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Exercise Guidelines in Pregnancy

Article in Sports Medicine May 2011


DOI: 10.2165/11583930-000000000-00000 Source: PubMed

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Sports Med 2011; 41 (5): 345-360
CURRENT OPINION 0112-1642/11/0005-0345/$49.95/0

2011 Adis Data Information BV. All rights reserved.

Exercise Guidelines in Pregnancy


New Perspectives
Gerald S. Zavorsky1,2 and Lawrence D. Longo3
1 Human Physiology Laboratory, Marywood University, Scranton, Pennsylvania, USA
2 The Commonwealth Medical College, Scranton, Pennsylvania, USA
3 Center for Perinatal Biology, School of Medicine, Loma Linda University, Loma Linda, California, USA

Abstract In 2002, the American College of Obstetricians and Gynecologists pub-


lished exercise guidelines for pregnancy, which suggested that 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 is recommended for pregnant women.
However, these guidelines did not define moderate intensity or the specific
amount of weekly caloric expenditure from physical activity required. Recent
research has determined that increasing physical activity energy expenditure
to a minimum of 16 metabolic equivalent task (MET) hours per week, or
preferably 28 MET hours per week, and increasing exercise intensity to 60%
of heart rate reserve during pregnancy, reduces the risk of gestational diabetes
mellitus and perhaps hypertensive disorders of pregnancy (i.e. gestational
hypertension and pre-eclampsia) compared with less vigorous exercise. To
achieve the target expenditure of 28 MET hours per week, one could walk at
3.2 km per hour for 11.2 hours per week (2.5 METs, light intensity), or pref-
erably exercise on a stationary bicycle for 4.7 hours per week (~67 METs,
vigorous intensity). The more vigorous the exercise, the less total time of exercise
is required per week, resulting in 60% reduction in total exercise time compared
with light intensity exercise. Light muscle strengthening performed over the
second and third trimester of pregnancy has minimal effects on a newborn in-
fants body size and overall health. On the basis of this and other information,
updated recommendations for exercise in pregnancy are suggested.

1. Introduction amount of weight during pregnancy can result in


obesity-associated co-morbidities, which are a
Regular aerobic exercise is an important major health concern in the US.[5]
component for the maintenance of overall health. In 2002, the American College of Obstetricians
Exercise is especially important in pregnancy, as and Gynecologists (ACOG) published exercise
women of childbearing age are at increased risk guidelines for pregnancy.[6] These suggested that
of gestational diabetes mellitus (GDM), which in the absence of medical or obstetric complica-
has been strongly linked with obesity.[1,2] As more tions, 30 minutes or more of moderate exercise a
women tend to gain an excessive amount of weight day on most, if not all, days of the week is recom-
during pregnancy, they also tend to retain the mended for pregnant women. These guidelines
weight after delivery.[3,4] Gaining an excessive were based on the 1995 joint recommendations
346 Zavorsky & Longo

by the Centers of Disease Control and Preven- Table I. The American College of Sports Medicine (ACSM) and
tion (CDC) and the American College of Sports American Heart Association (AHA)s physical activity recommend-
ations for men and non-pregnant womena
Medicine (ACSM).[7] However, these were gen-
eral public health recommendations, with no Aerobic activity Muscle strengthening activity

clarity on the definition of moderate intensity Adults aged 1865 y perform a For adults aged 1865 y, 812
minimum of 30 min moderate repetitions each of 810
exercise or the recommended amount of weekly intensity exercise for 5 d/wk or muscular strength exercises
physical activity energy expenditure. 20 min vigorous intensity should be performed on 2 or
It has been 15 years since those initial CDC exercise 3 d/wkb more non-consecutive d/wk
using the major muscle groups
and ACSM recommendations were establish-
For adults >65 y, moderate For adults >65 y, 1015
ed, and 9 years since their adoption by ACOG. intensity = 1214 on the Borg repetitions each of 810
Since then, new science has emerged that has en- RPE 620 point scale; vigorous exercises on 2 or more non-
hanced our understanding of the amount of intensity = 1516 on the Borg consecutive d/wk using the major
RPE 620 point scale[10] muscle groups with an effort level
physical activity expenditure per week required of 1214 to 1516 on the Borg
and the intensity of exercise needed to improve RPE 620 point scale[10]
health outcome and quality of life. In 2007, up- a These are the 2007 updated ACSM and AHA recommendations
dated physical activity recommendations were from Haskell et al.[8] and Nelson et al.[9] Moderate intensity
is now classified as activities that require 36 METs
published by the ACSM and the American Heart
(10.521 mL/kg/min) and vigorous activity is classified as
Association (AHA).[8,9] These included defini- >6 METs (>21 mL/kg/min).[8] Moderate intensity exercise can be
tions of moderate and vigorous exercise, and walking at 4.8 km/h, 3.3 METs); walking briskly at 6.4 km/h
provided recommendations for muscle strength- (5 METs); washing a car, garage, sweeping floors or washing
windows (3 METs); slow to fast ballroom dancing (34.5 METs);
ening activities (table I). badminton (4.5 METs); or swimming leisurely (6 METs).[11]
As such, we believe these updated 2007 rec- Vigorous intensity can be walking at a very brisk pace at 7.2 km/h
ommendations should be used to establish new (6.3 METs); jogging at 8.0 km/h (8 METs); walking on a treadmill
at 5.6 km/h (5% grade, 6.1 METs); swimming at a moderate/hard
ACOG guidelines for pregnancy in the absence of feeling of effort (811 METs).[11]
medical or obstetric complications. Pregnancy is b Moderate = 36 METs; vigorous >6 METs.
not a state of confinement, yet pregnant women
METs = metabolic equivalent tasks; RPE = rating of perceived exertion.
spend less time performing vigorous exercise with
less duration and frequency than non-pregnant
women.[12] Indeed, women who maintain their ex-
ercise regimen during pregnancy continue to exercise incorporate the emerging research findings over
at a higher intensity than those who stop.[13] Over the past decade.
time, these women gain less weight, deposit less fat,
have increased fitness and have a lower cardiovas-
2. Increasing the Amount of Vigorous
cular risk profile in the perimenopausal period Intensity Exercise is an Important Goal
than women who cease to exercise in pregnancy.[13] for Pregnant Women, Especially Those
Therefore, the purpose of this clinical opinion Who are Overweight or Obese
is 2-fold: (i) to provide evidence that increasing
weekly physical activity expenditure while in- Obese women have an increased risk of fetal,
corporating vigorous exercise provides the best neonatal and maternal morbidity;[14-24] therefore,
health outcome for pregnant women and their prevention of excessive weight gain1 during
infants; and (ii) to create new exercise guidelines pregnancy is important for the welfare of both
for pregnancy that are relatively specific, and that mother and child.[16,26] Regular physical activity

