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In This Chapter Benefits and Risks of Exercise During Pregnancy Maternal Fitness Gestational Diabetes Preeclampsia Maternal Obesity Maternal Exercise and the Fetal Response Contraindications and Risk Factors Physiological Changes During Pregnancy Musculoskeletal System Cardiovascular System Respiratory System Thermoregulatory System Programming Guidelines and Considerations for Prenatal Exercise Biomechanical Considerations for the Pregnant Mother Low-back and Posterior Pelvic Pain Pubic Pain Carpal Tunnel Syndrome Diastasis Recti About The Author Stress Urinary Incontinence Sabrena Merrill, M.S., has been actively involved in the fitness Nutritional Considerations industry since 1987. An ACE-certified Group Fitness Instructor Psychological Considerations and Personal Trainer, Merrill teaches group exercise, owns and Benefits and Risks of Exercise Following Pregnancy operates her own personal training business, has managed Physiological Changes Following fitness departments in commercial facilities, and lectured to Pregnancy university students and established fitness professionals. She Programming Guidelines and Considerations for Postnatal has a bachelor’s degree in exercise science as well as a master’s Exercise degree in physical education from the University of Kansas, and Biomechanical Considerations for the Lactating Mother has numerous certifications in exercise instruction. Merrill acts Case Study as a spokesperson for the American Council on Exercise (ACE) Summary and is involved in curriculum development for ACE continuing education programs. Additionally, Merrill presents lectures and workshops to fitness professionals nationwide. CHAPTER 23 Pre- and Postnatal Exercise Sabrena Merrill n increasing amount of research on exercise in pregnancy has led to a waning debate over the maternal and fetal risks of regular physical activity during pregnancy. There is a growing trend of women entering pregnancy with regu- Alar aerobic and strength-conditioning activities as a part of their daily routines. Many women who are not physically active view pregnancy as a time to modify their lifestyles to include more health-conscious activities, including exercise. Traditionally, the medical community has encouraged pregnancy (Zhang & Savits, 1996; Ning et al., 2003). Given pregnant women to reduce their habitual levels of physical the current epidemic of obesity and its associated comorbidi- exertion and refrain from starting strenuous exercise pro- ties, as well as the apparent health risks of not exercising, grams. These restrictive guidelines were based on concerns fitness professionals who are competent to work with this that exercise could negatively affect pregnancy outcomes population can provide safe and effective exercise program- by increasing core body temperature, raising the risk of ming to promote a healthy pregnancy and healthy lifestyle congenital anomalies, and shifting oxygenated blood and after the birth. nutrients to maternal skeletal muscles—and away from the fetus [American College of Obstetricians and Gynecologists Benefits and Risks of Exercise (ACOG), 1985; Shangold, 1989]. More recent investiga- During Pregnancy tions, however, focusing on both aerobic training and strength conditioning in pregnancy, have shown no increase in early vidence is increasing that regular prenatal exercise pregnancy loss, late pregnancy complications, abnormal fetal is an important component of a healthy pregnancy. growth, or adverse neonatal outcomes, suggesting that previ- EExpectant mothers can maintain or even improve ous recommendations have been overly conservative (Clapp, cardiovascular and muscular fitness. Additionally, regular 1989; Klebanoff et al., 1990; Hatch et al., 1993; Kardel et al., 1998; Sternfeld et al., 1995; O’Neill, 1996). exercise is associated with a lower incidence of excessive While prenatal exercise recommendations from allied maternal weight gain, gestational diabetes mellitus (GDM), healthcare professionals are becoming more commonplace, pregnancy-induced hypertension, varicose veins, deep vein the majority of women do not get the recommended mini- thrombosis, dyspnea, and low-back pain (Davies et al., 2003; mum amount of daily physical activity. It is estimated that Weissgerber et al., 2006). Furthermore, it has been shown only 42% of pregnant women exercise 30 minutes or more that women who continue regular, weightbearing exercise at least three times a week, and 23% of healthy, previously throughout the entire duration of pregnancy tend to have active women stop exercise or reduce it significantly during easier, shorter, and less complicated deliveries (Clapp, 2002). 