Arch Gynecol Obstet
DOI 10.1007/s00404-016-4204-9
REVIEW
An overview of maternal and fetal short and long-term impact
of physical activity during pregnancy
Camila Ferreira Leite1 • Simony Lira do Nascimento1 • Fernanda Rodrigues Helmo2
Maria Luı́za Gonçalves dos Reis Monteiro2 • Marlene Antônia dos Reis2 •
Rosana Rosa Miranda Corrêa2
Received: 20 May 2016 / Accepted: 6 September 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose To explore information available in the literature
about the possible benefits resulting from physical activity
(PA) in non-risky pregnant women, repercussion on
maternal organism, fetal development, and on long-term
offspring health.
Methods Critical narrative review using online databases.
Results Through critical discussion of studies focused on
PA practiced during pregnancy, it was observed that some
of the outcomes investigated on both mother and offspring
showed conflicting findings. Considering the impact of
maternal PA in certain offspring characteristics, due to the
fact that their findings come from studies with small
samples, they do not allow the stablishment of scientific
evidence. However, a feature that shows broad consensus
among studies is the view of PA during pregnancy as a safe
intervention for mother and fetus. In situations where
studies employing PA of moderate-intensity have not
enough power to ensure a positive influence on certain
clinical outcomes, what is observed is the lack of their
influence, not negative impacts. Regarding epigenetic
modulations measured late in the offspring, it has been
attributed to PA a positive modulatory role on metabolic,
hemodynamic and even on behavioral characteristics.
& Rosana Rosa Miranda Corrêa
rosana@patge.uftm.edu.br
1
Department of Physiotherapy, Federal University of Ceará,
Fortaleza, Ceará, Brazil
2
Institute of Biological and Natural Sciences, Discipline of
General Pathology, Federal University of Triângulo Mineiro,
Rua Frei Paulino No. 30, Bairro Nossa Senhora da Abadia,
Uberaba, MG 38025-180, Brazil
•
However, possible mechanisms involved in these epige-
netic changes have not been sufficiently explored.
Conclusion Maternal PA appears to be safe for both
mother and fetus, and additional studies are needed to
confirm the real influence of this practice in the offspring,
as well as the perpetuation and transfer of these features
between generations.
Keywords Exercise
Risk
Long-term effects
Pregnancy
outcome
Child development
Background
The beneficial effects of physical activity regular practice
(PA) reflect on individual’s physical well-being and health.
Regular exercise enthusiasts had reduced risk of cardio-
vascular diseases and lower incidence of obesity, diabetes
and hypertension [1]. PA promotes a reduction in body fat
percentage, strengthens skeletal muscles, improves respi-
ratory capacity and increases serum high density lipopro-
tein (HDL) cholesterol [2]. Furthermore, improved glucose
tolerance [3], improved endothelial function, and opti-
mization of the autonomic balance with an increase in
parasympathetic tone [4] are also consequences of PA
regularly practiced.
Besides these hemodynamic and physiological effects, it
seems that PA before pregnancy may represent a protective
factor for gestational course, having positive effects on either
the additional metabolic stress that occurs during pregnancy
[3] or the maternal psychological health against depression
symptoms at the onset of pregnancy and postpartum [5].
Therefore, the outcomes of PA practiced during the gesta-
tional period have been subject of several studies, which
demonstrated that specific features of gestation are being
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modulated by them, such as reduction in low back pain and/
or musculoskeletal discomfort, prevention of lower limbs
varicose veins, prevention of deep vein thrombosis, reduc-
tion of labor time [6], reducing rates of stillbirths [7], among
others which will be discussed throughout this review. Also,
it is believed that PA evokes intrauterine environment
modulations, exerting an influence on fetal development that
will extend throughout the child’s life, although [8] definitive
mechanisms need to be elucidated.
In clinical practice, pregnant women can meet the rec-
ommendations for PA in guidelines which do not bring a
specific training plan to be followed, but rather intend to
provide general advice for its practice. For example, the
American Congress of Obstetricians and Gynecologists
(ACOG) recommend the practice of moderate-intensity
exercise for pregnant women without medical or obstetric
complications, for at least 30 min on most, if not all, days of
the week [9]. A similar recommendation is given by the US
Department of Health and Human Services, proposing that
all healthy women should get at least 150 min of moderate-
intensity aerobic activity per week during pregnancy [10].
