1. Exercise in pregnancy
전임의 채용화

2. Effects of Physical Activity, Traditionally
• Raising core body temperature
• Increasing the risk of maternal musculoskeletal injury
• Moving transport of oxygen and nutrients to maternal skeletal
muscle rather than to the developing fetus.

3. • Prevalance of active pregnant women, as well as duration,
frequency and intensity : lower than that of adult woman
Evenson et al. 2004
Domingues et al . 2007
0
10
20
30
40
50
60
70
80
90
100
US Ireland Brazil Danish
Prevalence
Prevalence
Evenson et al,2004
Walsh et al, 2011
Domingues et al, 2004

4. Exercise guideline for
pregnant women

5. Exercise guideline for pregnant women
• In the absence of medical or obstetric complications,
• 30 minutes or more of moderate exercise a day on most,
if not all, days of the week.
• Women who were active before pregnancy may continue their
activities but change intensity and frequency over the course of
pregnancy.
2002, the American College of Obstetricians and Gynecologists
(ACOG)
Med Sci Sports Exerc 2007
ACOG 2002
not define ‘moderate intensity’ or the specific amount of weekly
caloric expenditure from physical activity required

6. Absolute Contraindications
• Hemodynamically significant heart disease
• Restrictive lung disease
• Incompetent cervix/cerclage
• Multiple gestation at risk for premature labor
• Persistent second- or third-trimester bleeding
• Placenta previa after 26 weeks of gestation
• Premature labor during the current pregnancy
• Ruptured membranes
• Preeclampsia/pregnancy-induced hypertension
2002, ACOG

7. Relatively Contraindications
• Severe anemia
• Unevaluated maternal cardiac arrhythmia
• Chronic bronchitis
• Poorly controlled type 1 diabetes
• Extreme morbid obesity
• Extreme underweight (BMI <12)
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in current pregnancy
• Pooly controlled hypertention
• Orthopedic limitations
• Poorly controlled seizure disorder
• Poorly controlled hyperthyroidism
• Heavy smoker
2002, ACOG

8. Warning Signs to Terminate Exercise
While Pregnant
• Vaginal bleeding
• Dyspnea prior to exertion
• Dizziness
• Headache
• Chest pain
• Muscle weakness
• Calf pain or swelling (need to rule out thrombophlebitis)
• Preterm labor
• Decreased fetal movement
• Amniotic fluid leakage
2002, ACOG

9. Type of exercise
• Aerobic exercise
 maintain cardiovascular fitness
 prevent chronic diseases
 involve large muscle groups in activities
,
Aerobic exercise Contraindication
walking or jogging gymnastics
using stationary bicycle Horseback riding
treadmill skiing
swimming Racquet sports
water aerobics exercises Contact sports
aerobic dance Suba diving

10. • Muscle strengthening
Use lighter weights, more reps
Try not to lift while flat on your back.
Try to avoid the valsalva manoeuver
Listen to your body
Sports Med 2011
• Strength training for pregnant women:
once or twice per week on nonconsecutive days
8 to 10 muscular strength exercises per session.
• These effects have been rarely studied.
: muscle conditioning practices such as Pilates, yoga, and weight training.
Zavorsky GS, 2011
to be careful with overexertion and overstretch

11. Intensity of exercise
Maternal age
(years)
Heart rate target
zone(beats/min)
Heart rate target
zone(beats/10sec)
<20 140-155 23-26
20-29 135-150 22-25
30-39 130-145 21-24
>=40 125-140 20-23
Artal et al 2003 Br J Sports Med
Modified heart rate target zones for aerobic exercise in pregnancy
Davies et al, J Obstet Gynaecol Can, 2003
Correpond to
60-80% aerobic capacity
Modified heart rate target zones for overweight and obese pregnant woman

12. Boring's rating of perceived exertion
6
7 Very,very light
8
9 Somewhat light
10
11 Fairly light
12
13 Somewhat hard
14
15 Hard
16
17 Very hard
18
19 Very,very hard
20
A rating of 12-14( light), 15-16(vigorous) :
appropriate for pregnant women
Borg et al, 1998

13. Frequency of exercise and rate of progression
• Previously sedentary women
 start with 15min of exercise three times a week
 gradually increase to 30min four times a week
at low to moderate intensity
• Active women
 keep their routine exercise or perform at least moderate-to-vigorous
exercise
 four times a week in sessions of 30min or more
• Athletes or women who have higher fitness status
 evaluated individually
 the intensity of exercise like running should be reduced
Davies et al 2003
J Obstet Gynaecol Can

