PREGNANCYANDEXERCISE

ABOUTPREGNANCY
acomplexbiologicalprocessfromgestationthroughlactationinvolvingdynamicchangestomaternalanatomyand
physiology
hormonallydriven/mediated
designedtomeetchangingfetalneeds
aseriesofphysiologicalchallengesforthewoman
Bodycomposition:
firsttwotrimesters:
highercirculatingestrogenandprogesteronepromote
pancreaticBetacellhyperplasiatoaugmentinsulinproduction;increasesmaternalfatnessforenergyreserve
lategestation:
maternalinsulinsensitivitydeclinesandfatnessdecreasesasfatenergydemandspeak
averageweightgain12kgwithfetusat3.5kg;largeruterus1kg;largerbreasts1.5kg;placenta0.7kg;amniotic
fluid0.8kg;maternalfluidgain2kg;maternalfatgain2.5kg
weightgainbytrimester:
13kg/68kg/3.4to4kg/withplateaunearterm
weightgainlessthan1kgpermonthisaclinicalconcern

Musculoskeletal:
weightgainandabdominalprotrusionaffectsbalance,postureandlocomotion
displacementofthediaphragmupwardcausescompensatoryincreaseinthoraxsize/diameter
changesinspinalmechanicsandpelvisrotation
centreofgravityshiftsforwardcausinglumbarlordosisinsomewomen(andlumbarflatteninginothers),forward
flexionofthespine,anteriorpelvictilt,andslumpingshoulders
50%havelowbackpain
estrogenandrelaxinleadtolaxityinconnectivetissues,predisposingsometojointandligamentdamageand
orthopedicoveruseinjury
roundandbroadligamentstrainandpainarecommon
diastasisrectiiscommon;maycauseprotrusionofanterioruterinewallinsome
Metabolism
restingVO2rises2030%becauseofincreasedfatfreemassgainassociatedwithfetalgrowth,anatomicalchanges
andcostsofincreasedQandVE
moreinsulinreleasedinearlystagesgreatermaternalCHOuse,reducedlipolysis,greateradiposity
inlaterstageslessmaternalCHOuseandincreasedfatoxidationduetoantiinsulinhormones(humanChorionic
Sommatomammotropinandothers)
maybepronouncedenoughtocausegestationaldiabeteswith
associatedfetalmorbidity
note:glucoseistheprimaryfetalfuel;crossesplacentalmembraneseasily
latetermmaternalCHOuseisprotectiveoffetalsupply
Cardiovascular
40to50%increaseinbloodvolume/waterandsodiumretentionduetoincreasedaldosteronesecretion
producesrelativeanemiawithlesserincreaseinRBCs,thusHctandHbconcentrationsdecrease(relatively)
vascularrelaxationwithenlargementofpelvicveinsandgreatervenouscapacitance
mediatedbygestationalhormones
heartvolumeandSVincreasesalongwithincreasedcontractility
duetoincreasedloading,augmentedvenousreturnandestrogen
restingHRincreases5to10bpminfirstmonth(hCGmediated)
HRcontinuestoincreaseafterwardduetoavascularshunttogrowinguteroplacentalunitandvasodilationeffectsof
gestationalhormones
QgoesuptomaintainBP

BPstaysconstantforfirst2trimesters,thenvenousreturnisoftenreducedwithcompressionofinferiorvenacavaby
graviduterus(greatestinsupinepositions)

Pulmonary/Ventilation
thoraciccageremodelingwithupwarddisplacementofthediaphragm;causesalteredlungvolumes
residualvolumedecreases;inspiratoryvolumeincreases;VCisunchanged;totallungcapacitychangesareminimal
increasedworkofbreathingandmorerelianceonaccessorymuscles
lesssmoothmuscletoneinairwayswithreducedpulmonaryresistance
ventilatorysensitivityincreases(mediatedbyestrogen)

lowerthresholdandincreasedsensitivitytoCO2,thusarterialO2saturationrisesandCO2drops
causesrespiratoryalkalosiswithbufferexcretionbykidney
MATERNALEXERCISE:ToleranceandChanges
Effectsinsubmaximalexercise:
weightsupported(swimming,cycling
VO2costnotchanged
weightdependent(walking,jogging,aerobics)
energycostsriseVO2increaseproportionaltoweightgain
agilityandweightstabilizationexercisecostsevenhigher
cardiopulmonaryresponsessamepatternsinsteadystateexerciseinuprightpositionbutvalueshigherforHR,Q,
SV,tidalvolumes,&VE
arterialCO2andpHlower
perceivedexertionunchangedforanygivenpoweroutput
inlategestationwithuprightexercise
SVandQlowerthanearliervaluesduetovenacavacompression
dypsneamayoccurwithexercise
physicalconditioningmayaugment,diminishorhavenoeffectsongestationalchanges
Effectsinbriefstrenuousexercise:
earlyresearchavoidedsuchexercise
recentevidence:lessrisktofetusinlowriskpregnanciesthanpreviouslythought
Effectsinprogressivemaximalornearmaximalexercise:
absoluteVO2maxnotaffectedbypregnancy
willvarydependentonactivityhabits
overcourseofgestationVO2maxinml/Kg/mindeclinesduetomassgain
maxHRmaybelower
ATunchanged
lowerRER&peakLA
bloodglucosedropsduringandpostexercise
linkedtoreducedliverglycogenstores,bluntedadrenal
responsestoexerciseandless
availabilityofCHOfor
contractingmuscle
issomeconjecturethatregularrepetitionofsuchexercisemaydeprivethefetusofglucoseandaffectgrowth
Effectsinprolongedsubmaximalexercise:(fewstudiesdone)
significantreductionsinmaternalglucoselevel
Effectsinstaticandresistanceexercise:
maternalHRhigher(asexpected)
maternalBPsimilartoorslightlylowerinfirsttrimesters,thenhigherinlatestages
FETALRESPONSES:acutematernalexercise
concernshavefocusedonthreefactors:
1.uteroplacentalbloodflowandoxygendelivery