The Royal College of Obstetricians and Gynaecologists
(RCOG) suggests that all women should be encouraged to
participate in aerobic and strength-conditioning exercise as
part of a healthy lifestyle during their pregnancy, as well as to
maintain moderate exercise during lactation, once there is
not any effect on the quantity or composition of breast milk
or even an impact on fetal growth [11].
So, in light of clinical guidelines that encourage preg-
nant women to maintain an active state during pregnancy,
the aim of this narrative review was to identify the infor-
mation available in the literature concerning PA during the
gestational period and the actual influence of them upon
mother and fetus during pregnancy, and also later, in the
offspring postpartum period. It is worthy to know that
exercise and PA level might represent different or com-
plementary concepts and then may pose distinct effects on
maternal and fetal health. Exercise is defined as any
structured, planned and repetitive form of PA, aimed at
improving health and maintaining one or more components
of physical fitness, while PA is any voluntary body
movement that increase energy expenditure above the basal
level (calories expended in the resting state) such as leisure
time or recreational activities, occupational activities,
including planned physical exercise or sports [12].
Physical activity during pregnancy and the benefits
to maternal organism
The benefits to maternal organism depend on the type and
modality of exercise. Aerobic exercise favors weight con-
trol [13], maintenance of physical conditioning, and it also
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Arch Gynecol Obstet
seems to reduce risks of gestational diabetes mellitus
(GDM) [14] in specific groups. As for light- to moderate-
intensity resistance exercises, they may improve muscle
resistance and flexibility with no complications to preg-
nancy [15, 16].
By modulating gestational weight gain (GWG), PA can
reduce the risk of obesity, which has a negative influence
on gestational course and is directly associated with
adverse health outcomes in both mother and offspring [17],
as well as it is closely associated with the development of
GDM, with increased risk of complications during preg-
nancy [18]. Therefore, pregnant women who join PA
programs and follow the recommendations specified in PA
guidelines tend to have appropriate GWG and to return to
pregestational body mass after delivery [19]. A longitudi-
nal study involving 2767 pregnant women found that more
than 150 min per week of PA during pregnancy, in
accordance with the Physical Activity Guidelines Advisory
Committee (2008) [10], was associated with 29 % lower
odds of exceeding GWG recommendations, while PA
practiced in lower levels (less than 150 min per week) were
not protective against excessive GWG [20], reinforcing the
importancy of meeting the PA guidelines. The search for
correct dose of PA required to ensure reduction in GWG
does not provide clear or consistent parameters to point out
about the best strategy for this purpose, but it does sig-
nalize that the adherence to exercise interventions acts as
an important feature to consider [21].
Results of a systematic review based on high quality
studies reinforce PA as a successful strategy in restricting
GWG during pregnancy [17]. It seems that benefits are
more intense when exercise program occurs during the
whole pregnancy and includes a combination of aerobic,
toning, resistance, strength, and flexibility exercises [22].
Some argue that interventions based on PA and dietary
counseling, usually combined with supplementary weight
monitoring, are the most effective strategy [23]. In this
regard, an important detail comes from a study conducted
with overweight or obese pregnant women, which showed
that PA added to dietary intervention without a personal-
ized PA prescription or a supervision program, was not
effective enough to reach the beneficial purposes, empha-
sizing that these overweight women may require more than
an advice only [24]. Thus, it is important to recognize that
for specific subgroups of pregnant women, the best results
are conditioned to supervised intervention programs.
Optimization of insulin sensitivity is another benefit that
may be modulated through PA performed by pregnant
women, particularly considering women with increased
baseline insulin resistance [25] and body weight status [26].
Pregnant women with obesity or overweight that had the
amount of PA effectively measured by an accelerometer
showed optimized insulin sensibility and reduced
Arch Gynecol Obstet
triglyceride levels, allowing supportive efforts for counsel-
ing obese women at risk for GDM in pregnancy to maintain
theirselves active during gestational period [26]. Differently,
when nulliparous women performed moderate-intensity
exercise for 15 weeks, from the 20th week of gestation, the
insulin sensitivity levels were similar to those found in
pregnant women in the control group [27]. Divergences
among results correlating PA and prevention of GDM occur
due to the lack of large and well-designed randomized trials
[28]. Besides, it is important to consider the fact that, since
behavioral interventions cannot be blinded easily from par-
ticipants [29], some women in the control group voluntarily
undertook far more PA than is usually seen in clinical
practice, and maybe this can mask results since differences
between groups (trained and sedentary pregnant women) can
be smaller than expected [30].