14. American College of Sports Medicine(ASCM) and the American Heart
Association (AHA) recommendations in 2007
: the amount of Physical-activity expenditure needed
the intensity of exercise needed

15. Quantified physical activity
using absolute intensity measurements
• Metabolic equivalent task(MET)
(1 MET:energy used by the body while sitting)
(1 MET = resting VO2 ~3.5mLO2/kg/min)
= about 1 kcal/kgxh
• Vigorous physical activity
:6METs 이상(bicycling uphill or swimming continuous laps
bicycling on a stationary bike)
• Moderate physical activity
: 3~6 METs (brisk walking at ~5-7km/h(3-4mph)
• Light physical activity
:2.5METs (walking at 3.2km/h (2.0mph)

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

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

18. Physical exercise
on maternal outcome

19. Musculoskeletal discomforts
• Lower back, pelvic, and/or joint pain
• A 10-week exercise program back pain intensity
functional ability during pregnancy
• Tailored strengthening exercise,
• Sitting pelvic tilt exercise programs
• Water gymnastics
 All had beneficial, although small, effects when compared with
standard prenatal care
Kluge J et al 2011
Pennick V et al 2007

20. Stress urinary incontinence
• The best way to prevent incontinence
 to exercise pelvic floor muscles every day
 following a vaginal assessment of correct contraction.
Mason L et al 2010

21. higher intensity exercise
to improve oxidative
capacity
To increase post-
exercise oxygen
consumption (VO2)
body fat percentage is
reduced to a greater
extent
weight gain is limited
in overweight and obese pregnant women.
Sports Med 2011
Prevent excessive weight gain.

22. Gestational diabetes control
• Moderate physical exercise performed during the entire pregnancy
improved levels of maternal glucose tolerance (50 g maternal glucose
screen 24–28 weeks) with no cases of gestational diabetes.
•Improving glycemic control in women who required insulin
Barakat et al 2012
Zhang et al 2006
•16 MET hours per week showed a 17% reduction in GDM risk,
•56 MET hours per week showed a ~30% reduction in GDM risk,
compared with subjects who did not exercise.

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

24. the psychological impact
• Clinical trials find positive effects of physical exercise on depressive
symptoms during pregnancy and postpartum
• Quality of life mainly with regards to physical and pain components.
• A greater sense of well-being
• Improved sleep
Robledo-Colonia et al 2012
Songoyard et al 2012
Nascimento 2011
Vallim et al 2011
Barakat et al 2011

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

26. Physical exercise on fetal or neonatal
outcome

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

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

29. Fetal distress
• FHR is increased by about 20 beats/minute within 30 seconds of
strenuous exercise stoppage.
• By 10 minutes post-exercise, FHR is 0–10 beats/minute higher,
compared with pre-exercise after a bicycle test to maximal or near
maximal exertion.
•  brief intense exercise does not cause fetal distress.
• Regular exercise training does not alter the fetal response.
Kennelly et al, 2002
Van Doorn et al, 1992
Barakat et al,2010

30. Neonatal birth weight
• Aerobic dance exercise and strength twice a week, performed by
sedentary pregnant women for a minimum 12 weeks
not associated with reduction in birth weight, preterm birth rate, or
neonatal well being measured with Apgar score.
Haakstad et al, 2011
• Vigorous exercise
no evidence of adverse results for fetal growth.
Kramer et al, 2006

31. Maternal assessment

32. Maternal assessment
before exercise recommendation
• Assessing the quantity and quality of dietary intake
• Maternal medical history and contraindications to exercise
• Exercise history both before and during the present pregnancy
(intensity, type, and duration)
• Prepregnant BMI
IOM (2009)
WHO 아시아-태평양 지역
대한 비만학회
Total weight
Gain (Kg)
Underweight < 18.5 < 18.5 12.5 – 18.0
Normal 18.5 - 24.9 18.5 - 22.9 11.5 – 16.0
Overweight 25.0 - 29.9 23.0 - 24.9 7.0 – 11.5
obese > 30.0 > 25.0 5.0 – 9.0
BMI (체질량지수)= 체중(kg)/ 키(m)2

35. Maternal advice
after exercise recommendation
• Should be aware of uterine contractions.
• No longer suggest the routine counting of fetal movements in the
second half of a woman’s pregnancy.
– Less than ten fetal movements in 12 hours is an indication that further
investigation at a hospital is warranted.
NICE guidline, 2004

36. Conclusion
The aim of exercising during pregnancy
 to maintain a good condition
without trying to reach a peak fitness level

37. Thanks you
for your attention