1 Excessive weight gain during pregnancy is defined as 9.0 kg in overweight women (pre-pregnancy body mass
index [BMI] = 25.029.9 kg/m2), or 5.9 kg in obese women (pre-pregnancy BMI 30 kg/m2). For pregnant women
of normal pre-pregnancy bodyweight (BMI = 20.024.9 kg/m2), optimal weight gain during pregnancy is between
2.1 and 9.9 kg. For pregnant women whose pre-pregnancy BMI is <20 kg/m2, optimal weight gain during preg-
nancy is 4.19.9 kg.[25]

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 347

performed before[1,25,27] and during pregnancy[1] Vigorous intensity exercise that increases the
has been shown to reduce the incidence of GDM, energy expenditure post-exercise compared with
for example, by at least 30%, depending on the low-intensity exercise,[37,38] should limit weight
amount of weekly physical activity energy expen- gain in overweight and obese pregnant women. In
diture and intensity of exercise. Vigorous exercise fact, for a given energy expenditure, vigorous
is important to prevent weight gain in pregnancy exercise programmes induce a greater loss of
and throughout life.2 Recent data demonstrate subcutaneous fat compared with a programme of
that skeletal muscle work efficiency changes dra- moderate intensity.[39] Thus, we propose that
matically when bodyweight is altered.[28] With higher intensity exercise may be an alternative
weight gain from lack of physical activity, effi- means to improve oxidative capacity .and increase
ciency of skeletal muscle decreases,[28] which at post-exercise oxygen consumption (VO2) so that
the outset is fine as more calories are burned with body fat percentage is reduced to a greater extent
heavier weight. However, weight gain from phys- compared with traditional low-intensity exercise,
ical inactivity usually means an increase in fat and weight gain is limited in overweight and
mass, which, biochemically, has been found to obese pregnant women.
decrease the bodys ability to gain future muscle Considerable evidence supports the use of
due to the attenuation of anabolic processes;[29] higher intensity exercise to reduce body fat per-
therefore, an obese individual has an impeded centage. Specifically, in overweight individuals,
ability to gain muscle. With weight loss through a 14-week exercise programme consisting of
physical activity, caloric expenditure decreases, moderate-intensity exercise (6070% aerobic capa-
not just because muscles have less weight to carry city) was compared with an exercise programme
around, but due to a reduction in the ratio of of high-intensity exercise (7590% aerobic capac-
glycolytic to oxidative enzymes in muscle without ity). Both groups exercised three times per week,
significant changes in enzymatic activity related and both expended the same amount of calories.[40]
to fatty acid oxidation.[28] As such, with weight The high-intensity group reduced their total body
loss, significantly fewer calories are expended with fat percentage from 27% to 22% (p < 0.05), while
physical activity,[28] and an increase in weight will the moderate-intensity group did not see a reduc-
occur once again. A programme of vigorous in- tion.[40] Another study demonstrated that mod-
tensity exercise may stop the yo-yo effect of the erate exercise intensity (4055% of aerobic capacity)
weight gain/weight loss cycle.[30] for 8 months did not reduce total fat mass
Non-oxidative type IIb muscle fibres (which (-2 3 kg) to the same extent as vigorous exercise
minimally burn fat) are increased in obese (6580% of aerobic capacity, -5 3 kg), even when
women,[31,32] and are directly related to body controlled for the same weekly distance and the
mass index (BMI). The larger the BMI, the more same total training time.[41] This has been shown
type IIb muscle fibres a woman possesses. In ad- elsewhere,[42] although, the exercise bouts were
dition, the larger the BMI, the lower the percent- not isocaloric.
age of type I oxidative (fat burning) fibres.[33] Another compelling reason why pregnant women
Weight loss by itself[34] or weight loss with physical should perform vigorous exercise as tolerated, is
activity[35,36] can, but not always,[28] improve mus- that the duration of labour is inversely associated
cle oxidative capacity in obese women with or with- with aerobic capacity after adjusting for birthweight
out diabetes. If the muscle oxidative capacity is (p = 0.03).[43] Kardel and colleagues[43] investigat-
increased with physical activity, then the capacity ed the effect of aerobic capacity on duration of
to burn fat throughout the day is increased. labour in 40 nulliparous women (aged 30 4 years)

.
2 Vigorous exercise is defined by the ACSM as an oxygen consumption (VO2) of >21 mLO2/kg/min, which is
taken to be >6-fold greater than the resting metabolic
. rate (>6 METs). However, this article shows that some
pregnant women are not able to exercise at that VO2. Therefore, the. definition of. vigorous exercise should be
defined as 60% of heart rate reserve (HRR) [preferably] or 65% of VO2 reserve (VO2R).

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
348 Zavorsky & Longo

who started labour spontaneously. Aerobic capa- One way to incorporate vigorous exercise is
city was measured in these women (bodyweight the use of interval training, which incorporates
.
= 77 9 kg) at 3537 weeks of gestation. Dura- brief intense
. bouts of exercise (>80% of VO2 re-
tion of labour was defined as the time between serve [VO2R]) with periods of rest. This has been
3 cm cervical dilation with regular uterine con- found to be time efficient while improving oxida-
tractions and delivery. The mean aerobic capa- tive capacity in skeletal muscle to the same extent
city was 2.1 0.3 LO2/min and duration of labour as traditional low-intensity continuous exercise.[57,58]
583 317 minutes. The potential determinants of Interval training has been shown to. be safe and
the duration of labour, identified by a Pearson more effective in improving peak VO2 and left
correlation were tested in a multivariate model. ventricular function in patients with coronary
They concluded that increased aerobic fitness artery disease than the traditional method of con-
was associated with shorter labour in nulliparous tinuous moderate exercise.[59-61] In 75-year-old
women who started labour spontaneously. Other subjects, which included overweight women with
earlier research confirms Kardels study. Clapp[44] stable post-infarction heart failure, 12 weeks of in-
found that his well trained groups who exercised terval training increased aerobic capacity by 46%,
during pregnancy had a significant shorter first several heart function parameters by 2030% and
stage of labour by 118 minutes than a group who improved their quality of life.[61] These changes
had stopped exercising before the end of the first were significantly greater compared with 12 weeks
trimester. Beckmann and Beckmann[45] found of regular continuous training.[61]
that nulliparous women who exercised regularly A major consideration is that if elderly over-
before becoming pregnant also had a signifi- weight women with heart failure and/or coronary
cantly shorter labour (first and second stages) by artery disease can successfully perform interval
~8 hours in total compared with a non-exercising training, then this type of research should be im-
control group. plemented in pregnancy to establish the extent to
The minimal threshold for independent living which type of exercise periodic intense exercise is
requires an aerobic capacity of approximately feasible, safe and results in appropriate exercise
15 (women) to 18 (men) mLO2/kg/min,[46,47] adherence. Interval training during pregnancy is
which is four to five metabolic equivalent tasks
. an exciting new possibility. However, until fur-
(METs) [a value of one MET = resting VO2, ther studies are performed, it is our opinion that
or ~3.5 mLO2/kg/min]. Thankfully, only about pregnant women should build up to continuous,
1% of women of childbearing age are at or below steady-state aerobic exercise of about 65% of
this minimum threshold.[48] Normal weight preg- aerobic capacity (vigorous exercise), which is ~60%
nant women in the second and third trimester of heart rate reserve (HRR) or ~7075% of maxi-
(pre-pregnancy BMI = 23 kg/m2) have an aerobic mum heart rate (HRmax).[62] This recommendation
capacity that ranges from 1.4 to 2.6 LO2/min, which is within the range of the recommendations from
equals about 2739 mLO2/kg/min.[49-53] Unfit, over- the Society of Obstetricians and Gynecologists of
weight (pre-pregnancy BMI = 25.0 to 29.9 kg/m2) Canada (SOGC)/Canadian Society for Exercise
or obese pregnant women (pre-pregnancy BMI Physiology.[63]
30 kg/m2) who are unaccustomed to exercise
have a low aerobic capacity relative to bodyweight 3. Increasing Weekly Physical Activity
(1822 mLO2/kg/min).[50,54] Endurance-trained Energy Expenditure is an Important
pregnant athletes have an aerobic capacity re- Goal for Pregnant Women
ported to be around 50 mLO2/kg/min.[55,56] Aero-
bic capacity in LO2/min remains quite stable Increasing weekly physical activity energy ex-
between the second and third trimester; however, penditure has been found to reduce the incidence
the aerobic capacity measured in mLO2/kg/min of the metabolic syndrome,[64] GDM[25] and sys-
may decrease by 10% by the third trimester due to temic inflammation,[65] while delaying ageing[66]
maternal weight gain.[52] and disability.[67] The risks of coronary heart

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 349

disease and cardiovascular disease also decrease bouts of exercise provided the fewest bene-
linearly in association with increasing physical fits.[73,74] Zhang and co-workers[25] conducted a
activity energy expenditure.[68] Johnson and col- prospective cohort study to assess whether the
leagues[64] studied the effects of three different amount, type and intensity of pregravid physical
6-month exercise programmes on components of activity are associated with GDM risk. The re-
the metabolic syndrome: low amount/moderate lative risks (RRs) of GDM decreased with total
intensity (equivalent to jogging 19 km/wk at pregravid weekly physical activity (figure 2), such
4055% of aerobic capacity), low amount/high that 16 MET hours per week showed a 17% re-
intensity (equivalent to jogging 19 km/wk at duction in GDM risk, and 56 MET hours per
6580% of aerobic capacity) or high amount/ week showed a ~30% reduction in GDM risk,
vigorous intensity (equivalent to jogging 32 km/wk compared with subjects who did not exercise.
at 6580% aerobic capacity). These investigators If the amount of pregravid weekly vigorous
showed that the high-amount/vigorous-intensity physical activity (figure 2) increased (vigorous
group had improvement in the highest number of exercise intensity 6 METs or 21 mLO2/kg/
metabolic variables, compared with the other two min), the RR for GDM also decreased by 20%
groups and a control group.[64] This makes sense and 25% if 6 and 15 MET hours per week of
because insulin resistance is negatively related to vigorous physical activity is performed, respect-
caloric expenditure from a single bout of exercise ively. Rudra et al.[27] demonstrated that those
(figure 1). From this study, the dose-response of who exercised strenuously up to maximal exer-
energy expenditure in reducing the risk factors tion using the Borg rating of perceived exertion
for metabolic syndrome were uncovered.[64] (RPE) scale in the year before pregnancy, showed
Reduced risk of GDM and pre-eclampsia is seen a 43% decrease in the risk for GDM. Also, those
when women exercise between 3 months and 1 year that performed 30 MET hours per week of en-
before or during pregnancy.[1,25,27,70,71] During ergy expenditure from physical activity in the
pregnancy, exercise programmes lasting at least year before pregnancy had a 50% decrease in the
several weeks[72] is the best way to reduce the risk of GDM, compared with only a 34% de-
fasting blood glucose level and to blunt the gly- crease in GDM if the exercise expenditure was
caemic response following a meal, whereas, single <14.9 MET hours per week.[27] Dempsey et al.[1]

a b
40 30

20 15
Change from rest (%)
Change from rest (%)

0 0

20 15

40 30

60 45

80 60 *
0 1.26 2.51 3.77 5.02 6.28 <3.77 (900) >3.77 (900)
(300) (600) (900) (1200) (1500)
Total energy expenditure during exercise, MJ (kcal)

Fig. 1. Exercise-induced changes in (a) homeostasis model assessment of insulin resistance as a function of total energy expenditure during
exercise; and (b) subjects who expended <900 or >900 (kcal) during the exercise bout. The data demonstrate that whole body insulin sensitivity
from a single bout of exercise is improved only when the total energy expenditure is >900 kcal per session. Reproduced from Magkos et al.[69]
with permission from Portland Press Ltd. * p < 0.05 compared with resting state.

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
350 Zavorsky & Longo

demonstrated that pregravid women who ex- per week performing the activity. For example,
ercised 21.1 MET hours per week during the 5 METs 0.95 hours per day 6 days per week =
year before pregnancy reduced GDM risk by 28.5 MET hours per week. Second, to convert
74%, while women who were pregnant and ex- MET hours per week into kcal/wk of energy expen-
pended 28 MET hours per week per week diture, one multiples 28.5 MET hours per week
during pregnancy reduced GDM risk by 33% by the resting metabolic rate of 3.5 mLO2/kg/min
(figure 3). However, due to the large confidence and by 60 min/h to get 5985 mLO2/kg/wk. Now,
intervals for the reduction in RR for GDM the bodyweight is needed. For this example, the
during pregnancy in the group that exercised 28 bodyweight of an individual is 58.7 kg, therefore,
MET hours per week compared with no exercise 5985 mLO2/kg/wk 58.7 kg = 351319.5 mLO2/wk
(RR = 0.67; 95% CI 0.31, 1.43), statistical signif- or 351.2 LO2/wk consumed in total for physical
icance was not reached. Nonetheless, this does activity. Since 5 kcal are yielded for every L of ox-
not negate the findings of how exercise during ygen consumed, then 351.2 LO2/wk 5 kcal/L =
pregnancy can reduce GDM risk. Therefore, it is 1756.6 kcal/wk.
our opinion that there is a potential benefit for The more vigorous the exercise, the less total
the adoption and continuation of an active life- time of exercise is required. For example, one
style for women of reproductive age that is of can exercise 3 METs 1.6 hours per day 6 days
vigorous intensity prior to and during pregnancy. per week = 28.8 MET hours per week; or one can
To obtain energy expenditure in MET hours exercise for less time at a higher intensity to
per week, one multiplies the number of METs achieve the same expenditure (e.g. 5 METs 0.95
required for the activity by the number of hours hours per day 6 days per week = 28.5 MET hours
per day multiplied by the total number of days per week). For a 54 kg woman, 28.5 MET hours per

Total physical activity


Vigorous activity
1.2

1.0

0.8
RR of GDM

0.6

0.4

0.2
8 16 24 32 40 48 56
MET h/wk

Fig. 2. Relative risks (RRs) of gestational diabetes mellitus (GDM) according to total physical activity (solid line) and vigorous activity (dotted
line) measured in metabolic equivalent task (MET) hours per week, continuous, prior to pregnancy. RRs are adjusted for age, race/ethnicity,
cigarette smoking status (never, past or current), family history of diabetes in a first-degree relative (yes, no), parity (0, 1, 2, 3), alcohol intake
(0.0, 0.15.0, 5.115.0 or >15.0 g/day), dietary factors (in quintiles of total energy, cereal fibre, glycaemic load and total fat) and body mass
index before the pregnancy. The error bars illustrate the approximate 95% CI.[25]

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 351

1.0 only have a lower baseline risk of myocardial in-


0.9 farction, they also have a lower RR that an
0.8 infarction will be triggered by heavy physical ex-
Adjusted RRs of GDM