Thus, despite difficulties of blinding the samples in PA
studies, it is observed that conflicting results in the litera-
ture vary according to pregestational conditions of insulin
resistance, as well as with the pregnant woman’s weight
and even with the gestational period in which PA was
initiated. Results of a recent meta-analysis that investigated
exercise-only based intervention and GDM risk suggest
that PA in pregnancy provides a slight protective effect in
the active pregnant women [31]. Alongside this protective
effect, PA should also be considered an appropriate treat-
ment strategy to normalize blood glucose levels and pre-
vent or delay the need for insulin during pregnancy [28].
Lastly, the development of new studies evaluating exercise
characteristics like duration, intensity and effectiveness of
PA regimens to reduce the risk of GDM would be useful
for providing basis of recommendations in obstetric guides
[31].
Regarding effects of PA before conception and during
pregnancy on preeclampsia risk and its complications, two
small clinical trials provided insufficient evidence for
reliable conclusions [32]. Another secondary study con-
sidering both, PA during pre-pregnancy period as well as
during pregnancy, indicated a trend toward a protective
effect of PA in preeclampsia prevention considering the
results of observational studies [33]. Hence, a third met-
analysis analyzed possible dose–response relationship
between physical activity and preeclampsia and high-
lighted higher PA levels in pre-pregnancy or early preg-
nancy seemed to be associated with a significant 20–35 %
reduction in the relative risk of developing preeclampsia
[34]. Initiating PA before or in early pregnancy is an
important aspect to be considered in preeclampsia pre-
vention since normal pregnancy requires proper invasion of
trophoblast into uterine and myometrial spiral arteries,
which occurs up to 14–16 weeks of gestation, a step often
defective in preeclampsia. Maternal exercise is beneficial
for placental and fetal growth because it diverts blood
toward muscles and skin and creates a transient hypoxic
environment, which is the key to stimulate adequate pla-
centation, and consequently a good utero-fetal circulation,
in addition to potential oxidative stress, endothelial func-
tion, immunity and inflammation mechanism that also are
mediated by exercise [35]. In agreement, there is also
insufficient evidence to support recommending rest or
restriction of activity to women with normal blood pressure
to reduce their risk of preeclampsia and its complications
[36]. So, this is another outcome that should be investi-
gated in future studies, since most evidences were based on
observational studies and few randomized clinical trials
designed to investigated this outcome have failed to con-
firm such promising protective effect. Thus, it is necessary
to offer subsidies for consistent evidence about a possible
protective role of PA, with a favorable impact not only on
gestational course, but also as a future prevention factor for
pregnant women, since both American Heart Association
(AHA) and ACOG consider preeclampsia as a risk factor
for women future cardiovascular disease [37].
Considering now pregnant well-being and functional
status, moderate quality evidence suggested that an eight to
20 week exercise training program significantly reduced
the risk of women reporting lumbo-pelvic pain, while a
12 week training program reduced the risk of lumbo-pel-
vic-related sick leave and improved functional status, with
primary outcomes of pain, disability, absenteeism from
work and adverse events [16].
Regarding labor, a systematic review with meta-analysis
stated that healthy pregnant women who exercised regu-
larly at light to moderate levels appeared to modestly
increase the chance for normal delivery [38]. Additionally,
it seemed that duration of labor was shorter, considering
aerobic fitness as a variable responsible for this outcome
[6]. In nulliparous women, the duration of labor was
inversely associated with maximal oxygen uptake after
adjustment for birthweight [6]. Another secondary study
that considered only findings available from randomized
controlled trials with structured physical exercise pro-
grams, showed a reduced risk of cesarean delivery by
almost 15 %, which in itself would represent an important
incentive for adoption of this practice by pregnant women
[39].
With respect to labor pain, pregnant women trained with
exercise program directly targeted to labor with birthball
performed three times a week, lasting 20 min each session,
with total duration of 6–8 weeks, had positive results
regarding self-efficacy during childbirth, with shorter first
stage labor duration and also less epidural analgesia than
the control group [40], demonstrating that specific exercise
program can modulate even labor pain.
