Texto de apoio ao curso de Especialização
Atividade Física Adaptada e Saúde
Prof. Dr. Luzimar Teixeira
Exercícios e gravidez
Am J Obstet Gynecol. 1987 Nov;157(5):1199-203. Links
Effects of aerobic and strength conditioning on pregnancy outcomes.
 Hall DC,
 Kaufmann DA.
Department of Exercise and Sports Sciences, University of Florida, Ocala.
This study evaluated the effects of a physical conditioning program on
pregnancy outcomes and the subjective pregnancy experience. Pregnancy
outcomes included length of labor, mode of delivery, length of hospitalization,
and gestational age, birth weight, and Apgar scores of newborn infants.
Subjective data included level of tension, general physical comfort, and selfimage. The 845 subjects in the study were divided into a control group (n =
393) and into groups of low, medium, and high levels of exercise (n = 82, 309,
and 61, respectively). Exercise sessions consisted of treadmill or bicycle warmup, individually prescribed exercises on weight-lifting equipment for arms, legs,
abdomen, and back, and 1- to 2-mile workout on bicycle ergometer. Pregnancy
outcomes were more favorable in the exercise groups, particularly the highexercise group. Significant data included length of hospitalization, incidence of
cesarean section, and Apgar scores. All patients reported positive subjective
responses to the conditioning program.
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Obstetrics & Gynecology 2003;101:313-319
© 2003 by The American College of Obstetricians
and Gynecologists
This Article
Abstract
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ORIGINAL RESEARCH
Pelvic Floor Muscle Training
During Pregnancy to Prevent
Urinary Incontinence: A
Single-Blind Randomized
Controlled Trial
Siv Mørkved, MSc, PT, Kari Bø, PhD, PT,
Berit Schei, MD, PhD and Kjell Åsmund
Salvesen, MD, PhD
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Articles by Mørkved, S.
Articles by Salvesen, K. A.
From the Department of Community Medicine and
General Practice, and National Center for Fetal
Medicine, Department of Obstetrics and Gynecology, Norwegian University of Science and Technology,
Trondheim; and The Norwegian University of Sport and Physical Education, Oslo, Norway.
Address reprint requests to: Siv Mørkved, MSc, PT, Department of Community Medicine and General
Practice, Medisinsk teknisk forskningssenter, N-7489 Trondheim, Norway; E-mail:
siv.morkved@medisin.ntnu.no .
TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
ABSTRACT
OBJECTIVE: Urinary incontinence is a chronic health complaint that severely reduces
quality of life. Pregnancy and vaginal delivery are main risk factors in the development
of urinary incontinence. The aim of this study was to assess whether intensive pelvic
floor muscle training during pregnancy could prevent urinary incontinence.
METHODS: We conducted a single-blind randomized controlled trial at Trondheim
University Hospital and three outpatient physiotherapy clinics in a primary care setting.
Three hundred one healthy nulliparous women were randomly allocated to a training (n
= 148) or a control group (n = 153). The training group attended a 12-week intensive
pelvic floor muscle training program during pregnancy, supervised by physiotherapists.
The control group received the customary information. The primary outcome measure
was self-reported symptoms of urinary incontinence. The secondary outcome measure
was pelvic floor muscle strength.
RESULTS: At follow-up, significantly fewer women in the training group reported
urinary incontinence: 48 of 148 (32%) versus 74 of 153 (48%) at 36 weeks’ pregnancy
(P = .007) and 29 of 148 (20%) versus 49 of 153 (32%) 3 months after delivery (P =
.018). According to numbers needed to treat, intensive pelvic floor muscle training
during pregnancy prevented urinary incontinence in about one in six women during
pregnancy and one in eight women after delivery. Pelvic floor muscle strength was
significantly higher in the training group at 36 weeks’ pregnancy (P = .008) and 3
months after delivery (P = .048).
CONCLUSION: Intensive pelvic floor muscle training during pregnancy prevents
urinary incontinence during pregnancy and after delivery. Pelvic floor muscle strength
improved significantly after intensive pelvic floor muscle training.