576 Chapter twenty-three Pre- and Postnatal Exercise Maternal Fitness considered an adjunct therapy for women with Healthy women who consistently exercise GDM. Preliminary studies have found that women throughout pregnancy show a marked reduction who participated in any type of recreational activ- in weight gain, fat accumulation, and fat reten- ity within the first 20 weeks of gestation decreased tion. In one study, pregnant exercisers had average their risk of GDM by almost half (Dempsey et al., increases in weight (29 pounds; 13 kg) and skin- 2004). Research has shown that even mild exercise • fold thicknesses (10 mm) well within the normal (30% of V O2max, regardless of modality) com- range, but their body-fat mass averaged 3% lower bined with nutritional control can help prevent than the control subjects who performed no exer- GDM and excessive weight gain during pregnancy cise during pregnancy (Clapp & Little, 1995). In (Batada et al., 2003). other words, the women who performed regular weightbearing exercise throughout their pregnan- Preeclampsia cies maintained a leaner body composition than A serious maternal-fetal disease called pre- their sedentary counterparts. eclampsia is diagnosed after 20 weeks of gestation Due to the many physiological adaptations that and characterized by persistent hypertension occur during pregnancy, women who continue (>140/90 mm/Hg) and proteinuria (24-hour moderate-to-high levels of endurance exercise can urinary protein level ≥0.3 g) (ACOG, 2002a). experience an increase in their maximal aerobic Complications associated with preeclampsia capacity by up to 10% postpartum, even though include preterm birth, abruptio placentae, renal exercise volume is typically reduced by the added failure, pulmonary edema, cerebral hemorrhage, responsibility of childcare (Clapp & Capeless, circulatory collapse, eclampsia, and the necessity 1991). Furthermore, improvements in aerobic for immediate delivery regardless of gestational • efficiency, but not necessarily V O2max, are seen in age. Risk factors for preeclampsia include abnor- women who begin a low-volume exercise program mal placental development, predisposing maternal (moderate intensity for 20 minutes, three to five constitutional factors, oxidative stress, immune days per week) during pregnancy (Clapp, 2002). maladaptation, and genetic susceptibility. A review of the literature examining physi- Gestational Diabetes cal activity and preeclampsia risk reveals several Glucose intolerance that is first recognized or epidemiological studies that indicate that regular diagnosed during pregnancy is called gestational leisure-time physical activity in early pregnancy diabetes. Maternal muscular insulin resistance is associated with a reduced incidence of pre- during mid-pregnancy is a normal response to hor- eclampsia (Weissgerber et al., 2004). Although monal adaptations that occur to ensure adequate not proven, several protective mechanisms associ- glucose regulation for fetal growth and develop- ated with exercise are thought to play a role in ment. In women with GDM, this insulin increase is preeclampsia prevention, including enhanced exacerbated, resulting in maternal hyperglycemia. placental growth and vascularity, enhanced anti- Women with GDM are more likely to have com- oxidant defense systems, reduction of the systemic plications such as a difficult labor and delivery, as inflammatory response, and improved endothelial well as delivery by Caesarean section (C-section). function (Weissgerber et al., 2006). Risk factors for GDM include a family history Traditional treatment of gestational hyperten- of diabetes, previous diagnosis of GDM, belonging sion and mild preeclampsia has focused on bed to a high-risk ethnic group (Aboriginal, Hispanic, rest to prevent blood pressure increases associated South Asian, Asian, or African descent), age ≥35 with daily activity. However, up to one-third of years, overweight [body mass index (BMI) ≥25], women fail to comply with bed rest recommenda- obesity (BMI ≥30), or a history of insulin resistance tions, and compliance does not affect pregnancy (ACOG, 2001). Once diagnosed, GDM patients outcome in women who develop mild preeclamp- are primarily treated through nutritional manage- sia in the latter part of gestation (Magee, Ornstein, ment by a registered dietician (R.D.). Exercise is & von Dadelszen, 1999). More recent treatment ACE ADVANCED HEALTH & FITNESS SPECIALIST MANUAL Pre- and Postnatal Exercise Chapter twenty-three 577577 guidelines for hypertension and mild preeclampsia delivery. Exercise performed before conception have shifted toward ambulatory management and during pregnancy may help to prevent these with careful patient monitoring (Lenfant, 2001; obesity-related complications by decreasing Moutquin et al., 1997). Exercise intervention BMI to a healthy range, preventing GDM and studies in women