Whereas mood fluctuations are common during preg-
nancy, with a greater susceptibility to depression [41] and
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anxiety, PA can be consider a non-pharmacological inter-
vention to ensure maternal psychological wellbeing, since
psychosocial mechanisms intrinsically associated with PA
practice or its results as social support, distraction, body
image and self-esteem, provide reasonable explanations for
mental health benefits [42]. Acutely evaluating the effects
of neurotrophic factors and maternal hormones immedi-
ately after a short period of aerobic exercise during preg-
nancy and postpartum period, it was demonstrated that
exercise increases serum concentrations of some factors
known to function as central regulators for neurogenesis,
which perhaps confirms that exercises have positive
implications in maternal mood and cognitive performance
[43]. By the way, the continuity of PA in postpartum period
should be encouraged as previously mentioned in this
review, according to RCOG suggestions [11]. Results of a
study that subjected women in postpartum period to a low-
impact exercise training program revealed that besides
improved physical fitness, exercises did not seem to affect
lipid levels and lactation-associated hormone levels [44].
Finally, urinary incontinence was another outcome
evaluated in pregnant women submitted to a birth prepa-
ration program with PA, educational activity and instruc-
tions for exercises at home [45]. Positive results related to
urinary incontinence control through self-reporting of
pregnant women were found [45], which is another
important maternal outcome that showed to be modulated
by specific pelvic floor exercises included in training pro-
gram. A systematic review confirmed that initiating muscle
training of pelvic floor during pregnancy appears to reduce
the prevalence of urinary incontinence up to 6 months after
delivery in for women having their first baby não entendi:
four women?? [46]. Finally, supervised pelvic floor muscle
training programs generate greater results probably due to
sufficient exercise dose to strengthen muscle [46].
In general, it seems that PA level as well as specific
exercise programs are able to affect maternal organism,
despite results from interventional trials or even from
secondary studies can be conflicting for methodological
reasons, mainly related to inclusion of distinct subgroups of
pregnant women, or even by non-standardization of ges-
tational period in which PA is performed. And how about
their safety? Is PA safe for both mother and fetus? Is there
agreement on that?
Physical activity during pregnancy: Is it safe
for both mother and fetus?
Evidence suggests that the recommended moderate-inten-
sity exercise during normal pregnancy does not impose
risks or cause stress to the fetus [47] and is considered safe
for both mother and fetus. Naturally, this statement is true
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Arch Gynecol Obstet
when mother avoids activities with high risk of falling [48]
or abdominal trauma, as well as activities that could cause
hyperthermia [49]. Scuba diving is not recommended
considering potential risk of air embolism to fetus [49].
Cases of hemodynamically significant heart disease,
restrictive lung disease, incompetent cervix/cerclage,
multiple pregnancy at risk for premature labor, persistent
bleeding during the second or third trimesters, placenta
previa after 26 weeks of gestation, premature labor during
current pregnancy, ruptured membranes or pregnancy-in-
duced hypertension/preeclampsia are considering absolute
contraindications to physical practice [9]. Cases of chronic
bronchitis, severe anemia, extreme morbid obesity, exces-
sive smoking, orthopedic limitations, extremely sedentary
lifestyle, intrauterine growth restriction, as well as lack of
hyperthyroidism control, hypertension or type 1 diabetes
are relative contraindications, and should be carefully
evaluated on individual basis [9].
When investigated the association between PA and
cervical length reduction or preterm labor, a prospective
cohort study did not find any association when women
were exercised at moderate levels [50]. Data from a large
longitudinal cohort of pregnant women revealed that there
are no associations between exercise during pregnancy and
the odds of adverse pregnancy outcomes (i.e., late preterm
birth, cesarean delivery or hospitalization during preg-
nancy) [51]. Thereby, for pregnant women without con-
traindications, potential adverse outcomes of exercise
performed in mild to moderately intensities are few. There
may be an increased risk of physical injury when consid-
ering maternal physiologic process of increased ligament
laxity, which may affect joint stability.
Considering the risk to fetus due to PA during preg-
nancy, the following need to be taken into account: (1) type
of exercise; (2) level of intensity and duration of the
exercise; (3) level of training before pregnancy; (4) whe-
ther or not pregnancy is complicated by any other factors
which may place the fetus at risk [49].
