Source: Physical Medicine and Rehabilitation by Randall Braddom, 4th Edition
Exercise during Pregnancy
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There is possible competition between exercising maternal muscle and the fetus for blood flow, oxygen
delivery, glucose availability, and heat dissipation during exercise.
Metabolic and cardiorespiratory adaptations to pregnancy can alter the responses from exercise training.
Participation in a wide range of recreational activities appears to be safe during pregnancy.
Participation in recreational sports with a high potential for contact, such as ice hockey, soccer, and basketball,
could result in trauma to both the woman and the fetus.
Recreational activities with an increased risk of falling, such as gymnastics, horseback riding, downhill skiing,
and vigorous racquet sports, have an inherently high risk for trauma in pregnant and non-pregnant women.
Those activities with a high risk of falling or for abdominal trauma should be avoided during pregnancy.
Scuba diving should be avoided throughout pregnancy, because during this activity the fetus is at increased risk
for decompression sickness secondary to the inability of the fetal pulmonary circulation to filter bubble
formation.
Exertion at altitudes of up to 6000 ft. appears to be safe, but engaging in physical activities at higher altitudes
carries various risks.
During pregnancy, women can continue to exercise and derive health benefits even from mild to moderate
exercise routines. Regular exercise (at least three times per week) is preferable to intermittent activity. Thirty
minutes or more of moderate exercise a day on most, if not all, days is recommended.
Women should avoid exercise in the supine position after the first trimester. Such a position is associated with
decreased cardiac output in most pregnant women. Because the remaining cardiac output is preferentially
distributed away from splanchnic beds (including the uterus) during vigorous exercise, such regimens are best
avoided during pregnancy.
Prolonged periods of motionless standing should also be avoided.
Women should be aware of the decreased oxygen available for aerobic exercise during pregnancy. They should
be encouraged to modify the intensity of their exercise according to maternal symptoms. Pregnant women
should stop exercising when fatigued and not exercise to exhaustion.
Weight-bearing exercises can under some circumstances be continued at intensities similar to those prior to
pregnancy throughout the pregnancy.
Non-weightbearing exercises, such as stationary cycling or swimming, will minimize the risk of injury and
facilitate the continuation of exercise during pregnancy.
Exercise should be terminated should any of the following occur: vaginal bleeding, dyspnea before exertion,
dizziness, headache, chest pain, muscle weakness, calf pain or swelling, preterm labor, decreased fetal
movement, and amniotic fluid leakage. In the case of calf pain and swelling, thrombophlebitis should be ruled
out.
Pregnant women may participate in a strength-training program that incorporates all major muscle groups, with
a resistance that permits multiple repetitions (i.e., 12 to 15 repetitions) to be performed to a point of moderate
fatigue.
Isometric muscle actions and the Valsalva maneuver should be avoided, as should the supine position after the
first trimester.
Morphologic changes in pregnancy should serve as a relative contraindication to types of exercise in which loss
of balance could be detrimental to maternal or fetal wellbeing, especially in the third trimester. Any type of
exercise involving the potential for even mild abdominal trauma should be avoided.
Pregnancy requires an additional 300 kcallday in order to maintain metabolic homeostasis. Women who
exercise during pregnancy should be particularly careful to ensure an adequate diet.
Pregnant women who exercise in the first trimester should augment heat dissipation by ensuring adequate
hydration, appropriate clothing, and optimal environmental surroundings during exercise. Exercise in cool
environments whenever possible.
Those who begin an exercise program after becoming pregnant are advised to receive physician authorization
and begin exercising with low-intensity, low- (or non-) impact activities, such as walking and swimming.
Many of the physiologic and morphologic changes of pregnancy persist 4-6 weeks postpartum. Thus
prepregnancy exercise routines may be resumed gradually as soon as it is physically and medically safe.
The American College of Obstetricians and Gynecologists recommends that women who currently participate in a
regular exercise program can continue their training during pregnancy, following the above recommendations.
Studies have demonstrated that women naturally decrease their exercise duration and intensity as their pregnancy
advances.
CONTRAINDICATIONS TO AEROBIC EXERCISE DURING PREGNANCY
Absolute Contraindications
• Hemodynamically significant heart disease
• Restrictive lung disease
• Incompetent cervix or cerclage
• Multiple gestation at risk for premature labor
• Persistent second- or third-trimester bleeding
• Placenta previa after 26 weeks’ gestation
• Premature labor during the current pregnancy
• Ruptured membranes
• Preeclampsia or pregnancy-induced hypertension
Relative Contraindications
• Severe anemia
• Unevaluated maternal cardiac arrhythmia
• Chronic bronchitis
• Poorly controlled type 1 diabetes
• Extreme morbid obesity
• Extreme underweight (body mass index <12 kg/m 2)
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in current pregnancy
• Poorly controlled hypertension
• Orthopedic limitations
• Poorly controlled seizure disorder
• Poorly controlled hyperthyroidism
• Heavy smoker
Further Reasons to Discontinue Exercise and Seek Medical Advice During
Pregnancy
• Vaginal bleeding
• Dyspnea before exertion
• Dizziness
• Headache
• Chest pain
• Muscle weakness
• Calf pain or swelling (need to rule out thrombophlebitis)
• Preterm labor
• Decreased fetal movement
• Amniotic fluid leakage
Low Back Pain in Pregnancy
Low back pain is a common problem in pregnancy. Two categories: those with low back pain and those with pelvic
girdle pain (pain below the iliac crest, such as sacroiliac joint-related pain).
Low back pain can begin at any time during the pregnancy and generally reaches a peak at 36 weeks. Pain decreases
after this point and in most patients is substantially improved by 3 months postpartum.
Etiology of low back pain in the pregnant woman:
• increased biomechanical strain due to changes in spine posture related to the anterior movement of the
pregnant woman’s center of gravity
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hormonal influence in pregnancy alters the lumbopelvic ligaments which influence the stability of the
lumbosacral spine and make it more vulnerable to loading
Individualized physical therapy, water aerobics, acupuncture, and massage therapy can be recommended to decrease
pain. Instruction on a home exercise program, use of a sacroiliac belt, and back school have not been shown to
significantly decrease pain intensity. No data support the use of lumbar–abdominal orthoses that are designed to
support the pregnant woman’s abdomen.. Medications generally thought of as safe and well tolerated can have
unexpected consequences during pregnancy. For example, the use of NSAIDs in late pregnancy can cause premature
closure of the ductus arteriosus and neonatal renal failure.
Most antidepressants have not been approved for use during pregnancy, and for most antiseizure medications,
such as gabapentin, there is evidence for increased incidence of birth defects in animals, and they have not
been well studied in humans.