Urinary incontinence is a chronic health complaint that severely reduces quality of life
and has many sufferers reporting effects on their social, domestic, physical,
occupational, and leisure activities.1–3 Aside from the personal and social costs to
sufferers, the direct and indirect health care costs are substantial. The approximate
annual cost of the condition in the United States has been estimated at $11.2 billion in
the community and $5.2 billion in nursing homes.4 Urinary incontinence is defined by
the International Continence Society as "the complaint of any involuntary leakage of
urine." Urinary incontinence is more common in women than in men and affects women
of all ages. Prevalence rates in women between 15 and 64 years of age vary from 10% to
30%.4 However, prevalence estimates of urinary incontinence during pregnancy and
after childbirth are even higher, varying between 20% and 67%, and 0.3% and 44%,
respectively.5–7
Pregnancy and vaginal delivery are considered to be one of the main risk factors in the
development of urinary incontinence because pregnancy and childbirth may cause
damage to the fascias, ligaments, pelvic floor muscles, and nerves supporting and
controlling the bladder neck and urethra.8–12
To prevent urinary incontinence, women have been encouraged to conduct pelvic floor
muscle exercises during pregnancy and after childbirth.13 Pelvic floor muscle training
after childbirth has been demonstrated to be effective in prevention and treatment of
urinary incontinence,14–18 but the effect of pelvic floor muscle exercises during
pregnancy on the prevention of urinary incontinence has been sparsely documented. We
are aware of two published randomized controlled trials (RCTs) addressing pelvic floor
muscle exercise during pregnancy.19,20 However, in Sampselle et al’s study19 the
dropout rate was high, and it is questionable whether this is a prevention study, whereas
only severity of incontinence—and not the prevalence of incontinence at baseline and
after intervention—was reported. In Reilly et al’s study20 only women with existing
bladder neck mobility were included.
At present there is insufficient evidence to determine whether pelvic floor muscle
training during pregnancy is effective or ineffective at preventing urinary incontinence
in childbearing women.
The aim of our study was to assess whether a 12-week intensive pelvic floor muscle
training program during pregnancy, carried out in a primary care setting, could prevent
urinary incontinence during pregnancy and after childbirth.
TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
MATERIALS AND METHODS
Nulliparous women attending the routine ultrasound control at The National Center for
Fetal Medicine, Trondheim University Hospital, at 18 weeks’ pregnancy were invited to
participate in the study. They received a written invitation and information about the
study as a supplement to the letter inviting them to the routine ultrasound control. The
women were asked to return a signed consent form if they wanted to participate in the
study. Women were eligible for the trial if they were nulliparous and 18 years or older,
with a single live fetus at the routine ultrasound scan. Exclusion criteria were pregnancy
complications, high risk for preterm labor, pain during pelvic floor muscle contractions,
ongoing urinary tract infection, or diseases that could interfere with participation. In
addition, women who lived too far from Trondheim to be able to attend weekly training
groups were excluded. The procedures followed were in accordance with the ethical
standards of the responsible regional committee on human experimentation and with the
Helsinki Declaration. The Regional Medical Ethics Committee approved the study. The
participants were not compensated financially.
Women were recruited to the trial from October 1998 to May 2000 and followed up
until April 2001. They came from a nonselected population from a geographically welldefined area consisting of four municipalities surrounding and including the city of
Trondheim. In this period, 1533 nulliparous women from this area attended a routine
ultrasound scan at the National Center for Fetal Medicine in Trondheim.
Three hundred forty-two women gave their signed consent to participate in the trial.
Forty-one women were excluded or withdrew before the first examination: 17 lived too
far away to be able to attend the training groups, eight had pregnancy complications,
four were not nulliparous, two had twin pregnancies, five were not able to meet for the
first assessment, and five withdrew for unknown reasons (Figure 1 ).
Figure 1. Trial profiles showing the flow of
participants through each stage of the randomized trial
comparing training and control group.
Mørkved. Prevention of Incontinence. Obstet Gynecol
2003.
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(27K):
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Three hundred one women were randomly allocated to a pelvic floor muscle training
group or to a control group. Randomization was done in blocks of a maximum of 32
with the use of opaque, sealed envelopes. The professional staff involved in the training
groups or the outcome assessments had no access to the randomization procedure. A
secretary with no other involvement in the trial prepared the envelopes. All the
envelopes were mixed thoroughly before they were stored in a larger envelope. Each
participant drew and opened one envelope herself and was enrolled by the secretary in
the secretary’s office. The women were asked not to reveal any information about group
allocation to the principal investigator (SM) doing the assessments. The principal
investigator was not involved in the training of the women and was blinded to group
allocation while making the assessments and plotting the data.