Exercise characteristics and environmental factors may
significantly vary the exercise response of pregnant women
compared with those of nonpregnant women [52]. How-
ever, mother’s body responds differently to exercise and
makes use of compensating physiological mechanisms in
numerous conditions. For example, one of the possible
concerns regarding PA safety for the fetus considers the
redistribution of maternal blood flow during the activity. In
fact, decreased uteroplacental perfusion during gestation is
regarded as an important probable cause of restricted
intrauterine growth [53]. By optimizing skeletal muscle
perfusion during exercise, there could be a possible
restriction of perfusion for the developing fetus [54] that is
directly proportional to the intensity of exercise and to the
muscle mass used [55]. Therefore, it is concerned that high
Arch Gynecol Obstet
or moderate aerobic exercises could be considered haz-
ardous, as they could cause transient fetal hypoxia [56],
and hence, restricted fetal growth [57]. However, this
concern is discarded once the body makes use of an
adaptive and protective mechanism that confers a protec-
tive effect to the fetus due to maternal exercise practice.
Accordingly, light to moderate PA results in increased
maternal and fetal hemoglobin levels, improving transport
and diffusion of hemoglobin from mother to fetus across
placenta [58]. Since viability and delivery ratio of oxygen
and nutrients through placenta are major regulators of fetal
and placental growth [59], it stands out as an important
advantage of PA. Besides this adaptive capacity, umbilical
artery blood flow velocity waveform measurements in
pregnant women after exercise showed a reduction in
systolic and diastolic blood pressure, which was likely due
to the effects of PA on vascular resistance reduction, thus
increasing blood flow to the fetus [47].
Besides certainty of perfusion, reflections concerning
the mother’s blood glucose availability are also considered.
Intermittent decreases in maternal blood glucose levels
after exercise can lead to sudden changes in the placenta,
hence reducing transport of nutrients to the fetus [54].
However, PA promotes an alteration in metabolic pre-
dominance, increasing the use of lipids [57], which may be
a way of optimizing the use of glucose during gestation,
since the constant supply of nutrients to the fetus is mainly
composed of carbohydrates, the most important source of
energy for fetal heart [59]. Functional differences are also
observed in placenta with PA practice, with optimized
capacity, lower amount of nonfunctional tissue and a sig-
nificantly higher volume of villous tissue, mainly in
intermediate villi and terminal villi [60]. Besides, maternal
PA is potentially capable of evoking epigenetic changes,
culminating in the differentiation of gene expression
involved in amino acid metabolism and transport measured
in villous tissue samples [61]. Taken together, one should
consider that mother’s body has physiologically compen-
sating mechanisms during physical activities that ensure
her and developing fetus safety, especially demonstrated
when PA are performed at low or moderate-intensity.
In contrast with maternal influences, the influence of
exercise during pregnancy on offspring parameters, such as
weight, height and body fat percentage is not as linear. As
the variable weight is the primary focus of several studies
addressing the influence of PA during pregnancy on fetal
growth and it is also used to investigate late postnatal
health status [62], birth weight is the most easily measured
outcome as an indicator of intrauterine environment impact
on fetal development. Some studies showed no difference
between offspring birthweight of active and sedentary
mothers [63], but others showed reduced birthweight in the
offspring of active mothers [64]. Actually, a meta-analysis
that considered only studies with supervised exercise pro-
grams for pregnant women, with the minimum frequency
of fortnightly meetings, showed that this type of inter-
vention reduces the risk of having a large newborn without
a change in the risk of having a small newborn [65].
However, in general, the repercussion evoked by any
maternal interventions that has as result low birth weight, is
not positive, since it is believed that the potential risk
associated with PA would be a reduction in the size of live
offspring. In the follow-up of children who had a lower
birth weight due to maternal practice of PA, normal values
of head circumference measurements and normal height
were observed at the age of five, in comparison with
children of the same age [64]. On the other hand, if the
influence of maternal PA contributes to a decrease in off-
spring size at birth, resulting in a thin-fat phenotype, it
seems relevant to investigate whether PA contributes to a
reduced risk of obesity and subsequent postnatal diseases
[54]. As macrosomia also has a negative impact on chil-
dren development, maternal PA would be beneficial par-
ticularly when the activity is practiced by overweight or
obese women whose children have a higher risk of devel-
oping late obesity [54], cardiovascular and metabolic
complications in adult life [66]. A recent systematic review
with meta-analysis including randomized controlled trials
that performed supervised prenatal exercise concluded that
a reduced risk of delivering a large-at-birth newborn was
seen among active pregnancy, without a change in the risk
of having a small newborn, which, in a way, can impact on
reducing cesarean delivery rates [65].
