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I. Introduction

    For a good many years now women have been leading more active lives. The advent of technology, the introduction of home appliances and the emergence of feminist movements above all have wrought changes in the way contemporary women lead their lives. Some women make use of the improvement in their status to dedicate themselves to pursuing professional careers and/or to experience the full joy of engaging in physical activities. The latest research work demonstrates that women are usually engaged in work even until the end of pregnancy (6, 9, 16). Pregnant women are making more use of physical exercising programs (17). As a consequence, a wide variety of programs aimed at the pregnant woman have been implemented.

    The American College of Obstetricians and Gynecologists (ACOG) has recommended physical exercise to pregnant women who do not present medical or obstetric complications. They indicate that the beneficial aspects of physical exercise would maintain and/or improve mothers’ cardiorespiratory and muscular fitness, which would in turn help them to have better control over their bodies during the physiological and psychological processes of adjustment. As a consequence, their bodies would adjust toward an optimal environment for the growth and development of the fetuses (1, 7).

    The Melpomene Institute has encouraged pregnant women to undergo regular exercise sessions intended to achieve positive psychological effects in enhancing their self-image (20).

    The Japanese Association of Obstetricians and Gynecologists for Maternity Safekeeping has recommended physical activities during pregnancy and has plans to spread word of the benefits of such activities amongst obstetricians, gynecologists and other professionals concerned with the well-being of pregnant women (10).

    As a response to the “fitness boom” of the 1970s and the increased desire of pregnant women to participate in a variety of exercise modes the ACOG issued in the year of 1985 a set of guidelines and recommendations for maternal exercising during pregnancy. The intensity of exercise for pregnant women advised by the ACOG should not yield a rate of heartbeat of more than 140 per minute and the duration of strenuous exercise should be close to 15 minutes or less (19). These general recommendations were designed to serve a very heterogeneous population and for this reason were considered conservative and overcautious by many researchers (13, 15, 23).

    In the meta-analysis conducted by Lokey et al. (13) many exercise programs exceeded the recommendations established by the ACOG, but none of them was considered to be hazardous or prejudicial to mothers or fetuses.

    The programs analyzed by Lokey et al. were performed for an average of 43 minutes a day, three times a week and at heart rates of up to 144 beats per minute. Furthermore, a study conducted by Zeanah and Schlosser (23) demonstrated that women with uncomplicated pregnancies could exercise regularly exceeding the ACOG recommendations.

    In 1994 the ACOG revised the previous set of recommendations and adopted a less conservative posture. The new guidelines advised healthy pregnant women to exercise throughout pregnancy and the postpartum period with almost no restrictions regarding the exercise mode, intensity and duration (1).

II. Recommendations for maternal exercising during pregnancy

    A great number of researchers (1-5, 8, 11, 12, 14, 18, 19, 21, 22) have contributed to the widespread knowledge of maternal exercise safety recommendations, prescriptions, tips and/or guidelines. A comprehensive list of these recommendations is provided below.

1. Women should discuss their exercise plans with their health-care provider, especially if they might be prone to present complications based on their medical and obstetric history;

2. Women who have been sedentary before pregnancy should begin with physical activity of a very low intensity and gradually increase their exertions during exercise;

3. Regular exercise i.e. at least three times per week is preferable to intermittent activity;

4. Exercise within their comfort range. Exercising to the point of exhaustion, or feeling chronically fatigued is detrimental to both mothers and fetuses;

5. Take time to adequately warm up and cool down preventing musculoskeletal injuries. Avoid stretching to the point of maximum resistance since the progressive laxity of joints and ligaments predisposes pregnant women to injuries;

6. Emphasis should be placed on proper caloric intake to compensate for the additional caloric cost of exercising;

7. Women should avoid overheating and dehydration by drinking plenty of fluids before, during and after their exercise sessions; and they should not exercise in hot, humid environments or when they are febrile. It is recommended that they wear clothing appropriate to facilitating heat dissipation;

8. It is recommended that cushioned and stable shoes to reduce impact shock be worn;

9. Women should avoid exercising in the supine position after the fourth month of gestation is completed, since this position is associated with decreased cardiac output in most pregnant women. They should also avoid prolonged periods of motionless standing after the first trimester because this position can cause a decrease in blood flow;

10. Exercises that involve the Valsalva’s maneuver such as weight lifting should be avoided in the third trimester. Before the third trimester relatively light weights and moderate repetitions are accepted for maintaining flexibility and muscle tone. However, heavy weights should be avoided at any time during pregnancy, except under proper prescription and supervision;

