William M. Gilbert, MD Regional Medical Director, Women’s Services Sutter Health, Valley Region & Clinical Professor, Department of OB/GYN, University of California, Davis Physical Activity (PA) restrictions including Many myths about maternal activity levels in bed rest pregnancy ◦ Evidence for these restrictions ◦ Bed rest with first trimester bleeding Examine normal PA levels in pregnancy. ◦ Too much exercise causes bad things: PTL, PTD, SGA ◦ What level of PA is safe, if any? ◦ Bed rest with incompetent cervix ◦ Is too much (marathon runner) PA bad? ◦ Increased activity may put you into labor PA and the effect on pregnancy outcomes. ◦ Potentially bad: SGA/IUGR, PTD, LGA ◦ Potentially good: C/S rates, DM, preeclampsia
Regular physical activity (PA) in all stages of life, including pregnancy, promotes health benefits. Most Americans do not reach this goal 81% Most pregnant women decrease PA once pregnant. Obese patients more likely to decrease PA A. Go back to work than normal weight patients B. Off work until the bleeding stops or an 17% SAB 150 min/week at moderate intensity. 2% C. Give progesterone injections ◦ 5 -30 min sessions Go back to work Off work until the bleedi.. Give progesterone inject... International Physical Activity Questionnaire short form (IPAQ-SF) ◦ Good test-retest reliability for PA ◦ Inactive or low (< 150 min/week) ◦ Active (> 150min/week), Moderate, Moderate to vigorous, vigorous Metabolic Equivalents (MET) ◦ Amount of calories burned at complete rest ◦ 1 MET- About 70 kcal
Sousa Rego et al., 2016 1,380 women Surveyed PA in the second trimester ◦ All levels of PA including High PA was not associated with LBW, PTD, IUGR Owe et al. 2012 – 61,0908 Norwegian Mother and Child Cohort study ◦ Surveyed at 17 and 30 weeks gestation on PA ◦ 3-5 times per week at both gestational ages Decreased risk of PTD aOR 0.82 (0.73, 0.91) Slight increase in post term delivery aOR 1.14 (1.04, 1.24) Committee Opinion Number 650 2015 ◦ Reaffirmed 2017 ◦ Exercise recommendations Basically any/all PA is good in normal women ◦ Absolute contraindications ◦ Relative contraindications ◦ Examples of safe and unsafe PA during pregnancy
Often women unable to get exercise due to Pre Term Delivery exhaustion or N/V ◦ Poor, limited data but no benefit Bleeding and decreasing PA ◦ Cochrane review -Sosa et al. 2015 One study of 1266 women ◦ Poor, limited data but no benefit No difference in PTD – RR 0.92 (0.6, 1.6) ◦ Cochrane review –Aleman et al 2005 No evidence supporting or refuting use of bed rest Two studies of 84 women Bed rest – loss of physical conditioning, No difference in SAB – RR 1.54 (0.92, 2.58) economic loss, psychological stress, increase Insufficient evidence supporting use of bed rest in DVT/PE Bed rest – loss of physical conditioning, economic loss, psychological stress. Can lead to MORE stress!! “ Although bedrest and hydration have been recommended to women with symptoms of PTL to prevent PTD, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely 47% recommended” A. IV hydration 34% B. IV hydration and bed rest in the hospital C. Send the patient home and come back ACOG Practice Bulletin #171 2018 13% for 2 nd beta in 24 hours. 7% D. None of the above n e o . v . . t i t . . o a s a b e e r a d r m e y d h o h e h t V b t f I d n o n e e a i n t o n a o p N i t e a h r d t d y n h e V S I
Practice Bulletin Number 142 2014 Hispanic population 2006 – 2011 ◦ Reaffirmed 2019 ◦ Proyecto Buena Salud prospective cohort -1313 Cerclage for the Management of Cervical ◦ Pregnancy Physical Activity Questionnaire Sedentary activity Increase in C/S rates Insufficiency ◦ OR 1.54 (1.02-3.33) ◦ Much controversy about cerclage use without proper indications When planned C/S removed ◦ Recommendation Level B ◦ High PA pre-pregnancy OR 0.61, (0.38-0.99) ◦ “Certain non surgical approaches, including activity ◦ Moderate intensity mid/late pregnancy 50% restriction, bed rest, and pelvic rest, have not been reduction in C/S rates proved to be effective for the treatment of CI and Russo et al 2019 their use is discouraged” Pastorino et al., 2018 Sanda Et al. 2017 Meta-analysis of 8 population based studies Effect of a prenatal lifestyle intervention on with 72,694 patients PA level in late pregnancy and the first year postpartum Examined early and late PA on birth outcomes Norwegian Fit for Delivery (NFFD) RCT ◦ Leisure time PA (LTPA) - Moderate to vigorous or Vigorous Healthy primips, BMI > 19 two groups ◦ Outcomes BW, LGA, Macrosomia, SGA ◦ Intervention group: twice weekly group exercises Late but not early LTPA ◦ Control: standard prenatal care ◦ Lower risk of LGA, macrosomia ◦ IPAQ-SF at 16, 36 weeks and 6 and 12 months PP ◦ No increase in SGA
Sanda Et al. 2017 Abenhaim et al. 2008 Results Retrospective cohort study of 36,140 patients ◦ Intervention group maintained PA levels at 36 Examined hospitalized patients (677) with: weeks in normal weight and physically active. ◦ PTL (71%), PROM (18%), incompetent cervix (8%) ◦ Control group all decreased their PA Bed rest reduction in Preeclampsia ◦ The intervention effect on obese or inactive patients ◦ OR 0.27 (0.16, 0.48) depended upon level of PA Delivery prior to 34 weeks Conclusion: ◦ OR 0.12 (0.03, 0.5) ◦ 1.Group exercise intervention maintained PA Reduction in IUGR through 36 weeks. ◦ OR 0.38 (0.18, 0.84) ◦ 2. No postpartum effect was seen McCall et al. O&G 2013 Evidence does not appear to support bed rest for MOST obstetrical complications: “Therapeutic” bed rest in pregnancy: unethical and unsupported by data. ◦ First trimester bleeding, IC, PTL, IUGR, PE In fact, may cause more harm: Cochrane reviews do not support: ◦ Loss of physical condition, financial loss, increase in ◦ Threatened AB, Hypertension, PTD, Multiples or Stress, DVT/PE. IUGR Increasing physical activity: If bed rest is to be used, it should be only ◦ Panacea for most obstetrical problems! within a formal clinical trial Lower C/S, LGA, Macrosomia, SGA, PTD ◦ Intervention works to increase PA but at acceptable cost?
References 1. Sanda, B., Vistad, I., Reme Sagedal, L., Hagen Haakstad, LA., Lohne- Understanding this evidence, how do we Seiler, H., Klungland Torstveit, M. Effect of a prenatal lifestyle intervention on physical activity level in late pregnancy and the first year postpartum. PLOS ONE educate our patients? November 27, 2017; https://doi.org/10.1371/journal.pone.0188102 ◦ Bleeding in the first trimester? 2. Sousa Rego, A., Seabra Soares de Britto e Alves, M., Lucena Batista, RF., ◦ Short cervix on 2 nd trimester ultrasound Costa Ribeiro, CC. (2016). Physical activity in pregnancy and adverse birth outcomes. Cad.Saude Publica Health 2016; 32(11):e00086915 / Increasing physical activity to improve www.ensp.fiocruz.br/csp DOI: 10.1590/0102-311X00086915 3. Cerclage for the management of cervical insufficiency. The American outcome College of Obstetricians and Gynecologists Women’s Health Care Physicians. ◦ Stress maintaining PA! 150 min/week Practice Bulletin . Number 142, February 2014 (Reaffirmed 2019). 4. Pastorino, S., Biship, T., Crozier, SR., et al. Associations between ◦ Increasing activity in those who are inactive maternal physical activity in early and late pregnancy and offspring birth size: ◦ Focus on benefits of PA in pregnancy remote federated individual level meta-analysis from eight cohort studies. BJOB: An International Journal of Obstetrics and Gynaecology. Epidemiology. October 16, We have much research and work to do!! 2018; www.bjog.org DOI: 10.1111/1471-0528.15476 5. Management of preterm labor. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians. Interim Update Practice Bulletin. Number 171, October 2016 (Reaffirmed 2018). 6. Aleman, A., Althabe, F., Belizan J., Bergel, E. Bedrest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003576. https://www.ncbi.nlm.nih.gov/pubmed/15846669 7. Russo, LM., Harvey, MW., Pekow, P., Chasan-Taber, L. Physical activity and risk of cesarean delivery in hispanic women. J Phys Act Health. 2019 Feb 1;16(2):116-124. DOI: 10.1123/jpah.2018-0072. Epub 2019 Jan 9 8. Sosa, CG., Althabe, F., Belizan, JM., Bergel, E. Bed rest in singleton pregnancies for preventing preterm birth. Cochran Database Syst Rev . 2015 Mar 30;(3):CD003581. DOI: 10.1002/14651858.CD003581.pub3 9. Physical activity and exercise during pregnancy and the postpartum period. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians. Committee Opinion. Number 650, December 2015 (Reaffirmed 2017) 10. Sanda, B., Vistad, I., Hagen Haakstad, LA., Bernstsen, S., Reme Sageal, L., Lohn-Seller, H., Klungland Torstveit, M. Reliability and concurrent validity of the internal physical activity questionnaire short form among pregnant women. BMC Sports Science, Medicine and Rehabilitation. (2017)9:7 DOI: 10.1186/s13102-017-0070-4
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