(0.35, 1.47)
0.7 (0.31, 1.43) ertion.[77] There is no reason to suggest that the
0.6 (0.27, 1.21) maternal cardiac risk of exercise would be dif-
0.5 ferent during pregnancy.
0.4 The number of sudden cardiac arrests or other
0.3 (0.10, 0.65) cardiac events in the general population is one
0.2
event per 565 000 hours of exercise.[78] For indi-
0.1
viduals with known heart disease, it is one event
per 59 142 hours.[78] The absolute risk of sudden
0
<21.1 >21.1 <28.0 >28.0 death during any episode of vigorous exercise
Year before pregnancy During pregnancy equals about one death per 1.51 million episodes
in MET h/wk in MET h/wk of exertion.[79] Thus, the risk of exercise in trig-
Fig. 3. Adjusted relative risks (RRs) of gestational diabetes mellitus
gering cardiac events is very small. Compare the
(GDM) according to the amount of physical activity energy ex- risk of triggering sudden cardiac events (which is
penditure performed in the year before and also during pregnancy, about 0.01%) with the CDCs death rate for ac-
adjusted for maternal age, race, parity and pre-pregnancy body
mass index. No physical activity was made to have a RR of 1.0. cidental deaths (unintentional injuries), which is
Physical activity before and during pregnancy reduces RR of GDM. about 0.04%.[80] As such, the risk of death from
The numbers in parentheses illustrate 95% CI.[1] MET = metabolic
equivalent task. unintentional injuries in the US is higher than the
risk of triggering cardiac events from exercise;
week = approximately 1616 kcal/wk (or 269 kcal/day therefore, the risks must be placed in perspective
for 6 days). If one exercises 6 days in a 7-day cycle, to a real-world context. The US death rate of all
then the energy expenditure in MET hours per week causes (accidents, homicides, suicides, diseases,
is calculated over 6 days of exercise. cancer, infection, dying of old age, etc.) is about
0.8%,[80] so when compared with the risk of ex-
4. Potential Risks of Exercise in Pregnancy ercise, these other issues provide more risk to
4.1 Cardiac Risks of Exercise
human health than a vigorous exercise session in
sedentary pregnant women.
With regard to the frequency with which
myocardial infarction is triggered by exertion, it
4.2 Risk of Regular Exercise Training Resulting
is important to distinguish absolute from RR.
in Small for Gestational Age Infants and
The absolute risk of a 50-year-old non-smoking, Increased Risk of Preterm Birth
non-diabetic individual having a myocardial in-
farction during a given 1-hour period, is ap- Small for gestational age (SGA), which is a
proximately 1 in 1 million (0.0001%).[75,76] If an birthweight that is in the 10th percentile or below
individual is habitually sedentary, but engaged for the gestational age of the infant, is usually a
in heavy physical exertion (>6 METs) during consequence of compromised intrauterine devel-
that hour, the risk would increase 100-fold over opment, and is considered a risk of perinatal
the baseline value, but the absolute risk during morbidity and mortality.[81] Regardless of wheth-
that hour still would be only 1 in 10 000 (0.01%). er a woman is sedentary or an endurance ath-
The research has shown that a single episode of lete, exercise during the first two trimesters has
vigorous physical exertion can increase the short- not been shown to affect birthweight.[82] How-
term risk of myocardial infarction.[77] The para- ever, female endurance athletes who exercise
dox, however, is that increased frequencies of vigorously (6 per week, >1 hour per session for
vigorous exercise at >6 METs is associated with 10 weeks, >50% of age predicted HRmax) into the
a reduction in the long-term risk of coronary third trimester, produce infants that are on aver-
events. Individuals who exercise regularly not age 212 g (95% CI 149, 276) smaller than active

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
352 Zavorsky & Longo

controls (3 per week, 30 minutes per session diture, pregnant women who exercised 1015 MET
for 10 weeks, >50% of age-predicted HRmax), and hours per week (7151071 kcal/wk for a 68 kg wo-
437 g (95% CI 268, 606) smaller than sedentary man) experienced a 17% reduction in the risk of
controls.[82] Nonetheless, a 200400 g decrease in preterm births (RR 0.83; 95% CI 0.71, 0.96), and
mean birthweight is not clinically meaningful for those who exercise for more than 15 MET hours
two reasons. First, this difference in weight is less per week (>1071 kcal/wk for a 68 kg woman) ex-
than the 500 g difference between the 50th per- perienced a 12% reduction (RR 0.88; 95% CI 0.78,
centile and 10th percentile in recent published 1.00) in preterm births.[88]
tables.[83] Second, SGA is an anthropometric
characteristic that does not necessarily have ad-
4.3 Risks of Exercise Resulting in an Abnormal
verse health implications, and is therefore com- Fetal Heart Rate (HR) Response
monly used (but not necessarily appropriately) as
a proxy for the pathological outcomes believed to A misconception about exercise in pregnancy
be associated with an inadequate rate of fetal is that fetal health may be compromised because
growth[84] (i.e. the majority of SGA births are uterine blood flow can decrease progressively
small for no demonstrative reason; an aetiology is with exercise intensity and duration (by up to
not found in >50% of cases of SGA).[85] Third, ~20%).[89,90] However, several . compensatory
more recent data published in 2010 with a larger mechanisms act to preserve fetal VO2 even during
sample size suggests no real clinically meaningful exhaustive exercise.[90,91] In sheep, the increased
difference in birthweight of infants born to women haemoglobin concentration from pregnancy
who exercise during pregnancy for >5 hours per maintains total oxygen delivery to the uterus and,
.
week compared with pregnant women who do with increased uterine oxygen extraction, VO2
not exercise.[86] In this study of ~80 000 infants, it remains unaltered.[90] In humans, the measure-
was found that women who exercised during preg- ment of fetal umbilical and maternal uterine
nancy had a decreased risk of having a SGA child pulsatility index (PI), which is the best non-
or a large for gestational age child (birthweight invasive technique to assess changes in resistance
greater than the 90th percentile for gestational to blood flow in those areas, was assessed in
age).[86] These data suggest that women who ex- pregnant women (third trimester) immediately
ercise >5 hours per week have smaller infants by after strenuous exercise above the anaerobic
only 11 g than those of non-exercisers;[86] therefore, threshold.[92] Compared with rest, there were
differences may not be clinically meaningful. modest changes in the right uterine PI without
As a corollary, SGA-identified fetuses may not changes in umbilical artery PI or left uterine PI
tolerate the mild diversion of cardiac output from in pregnant women 2 minutes post-exercise.[92]
the uterus to the skeletal muscles during exercise. However, by 5 minutes post-exercise, right uter-
Therefore, there is a slight chance of post-exercise ine PI returned to baseline values.[92] Therefore,
bradycardia. This has occurred previously in a sheep and human data imply that limited stren-
subsequently diagnosed growth-restricted fetus.[87] uous exercise above the anaerobic threshold has
While there are many SGA fetuses who are not minimal effects on total
. uterine and umbilical
growth restricted, the clinician does not know oxygen delivery and VO2.
which is which until after birth. As such, cau- Fetal heart rate (FHR) monitoring has been
tion is advised against exercise in the growth- widely used to monitor fetal well-being before and
restricted fetus. after exercise. The earlier studies demonstrating
In terms of preterm births, exercise during fetal bradycardia (FHR <110 beats/minute for
pregnancy actually reduces the risk of complica- 10 seconds) during exercise[93-95] have been dis-
tions. Using data of over 85 000 births, >5 hours a missed as representing motion artifact.[96,97] FHR
week of exercise during pregnancy reduced the is increased by about 20 beats/minute within
risk of preterm birth by 18% (RR 0.81; 95% CI 30 seconds of strenuous exercise stoppage.[98] By
0.64, 1.04).[88] When calculating energy expen- 10 minutes post-exercise, FHR is 010 beats/minute

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 353

higher, compared with pre-exercise after a bicycle 2039 years-of-age group combined. Nonetheless,
test to maximal or near maximal exertion.[87,98,99] developing an HR zone generalizable to pregnant
This suggests that brief intense exercise does not populations may not be appropriate because of
cause fetal distress. Furthermore, regular exercise the individual variation of resting HR, and the
training does not alter the fetal response.[100] More large standard deviation of predicting HRmax
recently, researchers have demonstrated that FHR from age (HRmax = 220 minus age), which is
response to strenuous maternal exercise is not a 1012 beats/minute.[104]
predictor of fetal distress since the incidence did not To identify the optimal HR for a given inten-
vary with the level of fitness, maternal BMI or fetal sity in a given individual, the HRR method was
weight.[98] developed by Karvonen.[105] The HRR method
essentially uses the difference between HRmax
5. Developing New Exercise Guidelines and resting HR (in which both should be mea-
in Pregnancy sured directly and not predicted). The reserve
available is the difference between measured
In 2003, the SOGC published guidelines that HRmax and measured resting HR. Then, a given
were somewhat more specific than the ACOG intensity is provided, and the correct exercise
guidelines. The SOGC suggested that pregnant prescription HR can be determined from the
women should perform 15 minutes of continuous following formula:
aerobic exercise 3 days per week, with progres- Prescription HR = % intensity (HRmax that is
sion to 30 minutes sessions four times per week in measured from an aerobic capacity test - resting
previously sedentary women.[63] For most preg- HR obtained from 5 minutes of sitting upright on
nant women, the intensity of exercise is recom- a chair) + resting HR.
mended to be 1214 (out of 20) on the Borg RPE HR zones are published for pregnant over-
scale.[63] RPE is the perceived, subjective, overall weight or obese women.[54] However, since the
effort of exertion and fatigue from 6 (no exertion) minimum intensity for improving aerobic fitness
to 20 (maximal exertion). A rating of 6 = no ex- was updated in 2002,[106] the HR zones provided
ertion at all, 78 = extremely light, 910 = very light, for sedentary, overweight and pregnant women
1112 = light, 1314 = somewhat hard, 1516 = begin at an exercise intensity of 101 beats/minute,
hard, 1718 = very hard, 19 = extremely hard and which is too low.[54] According to Swain and
20 = maximal exertion. This scale scores the total, Franklin,[106] those individuals
. classified as hav-
overall exertion and fatigue level of exercise. The ing low initial fitness (VO2max <40 mLO2/kg/min),
more exertion, the less total time of exercise is based on a graded exercise test to maximum, will
required to reach the recommended weekly phys- show improvements in aerobic. capacity only if
ical activity expenditure goal. the training intensity is 30% VO2R..3 For those
Basal resting heart rate (HR) is increased by with higher aerobic capacities (VO2max >40
1015 beats/minute in pregnancy.[101-103] In turn, mL/kg/min),. the minimal training intensity has to
HRmax is blunted by 1015 beats/minute, com- be 45% VO2R.[106] The percentage of HRR .
pared with the predicted HRmax of 220 minus (%HRR)
. is equal to the percentage of VO2R
age[50,54,103] (although not always[102]), the HRR (%VO2R) unless the woman is overweight, seden-
is lowered. Thus, the target HR zones are mod- tary and pregnant. . In overweight, sedentary preg-
ified in the SOCG guidelines. For example, the nant women, %VO2R is slightly higher. by about
target HR zone for a non-obese pregnant woman 5% compared
. with %HRR, until 70% VO2R after
2029 years of age is 135150 beats per minute, which %VO2R and %HRR are about equal.[54]
130145 for a woman 3039 years-of-age and Prescribing exercise intensity based on %HRR
125140 for a woman 40 years of age.[63] This provides the most accurate training prescription,
equates to 7179% of predicted HRmax for the especially when the patients resting and HRmax is
. . . .
3 Prescription VO2 = %intensity (VO2max - resting VO2) + resting VO2.

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
354 Zavorsky & Longo

Table II. Updated aerobic exercise recommendations during pregnancya


.
Gestational age (wk) %HRR %VO2R RPE Total target exercise energy
expenditure (MET h/wk)
Previously sedentary and/or overweight/obese pregnant women unaccustomed to exercisea
13 3539 4045 1214 16
36 4555 5060 1315 28
69 60 65 1516 28
1026 60 65 1516 28
2740 45 50 1314 16
Previously healthy and/or physically active pregnant womena
13 4555 5060 1315 16
36 5060 5565 1415 28
69 60 65 1516 28
1026 60 65 1516 28
2740 50 55 1415 16
a See table III for the estimated converted total amount of energy expenditure from physical activity in kcal/wk. The Borg RPE scale is from
6 (no exertion) to 20 (maximal exertion).[10] Some of the suggested programme shown in this table for exercise intensity is based on the
American College of Sports Medicine[8,48] and elsewhere.[54] The target goal for the amount of physical activity per wk expended during
pregnancy is based on the study by Dempsey et al.,[1] which shows a 33% risk reduction in GDM in women who exercise 28 MET h/wk
during pregnancy. The complications are listed in table V.[6] These recommendations are for individuals without medical and obstetrical
complications.
GDM = gestational
. diabetes mellitus; MET = metabolic equivalent task; RPE = rating of perceived exertion; %HRR = percentage of heart rate
reserve; %VO2R = oxygen consumption reserve.

known (table II). The actual target HRs, which circumspect, because the definition of moderate
have been listed elsewhere,[50,54] are not provided and vigorous should be based on each individ-
in table II because each pregnant woman will have uals own aerobic capacity. For example, some
a different resting and HRmax. Let us consider an pregnant women have an aerobic capacity that
exercise HR for a sedentary overweight pregnant approaches 46 mLO2/kg/min, which is 13 METs
woman with GDM. At the beginning of the or 13-fold greater than the resting metabolic
programme, the intensity would be ~3539% HRR. rate.[55] An activity level of 7 METs would be
If her resting HR is 90 beats/min (after sitting up- moderate rather than vigorous intensity for them,
right in a chair for 5 minutes), and measured HRmax . they would only be exercising at ~53% of
as
(measured from . a graded exercise test to volitional VO2max. On the other hand, an unfit, sedentary,
exhaustion) [VO2max test] is 185 beats/minute, then overweight pregnant woman may have an aerobic

39% HRR = 0.39 (18590) + 90 = 127 beats/minute.
A HR of 127 beats/minute would be her prescrip-
capacity of only 21 mLO2/kg/min or 6 METs.[54]
An activity level of 6 METs would not be mod-
tion HR. erate
. for her, as she would be exercising at 100%
Pregnant women can monitor their HR during of VO2max, therefore, the terms moderate and
pregnancy using a simple HR monitor (e.g. Polar vigorous are relative, depending on the fitness
FS1), which is relatively inexpensive. For those level of the pregnant woman. That is why exercise
women who are not willing or able to purchase intensity based on %HRR and the Borg RPE
one, then pulse rates can be monitored from their scale are the best ways to prescribe exercise in-
wrists at intervals or the Borg RPE scale can tensity in all individuals, including pregnant
be used (see table II). An additional considera- women with GDM, and for those who are sed-
tion is that the definition of moderate intensity entary or overweight.
classified as physical activity requiring 36 METs Given that obstetricians and gynecologists
(10.521 mLO2/kg/min), and vigorous activity may wish to simplify exercise prescription by
classified as >6 METs (>21 mLO2/kg/min)[8] is eliminating the use of HRR and its calculations,

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 355

we understand the practicality of using the Borg Table III. The minimum and target amount of energy expenditure
RPE scale for exercise intensity, so we have added recommended per wk from physical activity converted to kcal/wk and
hours of activity per wk during pregnancy according to bodyweight
the scale in table II. Based on the womans weight at start of pregnancya
prior to pregnancy, the amount of weekly physi-
Weight of woman Minimum energy Target energy
cal activity energy expenditure in kcal/week at the start of expenditure of expenditure of
during pregnancy is provided in table III. How- pregnancy (kg) 16 MET h/wkb 28 MET h/wkc
ever, we also recognize that calculating the energy (kcal/wk) (kcal/wk)
expenditure from exercise in a pregnant woman 45.2 759 1328
in kcal/week may not be user friendly for the pa- 49.7 835 1461
tient or physician, so an estimated total time of 54.2 911 1594
exercise is also reported in table III (see foot- 58.7 986 1726
notes). Muscle strengthening guidelines are report- 63.2 1062 1859
ed in table IV for women who wish to supplement 67.8 1138 1992
their aerobic exercise training periodically. 72.3 1214 2125
Several physical activity questionnaires are
76.8 1290 2258
suitable for obtaining an estimate of weekly en-
81.3 1366 2390
ergy expenditure during pregnancy. We suggest
85.8 1442 2523
the use of a questionnaire that estimates previous
energy expenditure, such as the 7-day physical 90.3 1518 2657

activity recall,[107-109] the Kaiser Physical Activity 94.9 1594 2789


Survey in Women[111,112] or the Pregnancy 99.4 1669 2921
Physical Activity Questionnaire.[113] These ques- 103.9 1745 3054
tionnaires can be completed in a structured 108.4 1821 3187
1520-minute interview. Nonetheless, for simplic- 112. 9 1897 3320
ity, we provide an estimated number of hours of 117.4 1973 3453
physical activity needed per week based on two 122.0 2049 3586
different modes of exercise that would allow a
126.5 2125 3718
pregnant woman to achieve the target energy expen-
131.0 2201 3851
diture (this is listed in table III in the footnotes).
135.5 2276 3984
140.0 2352 4116
5.1 Exercise Testing to Determine Maximum
144.5 2428 4248
HR (Peak HR and Aerobic Capacity) a For every 4.5 kg increase in bodyweight, the weekly energy
expenditure increases by about 76 kcal for the minimum required
Individualizing an exercise programme for 16 MET h/wk category and 133 kcal/wk for the target 28 MET
pregnant women involves medical screening with h/wk category. The minimum and target energy expenditure is
the use of a physical activity readiness question- based on recent data by Dempsey et al.[1] and Zhang et al.[25] To
estimate the total weekly physical activity energy expenditure
naire for pregnancy,[114] an estimation of previous
from vigorous exercise, a questionnaire such as the 7-day
physical activity level and developing a programme physical activity recall can be used.[107-109] However, for
specific to the womans situation. Informing simplicity, the required number of h/wk of exercise is estimated
the patient about limitations, contraindications here. This is based on two different modes of physical activity. As
one can see, the more vigorous the exercise, the less total time of
and warning signs should also be performed exercise is required per wk.
(table V).[6] On the basis of numerous studies, b Light = approximately 6.4 h/wk walking (2.0 mph, 2.5 METs);
exercise testing to maximum exercise capacity in vigorous = approximately 2.7 h/wk bicycling on a stationary bike
pregnant women is safe for both the mother and (~67 METs).
the fetus.[43,87,92,98,99,103,115,116] Therefore, before c Light = approximately 11.2 h/wk walking (2.0 mph, 2.5 METs);
an exercise programme is given to a woman, a vigorous = approximately 4.7 h/wk bicycling on a stationary bike
(~67 METs).
graded exercise test using a cycle ergometer or
MET(s) = metabolic equivalent task(s); mph = miles per hour.
treadmill would be an ideal scenario to obtain

