
  • Women participating in higher-intensity sports should be monitored closely.


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