Probably, the reason of divergent results regarding
influence of maternal PA on fetal growth is related to a sum
of variables and also with the way maternal physical state
is accessed, which are important obstacles faced by
researchers. Studies involving intervention in lifestyle of
pregnant women have significant challenges and limita-
tions and there are gaps in their results [67]. Moreover,
methodological issues also hinder interpretation of find-
ings. For example, a considerable amount of studies adopts
the measurement of PA through questionnaires and self-
reports, and not through motion sensors or supervised PA
[68]; other studies show incomplete data about the fre-
quency, intensity, duration and type of activity, or this
information is collected at any gestation age [62]. More-
over, neonatal outcomes, such as birthweight, birth length,
Apgar scores at 1 and 5 min and gestational age are not
always presented in studies, and when reported there is
often variables inconsistency hindering accurate interpre-
tation [52]. Even with these obstacles related to study
designs or failure to clearly conclusive data, the expertise
of specialists enables indication of PA for pregnant women,
and renowned associations disseminate these recommen-
dations to pregnant women without risk and after medical
123

approval as guidelines. Unfortunately, methodological
issues and bias in clinical studies preclude some conclusive
evidence regarding PA and favorable outcomes for the
mother and fetus.
So far, it is observed that considerations regarding
maternal and fetal outcomes took into account moderate-
intensity maternal PA. Guidelines for vigorous or strenuous
exercise are vague and there is insufficient data to counsel
pregnant women, particularly athletes who wish to con-
tinue training during pregnancy [69]. At this particular
point, a large breakdown exists between what is expected
from PA performed by pregnant athlete and what the
guidelines for gestational PA recommend. This is because
the current literature states that women should exercise at
the same level as previously, while current exercise
guidelines encourage moderate-intensity, low-impact aer-
obic exercise program for pregnant women. So what should
be recommended to women that preconceptually trained at
intense levels, with high performance or who exercised
recreationally following high-intensity power training as
CrossFitTM, for example? [70]. Would it be appropriate to
interrupt a high-intensity training, until it is proven that any
unsafe or unhealthy conditions occur as a result of PA?
[70]. For Women’s Sports Foundation, which since 1974
dedicates to creating leaders by ensuring all girls access to
sports, it is up to women, together with their caregivers, to
make decisions about the maintenance of previously
practiced PA during pregnancy.
A review about prenatal exercise guidelines since the
1950s until now evidenciated difficulties to find clear
exercise guidelines for pregnant women regarding specific
intensity and frequency, as well as the upper limits of
exercise frequency and intensity for already highly active
women and athletes [70]. This difficulty of specific stan-
dardization training regime for general use by pregnant
athletes is a function that different sports may require
emphasis on different types of training, as well as consid-
erations of previous maternal fitness levels should also be
considered for exercise prescription [71]. When pregnant
top athletes with significantly different initial aerobic
capacity were submitted to the same physical training
protocol, consisting of strength exercises, aerobic training
and interval aerobic exercise, however, performed more
intensively in more conditioned pregnant and with medium
intensity in the other, showed that all pregnant women
responded similar to exercise during pregnancy and post-
partum [71]. When changes in physiological variables
occurred between groups during the registration period,
after normalization to percentage maximal oxygen con-
sumption, their responses were essentially the same [71].
Thus, authors concluded that well-trained pregnant women
with uncomplicated pregnancy may perform strenuous
physical training without danger [71].
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Arch Gynecol Obstet
In this way, Zavorsky and Longo [72] argue that
increasing weekly physical activity expenditure while
incorporating the amount of vigorous-intensity exercise is
an important goal for pregnant women, especially those
who are overweight or obese, since subestimated exercise
intensity might prevent women and fetus from benefits.
They also suggest that light strength training during the
second and third trimesters does not affect newborn size
or overall health, and then it can be performed once or
twice per week on nonconsecutive days, with 8–10
strength exercises per session [72]. As suggested by
Nascimento et al. [73] resistance exercise should be
recommended.