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
356 Zavorsky & Longo

Table IV. Muscle strengthening exercise guidelines during pregnancya outlined in table II using %HRR would be ap-
For pregnant women aged 1845 y, 810 muscular strength propriate. Should HR not be measured or re-
exercises can be performed over one to two sessions per wk (non- corded during exercise, the Borg RPE scale could
consecutive days). One aerobic training session can be replaced by be a substitute for determining exercise intensity.
a muscle strengthening session in the weight room or at home
Exercises that stimulate large muscle groups
Use lighter weights, more reps
such as stationary cycling, swimming, walking or
Heavy weights may overload joints already loosened by increased
levels of the hormone relaxin during pregnancy. Thus, perhaps it jogging are recommended. A standard stationary
would be wise to use lighter weights and do more repetitions instead. bicycle can substitute for one that is recumbent.
For example, if one usually performs leg presses with 15.8 kg for A pregnant woman who has just finished exercise
812 reps, try 9.0 kg for 1520 reps. Or, if one typically performs a
chest press with 6.8 kg for 812 reps, try 3.6 kg for 1520 reps
should be aware of uterine contractions. Women
Avoid walking lunges
should be informed that stimulation of the uterus
These may raise the risk of injury to connective tissue in the pelvic
(i.e. as it moves inside the body from exercise) will
area cause contractions or tightening. Women should
Watch the free weights seek medical advice when these contractions be-
One should be careful with free weights as free weights may involve come increasingly painful and do not dissipate
the risk of hitting the abdomen. Women can use resistance bands within a reasonable time frame after exercise.
instead, which offer different amounts of resistance and varied ways When monitoring fetal movements pre-, dur-
to do weight training and should pose minimal risk to the stomach
ing or post-exercise, the National Institute for
Try not to lift while flat on your back.
Health and Clinical Excellence recommends that
In the second and third trimester, lying on your back may cause the
uterus to compress a major vein, the inferior vena cava into which health professionals should no longer suggest the
blood from the pregnant uterus flows. This increased pressure can routine counting of fetal movements in the sec-
be transmitted to the placenta, to compromise fetal blood flow in the ond half of a womans pregnancy.[117] Neverthe-
gas exchange area, thereby limiting oxygen supply to the infant.
An easy modification is to tilt the bench to an incline
less, pregnant women should continue to be aware
Try to avoid the valsalva manoeuver
of fetal movements throughout the day. Less
This manoeuver, which involves forcefully exhaling without actually
than ten fetal movements in 12 hours is an in-
releasing air, can result in a rapid increase in blood pressure and dication that further investigation at a hospital is
intra-abdominal pressure, and may decrease oxygen flow to the warranted.[117]
fetus. However, on rare occasions, the uterus can be displaced
against the inferior vena cava, which can result in a decrease in blood
pressure. Thus, a decrease in blood pressure can also occur with the 6. Conclusions
valsalva manoeuver, but this is uncommon
Listen to your body The updated 2007 ACSM and AHA recom-
The most important rule is to pay attention to what is going on mendations are used to help establish new
physically. If you feel muscle strain or excessive fatigue, modify the guidelines for pregnancy, in the absence of med-
moves and/or reduce the frequency of the workouts. Pregnancy is
not the time to perform heavy weightlifting but muscle strengthening
ical or obstetric complications. These recommen-
according to these guidelines will burn calories and increase the dations are based on recent findings that suggest
resting metabolic rate increasing the amount of physical activity ex-
a Light muscle strengthening training (resistance exercise training) penditure to at least 16 MET hours per week. To
performed over the second and third trimester of pregnancy does
achieve the minimum expenditure of 16 MET
not have a negative impact on the newborn infants body size and
overall health.[110] hours per week, one could walk at 3.2 km per
hour for 6.4 hours per week (2.5 METS, light
intensity), or preferably exercise on a stationary
HRmax and current fitness. However, access to bicycle for 2.7 hours per week (6.07.0 METS,
this type of testing is limited by the number of more vigorous intensity). Incorporating vigorous
exercise physiologists, adequate equipment and/ exercise at about 60% HRR, obtained from the
or patient finances; as a result, exercise testing is pregnant womans own resting and HRmax will
impractical for a majority of pregnant women. provide the best health outcome. Use of these
As such, HRmax can be estimated by the formula new aerobic exercise and muscle strengthening
220 minus age; subsequently, the programme guidelines for pregnancy (tables II, III, IV), which

2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (5)
Updated Exercise Guidelines in Pregnancy 357

Table V. Absolute and relative contraindications to aerobic ex- Acknowledgements


ercise during pregnancy as well as warning signs to terminate
exercise while pregnant (reproduced from the ACOG Committee Gerald S. Zavorsky, PhD, holds a Certified Strength and
opinion,[6] with permission from the American College of Obste- Conditioning Specialist credential from the National Strength
tricians and Gynecologists) and Conditioning Association and a Certified Exercise
Absolute contraindications Physiologist credential from the Canadian Society for Ex-
Haemodynamically significant heart disease
ercise Physiology. Lawrence D. Longo is an obstetrician-gy-
necologist with extensive expertise in exercise and pregnancy
Restrictive lung disease in both animal and human models.
Incompetent cervix/cerclage No sources of funding were used to assist in the prepara-
Multiple gestation at risk for premature labour tion of the article. The authors have no conflicts of interests to
declare that are directly relevant to the content of this article.
Persistent second or third trimester bleeding
Placenta previa after 26-wk gestation
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