All women in both groups were individually instructed in pelvic floor anatomy and how
to contract the pelvic floor muscles correctly by a physiotherapist before randomization.
Correct contraction was assessed by vaginal palpation and observation of inward
movement of the perineum during contraction,21 and feedback (knowledge of results and
performance) was given.
The training group followed a specially designed exercise course including pelvic floor
muscle and general exercises. They trained with a physiotherapist for 60 minutes once a
week for a period of 12 weeks (between 20 and 36 pregnancy weeks). The
physiotherapist encouraged the women to perform near maximal pelvic floor muscle
contractions, and to hold the contraction 6–8 seconds. At the end of each contraction the
women were asked to add three to four fast contractions. The resting period was about 6
seconds. Group training was performed in lying, sitting, kneeling, and standing positions
with legs apart to emphasize specific strength training of the pelvic floor muscles and
relaxation of other muscles. Body awareness, breathing, and relaxation exercises and
strength training for the abdominal, back, and thigh muscles were performed to music
between positions. In addition, the women were encouraged to use their preferred
position and perform eight to 12 equally intensive pelvic floor muscle contractions twice
per day at home. Motivation was strongly emphasized by the physiotherapists. The
pelvic floor muscle training protocol has previously been published by Bø et al22 and is
in accordance with the recommendations for general training to increase strength of
skeletal muscles.23 Adherence to the training protocol was based on registrations in the
women’s personal training diaries (two sets of eight to 12 contractions per day) and the
reports from the physiotherapists who led the group training (participation in six or
more group training sessions). Five physiotherapists from three different outpatient
physiotherapy clinics in a primary care setting were involved in leading a total of 14
training groups, each including ten to 15 women.
Women in the control group received the customary information given by their midwife
or general practitioner. They were not discouraged from doing pelvic floor muscle
exercise on their own.
Women were examined at 20 and 36 weeks’ gestation and 3 months after childbirth. The
primary outcome measure was self-reports of urinary incontinence. Women reporting
urinary incontinence once per week or more during the last month were categorized as
incontinent.
Secondary outcomes were recordings, in a home voiding diary, of episodes of
involuntary leakage during the 3 days directly after the first assessment (20 weeks’
pregnancy) and immediately before the second (36 weeks’ pregnancy) and third (3
months postpartum) assessments.24 In addition, the women reported whether the urinary
leakage had changed (better, unchanged, worse) from baseline registration at 20 weeks’
to 36 weeks’ gestation. Vaginal palpation and observation during contraction were used
to assess the women’s ability to perform pelvic floor muscle contraction.21 Pelvic floor
muscle strength (vaginal squeeze pressure [cm H2O]) was measured by a vaginal
balloon catheter (balloon size 6.7 x 1.7 cm) connected to a pressure transducer (Camtech
Ltd., Sandvika, Norway). The method was found to be reliable and valid in a previous
study.21
We aimed to recruit 290 women, giving 85% power ( = 5%) to detect a 50% difference
in self-reported urinary incontinence between the two groups, assuming that 42% of the
women would be incontinent without intervention. These figures were conservatively
based on findings in a previous study.25
The principal analysis was done on an intention to treat basis. The missing last values
were carried forward by their baseline values. Groups were compared with exact
computation of the Pearson 2 test if data were categoric. Relative risks and their 95%
confidence intervals were calculated for comparisons of proportions (observed ratio of
proportions [StatXact 5; Cytel Software Corp., Cambridge, MA]). Normality was
evaluated by using the Shapiro-Wilk W test for normality, and the Mann-Whitney U test
was used to compare distributions between groups when variables were not normally
distributed (SPSS 10.7; SPSS Inc., Chicago, IL). The influence of covariates on the
primary outcome variable was explored using logistic regression for odds ratio (SPSS
10). Additional subgroup analyses were carried out on groups according to onset of
incontinence. Results are given as mean values with 95% confidence intervals. P values
less than .05 were considered significant.
TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
RESULTS
In all, 301 nulliparous women were randomized to a training group (n = 148) or a
control group (n = 153) (Figure 1 ). The trial groups were comparable at baseline
(Table 1 ). Seven women in the control group and five women in the training group
withdrew after the first assessment. The reasons for withdrawal were diseases connected
to pregnancy (n = 6) or personal (n = 6) (eg, changes in work situation, familiar causes,
relocation).
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Table 1. Background and Outcome Variables Before Treatment in
the Training and the Control Groups
In all, 120 (81%) of 148 women in the training group followed the training protocol.
The remaining 28 women were introduced to the training program but participated in
less than half of the group training sessions and did not return their personal training
diaries after the 12-week training program.
At follow-up, significantly fewer women in the training group than in the control group
reported urinary incontinence: 48 of 148 (32%) versus 74 of 153 (48%) at 36 weeks’
pregnancy and 29 of 148 (20%) versus 49 of 153 (32%) at 3 months postpartum (Table
2 ).
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Table 2. Women With Self-Reported Urinary Incontinence at 36
Weeks’ Pregnancy and 3 Months After Delivery
We found a decreased risk of urinary incontinence among women in the training group,
who were 33% less likely to report urinary incontinence at 36 weeks’ pregnancy and
39% less likely to report urinary incontinence at 3 months postpartum relative to the
control group. The relative risk estimates are shown in Table 2 . Potential effects of
differences between groups according to baseline characteristics (age, body mass index,
pelvic floor muscle strength, physical activity, urinary incontinence at baseline) were
analyzed by logistic regression for odds ratio and did not change the results of the
relative risk estimates.
Analyses of numbers needed to treat showed that intensive pelvic floor muscle training
during pregnancy prevents urinary incontinence in about one in six women during
pregnancy, and one in eight women after delivery.
The number of episodes of involuntary leakage during the 3 days directly after the first
assessment did not significantly differ between the two groups. At follow-up at 36
weeks’ pregnancy the number of leakage episodes was significantly lower in the training
group (25 of 148 versus 44 of 144, P = .014). At 3 months postpartum we found similar
results (20 of 148 versus 34 of 144, P = .049). In addition, significantly more women in
the intervention group reported a reduction in urinary leakage from 20 to 36 weeks’
pregnancy (29 of 148 versus nine of 153, P = .002).
The pelvic floor muscle strength was significantly higher in the training group at 36
weeks’ pregnancy (P = .008) and 3 months postpartum (P = .048) (Table 3 ).
View this Table 3. Pelvic Floor Muscle Strength (Mean and 95% Confidence
Interval) at 36 Weeks’ Pregnancy and 3 Months After Delivery,
table:
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window]
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We stratified women according to continence status before the pregnancy and at 20
weeks’ pregnancy. The results from these subgroup analyses were consistent with the
overall results (Table 4 ).
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Table 4. Subgroup Analyses Based on Groups Stratified According
to Continence Status Before Pregnancy and at Baseline
Intention to treat analyses, analyses including only women attending both pre- and
posttests, and per protocol analyses showed minor and insignificant differences in the
results.
No negative side effects of the training were reported. There were no statistically
significant differences in instrumental deliveries between the two groups. In the training
group, 110 women had vaginal deliveries, nine deliveries using forceps, 17 deliveries
using vacuum extraction, and 12 cesarean deliveries. In the control group, 107 women
had vaginal deliveries, 19 deliveries using forceps, 13 deliveries using vacuum
extraction, and 14 cesarean deliveries.
DISCUSSION
We found that intensive pelvic floor muscle training
during pregnancy prevents urinary incontinence during
pregnancy and after childbirth. We also found higher
pelvic floor muscle strength at 36 weeks’ pregnancy
(immediately after the end of the supervised training
period) and 3 months after delivery in the training
group.
TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
This was an RCT of nulliparous women, with blinding of the investigator, a low dropout
rate, the use of a standardized training protocol following recommendations from
exercise science,23 and high adherence to the training protocol. We have registered data
related to the onset of incontinence and performed subgroup analyses, indicating effects
on primary, secondary, and tertiary prevention. The results of the subgroup analyses
were consistent with the overall results in favoring the training group, which may
indicate that the intervention was effective irrespective of onset of incontinence. No
negative side effects of the intervention were reported. This is the largest of only three
published RCTs addressing the effect of intensive pelvic floor muscle training during
pregnancy.
In the present trial, only self-report was used as outcome measurement and in the
classification of continent and incontinent participants. Because we studied healthy
pregnant women, we found it important to use diagnostic tests and outcome
measurements causing minimal discomfort to the participants. To date there is no
agreement about what are the most appropriate outcome measures for urinary
incontinence. The Urodynamic Society and the standardization committee of the
International Continence Society have recommended using measures of urinary leakage
and self-reports to evaluate treatment effect.26 We refrained from using pad tests with
standardized bladder volume, to avoid inducing urinary tract infections among the
pregnant women, and decided to rely on self-reports only. In addition, results from a
previous study25 showed that only 45% of the women with urinary incontinence agreed
to participate in urodynamic assessment 8 weeks postpartum. This is not surprising, as
urodynamics are invasive and 23% of women will complain of moderately severe
discomfort.27 Lagro-Janssen et al28 have concluded that urodynamics are unnecessary in
most women presenting with urinary incontinence in general practice, but other studies
have focused on the need for urodynamic assessment in making a diagnosis and
formulating a treatment plan.29,30
In the present study we document a preventive effect of intensive pelvic floor muscle
training during pregnancy. Results from previous trials addressing pelvic floor muscle
training during pregnancy are inconsistent.19,20 In the study by Sampselle et al19 they did
not report the number of women with urinary incontinence before and after intervention,
and it is questionable whether this is a prevention study. Their results showed that when
controlling for baseline urinary incontinence score, the analyses of covariance showed
significantly less urinary incontinence in the training group at 35 weeks’ pregnancy, 6
weeks postpartum, and 6 months postpartum. However, at the end of the 12-month
period the difference had disappeared. The dropout rate was high, and no significant
difference in pelvic floor muscle strength was found between the groups. Reilly et al20
used the same definition of urinary incontinence and reported results that correspond to
those of the present study. Fewer women in the training group reported postpartum
urinary incontinence: 19.2%, versus 32.7% in the control group. However, they studied
only women in a high-risk group (with diagnosed bladder neck mobility) and found no
difference in pelvic floor muscle strength between the groups after exercise.
In the present trial the participants came from a non-selected population of nulliparous
women. All women were individually instructed in correct pelvic floor muscle
contractions. The training group followed a 12-week specially designed pelvic floor
muscle exercise course between the 20th and 36th weeks’ pregnancy, including group
training once per week and daily training at home. The training protocol followed
recommendations from exercise science,23 highlighting intensity and frequency of
training. Skilled physiotherapists were leading the training groups, gave instructions on
the pelvic floor muscle exercises, and encouraged the women to perform intensive
contractions. In addition, they emphasized the importance of adherence to the training
protocol and motivated the women to follow the protocol. Also, results from previous
studies suggest that the training protocol and a close follow-up by skilled
physiotherapists are important.14,15,22 In the present study the intervention was carried
out by five different physiotherapists in a primary care setting. This may indicate that
the training program can easily be implemented as one part of a public health strategy to
prevent urinary incontinence in childbearing women. However, there is still insufficient
knowledge about whether pelvic floor muscle training during pregnancy can prevent
urinary incontinence later in life. Long-term follow-up of the present trial and other
comparable populations are needed.
In conclusion, our results show that a specially designed pelvic floor muscle exercise
course during pregnancy prevents urinary incontinence during pregnancy and 3 months
after delivery.
Footnotes
The work was funded by The Norwegian Fund for Postgraduate Training in
Physiotherapy and the Norwegian Women’s Public Health Association.
The authors thank the physiotherapists Hildegunn Børsting, Trude Hoff Leirvik, Bente
Olsen, Monica U. Tøndel, and Bjørg Vada for their efforts in performing this study, by
leading the training groups. Professor of Biostatistics Ingar Holme, Norwegian
University of Sport and Physical Education, and Associate Professor Stian Lydersen,
Norwegian University of Science and Technology, gave valuable advice on the
statistical analysis. The English revision of the manuscript was done by Nancy Lea EikNes.
PII S0029-7844(02)02711-4
Received June 3, 2002. Received in revised form August 6, 2002. Accepted August 22,
2002.
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TOP
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MATERIALS AND METHODS
RESULTS
DISCUSSION
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HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Table 1. Background and Outcome Variables Before Treatment in the Training and the
Control Groups
Training group (n =
148)
Control group (n =
153)
Age (y)
28.0 (5.3)
26.9 (3.9)
Body mass index before pregnancy
23.1 (3.0)
23.4 (3.5)
Body mass index at 20 wk
24.5 (2.9)
24.8 (3.5)
Pelvic floor muscle strength (mL
H2O)
34.4 (16.3)
35.7 (17.2)
No. (%) exercising regularly
79 (53)
74 (48)
No. (%) exercising the pelvic floor
muscles
48 (30)
53 (28)
No. (%) incontinent at 20 wk
47 (32)
47 (31)
Values are mean (SDs) unless stated otherwise. N = 301. No statistically significant
differences were found.
Table 2. Women With Self-Reported Urinary Incontinence at 36 Weeks’ Pregnancy and
3 Months After Delivery
Training group
(N = 148)
Control group
(N = 153)
Significance
Relative risk
(95% CI)
n
%
n
%
36 wk
48
32
74
48
2
= 7.9, P =
.007
0.67 (0.50,
0.89)
3 mo after
delivery
29
20
49
32
2
= 6.1, P =
.018
0.61 (0.40,
0.90)
N = total no. of women; n = no. of women with urinary incontinence; % = proportion
of incontinent women; CI = confidence interval.
Table 3. Pelvic Floor Muscle Strength (Mean and 95% Confidence Interval) at 36
Weeks’ Pregnancy and 3 Months After Delivery, Measured by Vaginal Squeeze
Pressure (cm H2O)
Training group
Control group
P*
36 wk
39.9 (37.1, 42.7)
34.4 (31.6, 37.1)
.008
3 mo after delivery
29.5 (26.8, 32.2)
25.6 (23.2, 27.9)
.048
* Mann-Whitney U test.
Obstetrics & Gynecology 2003;101:313-319
Return to article
Table 4. Subgroup Analyses Based on Groups Stratified
According to Continence Status Before Pregnancy and at Baseline
36 wk
Continent
before
pregnancy
3 mo after delivery
TG
(n/N)
CG
(n/N)
29/120
52/124
0.57 (0.39,
0.84)
30/99
0.46 (0.24,
0.80)
Continent
13/94
before and at 20
wk
Relative risk
(95% CI)
TG
(n/N)
CG
(n/N)
14/120 28/124
9/94
13/99
Relative risk
(95% CI)
0.52 (0.28,
0.92)
0.73 (0.31,
1.66)
TG = training group; CG = control group; other abbreviations as in Table 2.
Subgroups are the group of women who were continent before pregnancy and the
group of women who were continent both before pregnancy and at the baseline
registration at 20 weeks’ pregnancy. Relative risk of urinary incontinence at 36
weeks’ pregnancy and 3 months after delivery for women in the TG vs those in the
the CG.
Rev. Bras. Reumatol. vol.45 no.3 São Paulo May/June 2005
download article in PDF format
doi: 10.1590/S0482-50042005000300018
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COMUNICAÇÃO BREVE BRIEF COMMUNICATION
Gravidez e exercício(*)
Pregnancy and exercise
Fernanda R. LimaI; Natália OliveiraII
Médica assistente e chefe do Ambulatório de Medicina Esportiva da Disciplina de
Reumatologia HC-FMUSP
II
Pós-graduanda e educadora física do Ambulatório de Medicina Esportiva da
Disciplina de Reumatologia HC-FMUSP
I
Endereço para correspondência
RESUMO
Com o crescente aumento de mulheres que praticam exercícios físicos e esportes
de forma regular, é importante que o especialista nas áreas clínicas se mantenha
atualizado sobre os benefícios e riscos da prática esportiva durante a gravidez, no
sentido de promover uma orientação segura e precisa para suas pacientes grávidas.
Palavras-chave: exercício físico, prática esportiva, gestação.
ABSTRACT
With the increasing number of women that perform physical activities and practice
sports regularly, it is important for the clinical specialists to be updated about the
benefits and risks of sports practices during pregnancy, with the aim of promoting a
safe and precise orientation of their pregnant patients.
Keywords: physical activity, sports practice, pregnancy.
INTRODUÇÃO
ALTERAÇÕES PROVOCADAS PELA GRAVIDEZ NO APARELHO LOCOMOTOR
Praticamente todas as mulheres grávidas experimentam algum desconforto
musculoesquelético durante a gravidez. Estima-se que cerca de 25% delas
apresentem ao menos sintomas temporários(1).