A study that investigated maternal and fetal hemody-
namic parameters before and after high-intensity PA,
practiced for a short period by sedentary, regular or highly
active women, revealed that overall fetal well-being was
reassuring after short-duration exercise [69]. In contrast,
strenuous exercise caused a transient bradycardia and
Doppler changes in umbilical and uterine artery immedi-
ately after exercise in a subset of highly active women, a
finding whose clinical considerations are still unclear [69].
Although deliveries were uncomplicated, the study was not
designed to evaluate neonatal outcomes [69].
Summarizing, the absence of scientific evidence
regarding safety of high-intensity PA during pregnancy,
prevents clear conclusions and recommendations for
switching or reducing the intensity of these activities.
Physical activity and its long and short term effects
on offspring
Regular maternal PA during pregnancy has a positive
effect on hemodynamic fetal parameters by reducing heart
rate and increasing heart rate variability [74]. It is believed
that chronic exposure to exercise may impact the devel-
opment of autonomic nervous system in the second and
third trimesters of pregnancy, influencing autonomic con-
trol of fetal heart rate [74]. Investigation of cardiac auto-
nomic function in fetuses of physically active mothers
showed that intrauterine breathing movements conferred
increased autonomic input, providing an adaptive advan-
tage [4]. However, it is not known whether these benefits
would be transient or long-term [4], and in the latter case, if
these changes could be transmitted to subsequent genera-
tions [67]. Given the fact that environmental stressors,
particularly in intrauterine development, should not have a
transient, but a permanent effect on the organism [75], a
question waiting to be answered is the following: is it
possible that perinatal programming evoked by PA cause
permanent epigenetic modifications with a potentiality to
propagate to the next generations?
Arch Gynecol Obstet
Concerning maternal PA and newborn weight, when
pregnant woman achieves a healthy weight gain during
pregnancy course, a preventive effect in the actual and
subsequent generations is established [19]. It is believed
that PA practice affects body composition, hence having a
late effect on the offspring, once maternal adiposity is
strongly related with offspring birth weight [76]. Therefore,
a healthy diet during pregnancy combined with an active
lifestyle are important factors for preventing long-term risk
of obesity for two generations [19], avoiding perpetuation
of intergenerational cycle of obesity [66], that actually
seems to exist. Children at the age of 8 years had high
weight levels associated with pregnancy maternal habits
[77].
Investigating the long-term consequences of maternal
self-reported PA for offspring cardiovascular health at the
age of 15 through a prospective cohort study, it was found
that greater maternal PA was associated with lower body
mass index, waist circumference and glucose and insulin
levels in the offspring considering crude analysis [78].
When the analyses were adjusted for confounders, the
associations were lost, pointing out that influences of
maternal PA on offspring cardiovascular health should be
interpreted with caution [78].
Regarding growth and development, offsprings of
women who continued vigorous exercise during preg-
nancy, were evaluated 5 years after birth, concerning five
neurodevelopment characteristics—general intelligence,
oral language skills, academic readiness skills, motor per-
formance and perceptual motor skills—and showed higher
scores in general intelligence and oral language skills than
the control group of children born in the same period of
time [64]. Also, at the age of 2 years, the offspring of
mothers that followed the recommended level of leisure
time PA during pregnancy had a beneficial effect on the
development of language [79], thus emphasizing the per-
manence of beneficial effects on offspring triggered by PA
in the prenatal period. In contrast, another longitudinal
study pointed out that some benefits presented early in the
offspring should be transient [78]. In this study, they
showed that high levels of PA during pregnancy may be
associated with increased offspring vocabulary in early life,
but in a transient way, since this advantage in vocabulary
score disappeared at 38 months of age [80]. So, regarding
neurodevelopment of the child, there is still limited
research available to use PA as a motivator for pregnant
women [81].
Just as favorable modulations in fetal environment
during pregnancy evoke positive consequences that can be
temporarily or permanently measured in the offspring,
negative modulations in fetal environment also have the
potential to evoke adverse epigenetic changes. As an
example, a study investigated the influence of maternal
depression levels in offspring epigenetic changes through
umbilical cord analysis [82]. If it is proved that physical
activity has indeed a modulatory role in maternal depres-
sion levels, an indirect protective effect evoked by exercise
can impact on offspring. Therefore, considering the range
of favorable results of maternal PA regularly practiced,
highlighting its potential in reducing depressive symp-
tomatology, it seems acceptable to consider that maternal
exercise may reduce the risk of neurodevelopment and
psychiatric disorders in offspring [83].