findingsfromlimitedhumandataplusanimalstudies:
lowerabsoluteuteroplacentalflowrelateddirectlytointensityandduration
therearecompensatoryeffectsthatminimizefetalhypoxia
hemoconcentrationofmaternalbloodinexercise
redistributionofuteroplacentalflowtofavourplacentalexchangeratherthanuterinesupply
increasedavO2exchangeatplacenta
2.heatdissipationandfetalhyperthermia
issuematernalfeverandteratogeniceffects(seriousdamageassociatedwithclosingofneuraltube)
maternalcoretemperaturedeterminesfetaltemperature
concern:canmaternalexerciseandexerciseinducedriseincoretemperaturecausefetalhyperthermia?
findings:
maternalcompensationsminimizetheeffects:
increasedperipheralvasodilation
lowersweatingthreshold
increasedventilatoryheatexchange
noevidenceofteratogeniceffectstodate
3.fetalglucosesupply
glucosecriticaltofetaldevelopment
glucoseuseinexerciseriseswithintensity
canleadtopostexercisetransientfallinfetalglucosesupply
notknownifcompensatoryeffectexists
MONITORINGFETALHEALTH:effectsofmaternaltraining
twovariablescitedfrequently:HRandfetalbirthweight
HEARTRATEasanindex
bradycardiaknownsignofdistressduetohypoxicstress
tachycardiaseeninmildhypoxiaorduringrecoveryfromhypoxia
inlighttomoderateaerobicexercise
normalfHRresponseisaslowrisewithgradualreturntobaselineabout20minaftermaternalexerciseends
fHRriseislinearwithintensityanddurationandvarieswithmaternalfitness
modestbradycardiaresponsesareseensometimes
inbriefmaximalaerobicexercise
limitedresearchnofHRreductionsseen
inprolongedaerobicexercise
somereportsoftransientbradycardiaovertime
inheavymuscularexertioninvariedpostures
minimalfHRchanges
FETALBIRTHWEIGHTSasanindex:
- chronicheavyworkandpoornutritionunacceptablylowfBW
- lackofexerciseandovernutritioncausesinsulinresistance,gestationaldiabetesmellitus;fetalmacrosomia(fBW>
4Kg
- majorityofstudiesonmoderateaerobicactivitynoeffectonfBW
- combinedwithearlierworkshowsadoseresponseeffect
- strenuousexercisewithinmaternalandfetaladaptivereservemaystimulatefetalgrowthandincreasefBWiftraining
beginsearlyinpregnancy
- lessthanonceperweekor5ormoredaysperweekarebothassociatedwithaveragefBWandbeyondreserve
negativegrowtheffects
MaternalTrainingAdaptations

Givenprofoundchangesassociatedwithpregnancy,onemightassumethatmaternaltrainingadaptabilitymightvary
controlledlongtermstudiesarerare,butdatashows:
VO2maxandATsame
atrestandinsubmaximalexercisehemodynamiceffectsofpregnancydominatethefitnesseffects;HRisnot
reduced,SVisnotincreasedgreatly(havingalreadyadaptedtopregnancy)
moderatetoheavysteadystateexercisereducedHRmorenoticeable
perceivedexertionatanyintensityisreducedbytraining
adipositymaynotdecreaseasmuch
atsubmaxloads:ventilatorydemands&perceptionofrespiratoryexertionarereduced
atsubmaxloads:CHOuselowered

MaternalTrainingandPregnancylinkedVariables
Exerciseprescriptionsshouldincludeusualcomponentsofafitnessregimenaerobics,resistanceandflexibility
Aerobicprotocolsexistto
- increasesCVendurance
reduceexcessfatgain
reduceprevalentmaternalfetaldiseases:
gestationaldiabetes
preeclampsia
womenwithnormalpregnanciescanstartnewprogramuptostartofsecondtrimester
exerciseintensitycangraduallyincreasetoendofsecondtrimester
prudenttoavoidincreasesinprogramsduringweeks4and5offirsttrimesterwhenneuraltubeisclosingdueto
chronicfetalexposuretohighcoretempsofexercisingunfitmother
donotbeginprogramsorincreaseprogramsinlasttrimester
inlatestagesavoidexerciseifexcessivefatigueresults
Resistanceexerciseprotocols:
existtoprovidemoderateresistanceandseveralrepstoachievemuscularfatigue;these:
increasemuscularconditioninggenerally
specificallyacttoreducediastasisrecti,lowbackpain,urinaryincontinenceandtostrengthenmusclestofacilitate
labouranddelivery
reduceshypotension
commonproblemstoavoid:Valsalvamaneuverandsupineexercise,rapiddirectionalchanges,bouncing(dueto
ligamentandjointlaxity)effects: