CLINICAL REVIEW: 2019 Canadian guidelines for physical activity throughout pregnancy

2019 Canadian Guidelines for Physical Activity

Throughout Pregnancy.

Michelle F Mottola, Margie H Davenport, Stephanie-May Ruchat, Gregory A Davies, Veronica J Poitras, Casey E Gray, Alejandra Jaramillo Garcia, Nick Barrowman, Kristi B Adamo, Mary Duggan, Ruben Barakat, Phil Chilibeck, Karen Fleming, Milena Forte, Jillian Korolnek, Taniya Nagpal, Linda G Slater, Deanna Stirling, Lori Zehr.

Br J Sports Med 2018; 52: 1339-1346. doi: 10.1136/bjsports-2018-100056

By Amanda O’Reilly

Fewer than fifteen percent of women will achieve the minimum recommendation of physical activity during their pregnancy despite the significant affect it has on her health as well as that of her fetus.

There continues to be uncertainty among some pregnant women and obstetric care providers as to whether prenatal physical exercise may increase the risk of pregnancy complications. The Guidelines Consensus Panel selected thirty-seven (20 rated critical, 17 rated important) outcomes related to maternal, fetal and neonatal health.

In the absence of contraindications (see Table. 1), following the guidelines is associated with a) fewer newborn complications (i.e., large for gestational age), and b) maternal health benefits (i.e., decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes).

CONTRAINDICATIONS TO PHYSICAL ACTIVITY THROUGHOUT PREGNANCY

ABSOLUTE RELATIVE

Ruptured membranes Recurrent pregnancy loss

Premature labour Unexplained persistent vaginal bleeding Placenta praevia after 28 weeks’ gestation Pre-eclampsia Gestational hypertension A history of spontaneous preterm birth Mild/moderate cardiovascular or respiratory disease Symptomatic anaemia

Incompetent cervix Malnutrition

Intrauterine growth restriction High-order multiple pregnancy (e.g. triplets) Uncontrolled type I diabetes Uncontrolled hypertension Eating disorder

Twin pregnancy after the 28 th week Other significant medical conditions

Uncontrolled thyroid disease Other serious cardiovascular, respiratory or systematic disorder

throughout pregnancy.

Six specific recommendations are provided with corresponding quality and strength of recommendations.

1: All women without contraindication should be physically active throughout pregnancy.

A)

Women who were previously inactive.

Strong recommendation, moderate-quality evidence.

One hundred and four exercise-only randomized controlled trials (RCTs) were identified. From these studies prenatal physical activity was associated with a reduction in the odds of gestational diabetes mellitus (38%), pre-eclampsia (41%), gestational hypertension (39%), prenatal depression (67%) and macrosomia (39%) without increasing the odds of adverse outcomes such as preterm birth, low birth weight, miscarriage and perinatal mortality.

Physical activity during the first trimester did not increase the odds of miscarriage or congenital anomalies however not engaging in physical activity from the first trimester increased the odds of pregnancy complications. Therefore, physical activity should be encouraged throughout pregnancy.

B)

Women categorized as overweight or obese (pre-pregnancy body mass index ≥25kg/m 2 .

Strong recommendation, low-quality evidence.

Despite low-quality evidence, there was evidence from RCTs of improvement in gestational weight gain and blood glucose in women categorized as overweight or obese.

C) Women diagnosed with gestational diabetes mellitus. Weak recommendation, low-quality evidence. This is a weak recommendation as the benefit between women who were physically active and those who did not was small.

2: Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications.

Strong recommendation, moderate-quality evidence.

The evidence presented demonstrated an association with clinically meaningful reductions in the odds of developing gestational diabetes mellitus, pre-eclampsia and gestational hypertension.

3: Physical activity should be accumulated over a minimum of three days per week; however, being active every day is encouraged.

Strong recommendation, moderate-quality evidence.

Accumulating more physical activity (frequency, duration or volume) over the week was associated with greater benefits. Physical activity below the recommendations also incurred some benefits. There is a dose-response relationship between physical activity and decreasing odds of pre-eclampsia, gestational diabetes, gestational hypertension and a reduction in depressive symptoms and circulating maternal blood glucose.

4: Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and / or gentle stretching may also be beneficial.

Strong evidence, high-quality evidence.

Evidence reviewed demonstrated that combining aerobic and resistance exercise during training was more effective at improving health outcomes than aerobic exercise alone.

5: Pelvic floor muscle training (PFMT) may be performed daily to reduce the risk of urinary incontinence. Instruction on the proper technique is recommended to obtain optimal benefits.

Weak recommendation, low-quality evidence.

The Guidelines Consensus Panel deemed this weak recommendation as pre-natal PFMT is associated with a 50% reduction in prenatal and 35% reduction in postnatal urinary incontinence.

6: Pregnant women who experience lightheadedness, nausea or feeling unwell when they exercise flat on their back should modify their exercise position to avoid the supine this position.

Weak recommendation, very-low quality evidence.

This recommendation is based primarily on expert opinion as there was limited information from RCTs regarding the balance of benefits and harms from physical activities performed in the supine position.

Along with the above guidelines there are safety precautions (Table. 2) and reasons to stop physical activity and consult a healthcare provider (Table. 3) provided by the Guidelines Consensus Panel.

SAFETY PRECAUTIONS FOR PRENATAL PHYSICAL ACTIVITY

Avoid physical activity in excessive heat, especially with high humidity. Avoid activities which involve physical contact or danger of falling. Avoid scuba diving.

Avoid physical activity at high altitude (>2500m) if this is not where you usually exercise / live. Seek supervision from an obstetric care provider if you plan to exercise competitively or significantly above the recommended guidelines. Maintain adequate nutrition and hydration. Know the reasons to stop physical exercise and consult a qualified healthcare provider immediately.

Table. 2

REASONS TO STOP PHYSICAL ACTIVITY AND CONSULT A HEALTHCARE PROVIDER

Persistent excessive shortness of breath that does not resolve on rest. Severe chest pain.

Regular and painful uterine contractions. Vaginal bleeding. Persistent loss of fluid from the vagina indicating rupture of the membranes. Persistent dizziness or faintness that does not resolve on rest.

Table. 3

LIMITATIONS IN THE RESEARCH

Despite women over the age of thirty-five years of age being considered high risk of prenatal complications there is very limited research targeting the benefits or risks of physical activity in this subgroup.

Research does not identify the safety or added benefit of exercising at levels significantly above the recommendations. RCTs prescribed to 7.0 metabolic equivalents as the upper limit. The safety and efficacy of chronic high-intensity physical activity for the mother, the fetus and the neonate are not known.

Future research efforts should focus on pregnant women over the age of thirty-five and develop a better understanding of what the upper limit of physical exercise is for pregnant women. Based off this guideline, all pregnant women should be encouraged to participate in physical exercise throughout their pregnancy unless they fall into the contraindication’s category.

A full set of references is available on request.

Please note these are the proposed courses for 2020. With the current COVID-19 situation this could also change. Once we are confirmed to go ahead registrations will be open via PNZ.

Lower Limb in Sport Venue and dates TBC

This course is for registered physiotherapists who work with individual athletes or teams in which lower limb injury is common. The focus of the course is on pathomechanics and kinetic chain deficits as they relate to injury prevention and performance, diagnosis and advanced rehabilitation of lower limb conditions.

By the end of the course you will understand the pathoaetiology of common lower limb injuries, be able to perform key clinical and functional tests, rehabilitate lower limb injury in a number of sporting contexts including football, running and contact sports, and develop individualised return-to-sport programmes.

Promotion and Prescription of Physical Activity and Exercise

22 nd & 23 rd of August at AUT North

This course is suitable forphysiotherapists wanting to improve their knowledge and skills in assessment and prescription of physical activity and exercise to use with patients on a daily basis. This course provides a bridge to Level 2 SPNZ courses and important background information for those considering university postgraduate study. The course will provide a combination of lectures, practical demonstrations, practical assessments and case studies and will cover the following topics: Principles of exercise prescription, Promotion and assessment of physical activity, Assessment of neuromuscular performance, Aerobic and functional capacity testing ,Strategies to enhance exercise adherence, Screening for return to sport, Exercise risk screening and goal setting, Physiological effects of disuse and ageing

Injury Prevention & Performance Enhancement.

21 st and 22 nd of November at AUT Millennium

This course will provide you with the key skills used in the enhancement of sporting performance and prevention of injury. It covers the analysis of physical, biomechanical and technical needs of sport, identifying key factors affecting performance and injury prevention.

You will learn how to assess athletes and implement an individualised programme designed to optimise movement efficiency, performance and minimise injury risk. You will learn how to develop a sport–‐specific screening assessment, how to monitor injury rates and target injury prevention strategies within different sporting contexts.