Finally, if maternal PA prevents the occurrence of
eclampsia as previously reported [33], then there is a
possibility of another protective effect on the offspring. A
retrospective cohort study found that individuals born at
term and after a primiparous pregnancy with preeclampsia
showed higher depressive symptom scores in adulthood
compared with those born after a primiparous normoten-
sive pregnancy [84]. It was also noted that this adverse
maternal condition was associated with more self-reported
cognitive impairment in the late reported offspring [85].
Moreover, it has also been found that exposure to maternal
hypertensive disorders during pregnancy increases the risk
of psychiatric and psychological impairments in the off-
spring seven decades later [86].
The scarce findings available in the literature about the
changes evoked by maternal physical activity measured
latter on offspring point to positive outcomes, whether per-
manent or temporary. Until now, many of these investiga-
tions have not clarified the triggering mechanisms of change,
making it impossible to make clear associations between
maternal physical activity and the outcome in the offspring.
Future recommendations
It is known that pregnant women are largely not under
recommended levels of PA [51]. Regarding the counseling
to motivate healthy pregnant women to exercise, a possible
strategy should address appropriate type and amount of
exercise as well as the potential benefits that exercises
evoke in pregnant woman, fetus and newborn infant [81].
Ideally, this review should be able to present physiological
variables measured in pregnant women, fetus and late in
the offspring life, specifically assigned to training modal-
ities (strength, endurance, sports, high performance train-
ing, etc.), which certainly would bring interesting
information to the reader. However, the available literature
is insufficient about these specific parameters. A recent
secondary study with meta-analysis corroborates this
information, since authors report that they were unable to
identify if any intensity or type of exercise was more
beneficial, and even presented the problem that lies in the
comparison of interventions between different studies,
123

emphasizing that further studies are needed to directly
compare different exercise interventions [65]. For this
purpose, large and well-designed studies are necessary,
allowing conclusive evidences.
Summary
Physical activity practiced during pregnancy, beyond the
benefit evoked to mother’s body, seems to have potentiality
to influence some offspring characteristics. Recent studies
demonstrate that potential concerns (cardiac risks of exer-
cise, small for gestational age fetuses and abnormal fetal
heart rate response) are minimal compared with overall
benefits gained from regular physical activity through
pregnancy. However, there is a wide divergence of data due
to small samples or partial investigation of possible clinical
outcomes. Thus, it is not possible to conclude, whether in
face of a possible effective influence of maternal PA in
offspring characteristics, these would be permanent and also
able to be transmitted to future generations.
Practical implications
1. In addition to provide favorable maternal health effects
during the pregnancy period, PA practiced by pregnant
women may have impactful effects on offspring.
2. Substantial evidence of influence of this maternal habit
in offspring is not yet possible since there are divergent
results in investigative analyses from different clinical
studies.
3. Considering that any influence of PA practiced by
mothers during pregnancy could be established in the
offspring, if it occurs in a transiently or permanently
way or even if it is able to be transmitted to next
generations, is something that remains unknown.
4. From a practical point of view, from the moment these
evidences are demonstrated, maternal PA may be an
effective strategy for prevention of future offspring
problems.
Acknowledgments We thank Conselho Nacional de Desenvolvi-
mento Cientifico e Tecnológico (CNPq), Coordenação de Aper-
feiçoamento de Pessoal de Nı́vel Superior (CAPES), Fundação de
Amparo a Pesquisa do Estado de Minas Gerais (FAPEMIG), and
Fundação de Ensino e Pesquisa de Uberaba (FUNEPU) for financial
support.
Compliance with ethical standards
Funding This study was funded by Conselho Nacional de Desen-
volvimento Cientifico e Tecnológico (CNPq) (Grant Number
470029/20110), Coordenação de Aperfeiçoamento de Pessoal de
Nı́vel Superior (CAPES) (Grant Number PNPD-02604/094),
123
Arch Gynecol Obstet
Fundação de Amparo a Pesquisa do Estado de Minas Gerais
(FAPEMIG) (Grant Number CDS-APQ-02135-14), and Fundação de
Ensino e Pesquisa de Uberaba (FUNEPU) (Grant Number CDS-922/
2009).
Conflict of interest The authors declare that they have no competing
interests.
Ethical approval This article does not contain any studies with
human participants or animals performed by any of the authors.
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