Exercise during pregnancy - 채용화 제일병원 전임의

1. Exercise in pregnancy 전임의 채용화

2. 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.

3. Prevalance of active pregnant women, as well as duration, frequency and intensity : lower than that of adult woman Evenson et al. 2004 Domingues et al . 2007 Evenson et al,2004 Walsh et al, 2011 Domingues et al, 2004

4. Exercise guideline for pregnant women

5. 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 Gynecologists (ACOG) Med Sci Sports Exerc 2007 ACOG 2002 not define ‘moderate intensity’ or the specific amount of weekly caloric expenditure from physical activity required

6. 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

7. 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

8. 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

9. 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

10. 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 overstre tch

11. 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 pregnancy 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

12. Boring's rating of perceived exertion 6 　 　 　 　 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

13. Frequency of exercise and rate of progression 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

14. 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

15. 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)

16. Recommended Energy Expenditure per Week During Pregnancy According to Body Weight at Start of Pregnancy For 4.5kg increase in bodyweight 76kcal/ wk for 16 MET h/wk 133kcal/ wk for 28 MET h/ wk increase Sports Medicine 2011 Zavorsky et al, Obstetric Gynecology 2011

17. Exercise in Postpartum Prepregnancy exercise routines gradually resume within days of delivery ( vary from individual ) No known maternal complications are assiociated with resumption of training Decreased incidence of postartum depression amd stress relieving Koltyn et al, 1997 Hale et al, 1996 ACOG 2002

18. Physical exercise on maternal outcome

19. Musculoskeletal discomforts Lower back, pelvic , and/or joint pain A 10-week exercise program  back pain intensity functional ability during pregnancy Tailored strengthening exercise, S itting 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

20. 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

21. higher intensity exercise to improve oxidative 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 P revent excessive weight gain .

22. 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 gestational 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 exercise.

23. Preeclampsia Recent trend toward a protective effect of physical activity in the prevention of preeclampsia. Dempsey et al 2005 Kasawara et al 2012

24. 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 components . A greater sense of well-being Improved sleep Robledo -Colonia et al 2012 Songoyard et al 2012 Nascimento 2011 Vallim et al 2011 Barakat et al 2011

25. Maternal hyperthermia No reports indicating that hyperthermia occurs during exercise among prengnat women

26. Physical exercise on fetal or neonatal outcome

27. Exercise and Miscarriage Few studies association between exercise and early pregnancy loss :mixed results

28. Fetal health Exercise intensity and duration  Uterine blood flow decrease progressively (by up to ~20%).  C ompensatory mechanisms act to preserve fetal VO2 remains unaltered. Lotgering et al, 1983

29. Fetal distress FHR is increased by about 20 beats/minute within 30 seconds 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, 2002 Van Doorn et al, 1992 Barakat et al,2010

30. Neonatal birth weight Aerobic dance exercise and strength twice a week, performed 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 exercise  no evidence of adverse results for fetal growth. Kramer et al, 2006

31. Maternal assessment

32. Maternal assessment before exercise recommendation Assessing the quantity and quality of dietary intake Maternal medical history and contraindications to exercise Exercise history both before and during the present pregnancy (intensity, type, and duration) Prepregnant BMI IOM (2009) WHO 아시아 - 태평양 지역 대한 비만학회 Total 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

33. Maternal advice after exercise recommendation S hould be aware of uterine contractions. N o 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

34. C onclusion The aim of exercising during pregnancy  to maintain a good condition without trying to reach a peak fitness level

35. Thanks you for your attention