As mulheres grávidas apresentam um risco aumentado de queixas
musculoesqueléticas, principalmente lombalgia(2). A mudança do centro de
gravidade, a rotação anterior da pelve, o aumento da lordose lombar e o aumento
da elasticidade ligamentar são os principais responsáveis pelos sintomas(2). Já foi
demonstrado que um programa de exercícios executado três vezes por semana
durante a segunda metade da gravidez parece colaborar na redução da intensidade
das dores lombares, aumentando também a flexibilidade da coluna (3).
BENEFÍCIOS DO EXERCÍCIO NA GRAVIDEZ
As mulheres sedentárias apresentam um considerável declínio do condicionamento
físico durante a gravidez. Além disto, a falta de atividade física regular é um dos
fatores associados a uma susceptibilidade maior a doenças durante e após a
gestação(4).
Há um consenso geral na literatura científica de que a manutenção de exercícios de
intensidade moderada durante uma gravidez não-complicada proporciona inúmeros
benefícios para a saúde da mulher(5).
Apesar de ainda existirem poucos estudos nesta área, exercícios resistidos de
intensidade leve a moderada podem promover melhora na resistência e
flexibilidade muscular, sem aumento no risco de lesões, complicações na gestação
ou relativas ao peso do feto ao nascer. Conseqüentemente, a mulher passa a
suportar melhor o aumento de peso e atenua as alterações posturais decorrentes
desse período(5).
A atividade física aeróbia auxilia de forma significativa no controle do peso e na
manutenção do condicionamento, além de reduzir riscos de diabetes gestacional,
condição que afeta 5% das gestantes. A ativação dos grandes grupos musculares
propicia uma melhor utilização da glicose e aumenta simultaneamente a
sensibilidade à insulina(5).
Os estudos também mostram que a manutenção da prática regular de exercícios
físicos ou esporte apresenta fatores protetores sobre a saúde mental e emocional
da mulher durante e depois da gravidez(6). Além disso, existem dados sugestivos de
que a prática de exercício físico durante a gravidez exerce proteção contra a
depressão puerperal(5).
Na literatura há alguns estudos envolvendo exercícios para a musculatura pélvica
durante a gravidez. Eles são unânimes em afirmar os benefícios deste tipo
específico de exercício como forma de prevenção à incontinência urinária associada
à gravidez(7-9).
RISCOS PARA O FETO
A prática de exercícios acarreta riscos potenciais para o feto em situações em que a
intensidade do exercício seja muito alta, criando um estado de hipóxia para o feto,
em situações em que haja risco de trauma abdominal e em situações de
hipertermia da gestante. Esses fatores podem gerar estresse fetal, restrição de
crescimento intra-uterino e prematuridade(2).
Há algumas evidências de que a participação em exercícios de intensidade
moderada ao longo da gravidez possa aumentar o peso do bebê ao nascer,
enquanto que exercícios mais intensos e com grande freqüência, mantidos por
longos períodos da gravidez, possam resultar em crianças com baixo peso (2).
Alguns estudos experimentais com animais demonstraram que temperaturas
corporais acima de 39°C podem resultar em defeitos de fechamento do tubo neural,
que deve ocorrer normalmente por volta do 25o dia após a concepção. Embora esse
risco não tenha sido confirmado em humanos, sugere-se evitar sempre situações
que resultem em hipertermia materna durante o primeiro trimestre de gravidez (2).
Durante o período de amamentação, desde que a ingesta calórica e hídrica da mãe
se mantenha normal, os exercícios leves a moderados não afetam a quantidade ou
a composição do leite, e por isso não exercem qualquer impacto sobre o
crescimento do lactente(10).
CONTRA-INDICAÇÕES DE EXERCÍCIO DURANTE A GRAVIDEZ
O exercício regular é contra-indicado em mulheres com as seguintes
complicações(2):
Contra-indicações absolutas
Doença miocárdica descompensada
Insuficiência cardíaca congestiva
Tromboflebite
Embolia pulmonar recente
Doença infecciosa aguda
Risco de parto prematuro
Sangramento uterino
Isoimunização grave
Doença hipertensiva descompensada
Suspeita de estresse fetal
Paciente sem acompanhamento pré-natal
Contra-indicações relativas
Hipertensão essencial
Anemia
Doenças tireoidianas
Diabetes mellitus descompensado
Obesidade mórbida
Histórico de sedentarismo extremo
PRESCRIÇÃO DOS EXERCÍCIOS
Todas as mulheres que não apresentam contra-indicações devem ser incentivadas a
realizar atividades aeróbias, de resistência muscular e alongamento. As mulheres
devem escolher atividades que apresentem pouco risco de perda de equilíbrio e de
traumas(10). O trauma direto ao feto é raro, mas é prudente evitar esportes de
contato ou com alto risco de colisão(2).
Deve-se tomar o cuidado de não se exercitar vigorosamente em climas muito
quentes e de prover a hidratação adequada, de modo a não prejudicar a
termorregulação da mãe(5).
Com base em pesquisas na área de exercício e gravidez, o Sports Medicine
Australia(5) elaborou as seguintes recomendações:
• em grávidas já ativas, manter os exercícios aeróbios em intensidade moderada
durante a gravidez;
• evitar treinos em freqüência cardíaca acima de 140 bpm. Exercitar-se três a
quatro vezes por semana por 20 a 30 minutos. Em atletas é possível exercitar-se
em intensidade mais alta com segurança;
• os exercícios resistidos também devem ser moderados. Evitar as contrações
isométricas máximas;
• evitar exercícios na posição supina;
• evitar exercícios em ambientes quentes e piscinas muito aquecidas;
• desde que se consuma uma quantidade adequada de calorias, exercício e
amamentação são compatíveis;
• interromper imediatamente a prática esportiva se surgirem sintomas como dor
abdominal, cólicas, sangramento vaginal, tontura, náusea ou vômito, palpitações e
distúrbios visuais;
• não existe nenhum tipo específico de exercício que deva ser recomendado
durante a gravidez. A grávida que já se exercita deve manter a prática da mesma
atividade física que executava antes da gravidez, desde que os cuidados acima
sejam respeitados.
REFERÊNCIAS
1. Borg-Stein J, Dugan SA, Gruber J: Musculoskeletal aspects of pregnancy. Am J
Phys Med Rehabil 84: 180-92, 2005.
[ Medline ]
2. Bennell K: The female athlete. In: Brukner P, Khan K: Clinical sports medicine,
2.a ed, Austrália, McGraw-Hill, 2001. p. 674-99.
3. Garshasbi A, Faghih Zadeh S: The effect of exercise on the intensity of low back
pain in pregnant women. Int J Gynaecol Obstet 88: 271-5, 2005.
[ Medline ]
4. Haas JS, Jackson RA, Fuentes-Afflick E, et al: Changes in the health status of
women during and after pregnancy. Gen Intern Med 20: 45-51, 2005.
5. [No authors listed]: SMA statement. The benefits and risks of exercise during
pregnancy. J Sci Med Sport 5: 11-9, 2002.
[ Medline ]
6. Sternfeld B, Quesenberry CP Jr, Eskenazi B, Newman LA: Exercise during
pregnancy and pregnancy outcome. Med Sci Sports Exerc 27: 634-40, 1995.
[ Medline ]
7. Gorbea Chavez V, Velazquez Sanchez M del P, Kunhardt Rasch JR: Effect of
pelvic floor exercise during pregnancy and puerperium on prevention of urinary
stress incontinence. Gynecol Obstet Mex 72: 628-36, 2004.
8. Morkved S, Bo K, Schei B, Salvesen KA: Pelvic floor muscle training during
pregnancy to prevent urinary incontinence: a single-blind randomized controlled
trial. Obstet Gynecol 101: 313-9, 2003.
[ Medline ]
9. Reilly ET, Freeman RM, Waterfield MR, Waterfield AE, Steggles P, Pedlar F:
Prevention of postpartum stress incontinence in primigravidae with increased
bladder neck mobility: a randomised controlled trial of antenatal pelvic floor
exercises. BJOG 109: 68-76, 2002.
10. Davies GA, Wolfe LA, Mottola MF, et al: Exercise in pregnancy and the
postpartum period. J Obstet Gynaecol Can 25: 516-29, 2003.
Endereço para correspondência
Dra. Fernanda Lima
Disciplina de Reumatologia da Faculdade de Medicina da Universidade de São Paulo
(FMUSP)
Av. Dr. Arnaldo, 455, s. 3.133, CEP 01246-903
São Paulo, SP, Brasil
E-mail: fernanda@movimento.med.br
Recebido em 15/02/2005. Aprovado, após revisão, em 29/04/2005.