11. Repetitive ballistic movements (jerky, bouncy motions) should be avoided, especially in the third trimester since there is a shift in the mother’s center of gravity as pregnancy progresses;

12. m) Women should be aware that in competitive team sports physical contact can cause abdominal trauma and for this reason should be avoided;

13. Pregnant women should be alerted to such signs as: excessive fatigue, dizziness, shortness of breath, palpitations, decreased fetal movement, persistent contractions, vaginal water leakage and vaginal bleeding. These signs should prompt the mothers-to-be to stop exercising and to seek proper medical attention.

III. Absolute and relative contraindications for exercising in pregnancy

    The aforementioned recommendations of maternal exercising apply to healthy, well-nourished women with uncomplicated pregnancies. On the other hand, exercise may not necessarily be appropriate for some pregnant women, more specifically for those who present serious obstetric complications, suffer from certain diseases or are undernourished. A list of absolute contraindications for exercising in pregnancy (1, 3-5, 11, 12, 14, 21, 22) is furnished as follows.

1. Bleeding or diagnosis of placenta previa;

2. Diagnosis of incompetent cervix;

3. Ruptured membranes or premature labor in prior and/or current pregnancy;

4. Development of toxemia or pre-eclampsia in current pregnancy;

5. Very low body fat and/or history of anorexic eating disorders;

6. History of two or more spontaneous abortions in previous pregnancies;

7. Diagnoses of clinically significant valvular or ischemic heart disease;

8. Type I diabetes mellitus, peripheral vascular disease, uncontrolled hypertension or thyroid disease, other serious systemic disorders (e.g. hepatitis, mononucleosis);

9. Multiple pregnancy;

10. No prenatal care.

    There are also some relative contraindications for maternal exercising in pregnancy. These relative contraindications may depend on the mother’s condition and/or the presence of any suffering. A list of the relative contraindications (1, 3-5, 14, 22) is provided below:

1. History of premature labor, or intrauterine growth retardation, or pre-eclampsia, or toxemia of pregnancy;

2. Diagnosis of anemia or iron deficiency;

3. Essential hypertension;

4. Significant pulmonary diseases;

5. Clinically significant cardiac arrhythmias and/or mild valvular heart diseases;

6. Obesity or type II diabetes mellitus;

7. Breech presentation in the last trimester;

8. Presence of twins after the 24th week of gestation;

9. Excessive weight gain or extreme underweight;

10. Sedentary lifestyle prior to pregnancy.

IV. Conclusions

    Many experts and organizations of professionals dealing with procedures related to pregnancy have a considered approach to exercising. They regard exercising as a safe and even a recommendable activity for pregnant women once they follow the guidelines for exercising defined by renowned medical associations such as the ACOG.

    While the ACOG’s recommendations and guidelines are designed toward a more general population, they may not necessarily be suitable to certain populations. Furthermore, not all women may appropriately comply with these guidelines. Pregnant women who present relative or absolute contraindications for exercising must ponder the relationship between the benefits of exercising and the possibility of endangering their fetuses’ health.

    After a considered assessment of the arguments for and against, those willing to take part in physical activity should consult a qualified professional in order to follow an exercising routine in accordance with their individual condition.

References:

1. American College of Obstetricians and Gynecologists Technical Bulletin n° 189. Exercise during pregnancy and the postpartum period. Washington, DC: ACOG, 1994.

2. American College of Obstetrics and Gynecologists. Guidelines for exercise. http://www.cleveland.com./living/health/fitness/pregnancy/acog.html.

3. Araujo D. Expecting questions about exercise and pregnancy? Physic. Sportsmed 1997;25(4): 85-93.

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6. Berkowitz G.S., Kelsey J.L., Holford T.R., Berkowitz R.L. Physical activity and the risk of spontaneous preterm delivery. The Journal of Reproductive Med 1983; 28: 581-88.

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10. Japanese Association of Obstetricians and Gynecologists for Maternity Safekeeping. Sport during pregnancy, 1995.

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18. Paolone A.M. and Worthington. Cautions and advice on exercise during pregnancy. Comtemp Obstet Gynecol 1985; 25: 150-8.

19. Pivarnik J.M. Maternal exercise during pregnancy. Sports Med 1994; 18 ( 4): 215-7.

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