PRE- and POST PARTUM EXERCISE

1. PRE- and POST PARTUM EXERCISE R. De Wet

2. Presentation • 28 year old Female patient • Present with no complaints. • She had read that exercise might be beneficial in her pregnancy and had thus come to see me to get more information on the subject.

3. HISTORY • Medical history: • This was her first pregnancy and had been trying for 2years. • She was at present 14weeks pregnant. • She didn’t have any chronic illnesses. • Family history: • There was no significant family history. • Further relevant history: • She herself had been an overweight baby (4.7kg) and subsequent overweight kid and teenager.

4. HISTORY • Medication history: • She was taking only antenatal supplements. • Exercise history: • She occasionally attended gym (spin and aerobic classes prior to her pregnancy. • Diet history: • She ate a healthy low fat, high fiber diet.

5. Clinical Examination • There was nothing of note found on the clinical examination. • Her BMI was 30

6. Special Investigations • Fasting blood glucose 4.5 • Cholesterol N • Rhesus Positive • Ultrasound of baby Normal • ECG Normal

7. Biomechanical Evaluation • No obvious abnormalities seen with • Clinical examination • Walking on the treadmill etc.

8. 3 Stage Assessment • Clinical • 14weeks pregnant • BMI 29 • Personal • Anxious because she had been an overweight child and teen • Contextual • This was her first baby and they struggled for 2years to fall pregnant. • She wanted to do all she can to give her baby the best start in life possible.

9. Problem List • Active • Need help and advice on an exercise program for her during her pregnancy • Passive • Patient is not a regular athlete or physically active person

10. Plan • I asked her to return the following day • General information session • We then moved on to the list I asked her to compile, on all the questions she would like answered. • We discussed the literature that I reviewed • Following this: • Made the decision together that we would work out an exercise program that she would be willing to follow.

11. Exercise and Follow-up Plan • Graded approach • start with 30min of walking every day except Wednesday and Sunday • At 20weeks • Returned and we repeated the ultrasound which looked fine • We then started her on more aerobic training. • Cycling most days (this was the most comfortable method of exercise for her) • Twice a week - special antenatal aerobic, weight baring class at the local gym.

12. Progression • We are currently awaiting the birth of her son in the next month. • On regular follow-up • ultrasound - fetus was growing well and the last ultrasound showed a +/-3kg baby.

13. You don’t always plan a pregnancy

14. But you can plan what to do once you are pregnant

15. Bad Mommy

16. Good mommyAdvice

17. Introduction • There are many advantages of exercising in pregnancy for both mother and baby • The discussion that follows will be mainly on the advantages for the baby • Some of the advantages for the mother that wont be discussed here include • Prevention and reduction of back ache • Reduction in the occurrence of postpartum depression • Increasing of maternal energy levels • Physical preparation of the body for the birth process • (How will I know if my vomiting is morning sickness or the flu?~If it’s the flu, you’ll get better.)

18. Discussion • Prenatal period is a potential unique physiological window in which: • Maternal and fetal adaptations can have major consequences for the long-term health and wellbeing of our children. • Studies have led to conflicting evidence as to the impact of exercise on fetal growth. • There is also a lack of consensus regarding the potential long-term risks or benefits for the offspring of exercising mothers.

19. Discussion • Based on the current evidence available: • Adaptations seem to be dependent on → Gestational period in which exercise training is initiated and maintained. • Recently it has been reported: • Might be a modest reduction in offspring birth size in response to regular non-weight-bearing aerobic exercise in the second half of pregnancy (Hopkins et al 2010). • This was accompanied by lower cord blood insulin-like growth factor I (IGF-I) and IGF-II suggesting that →maternal exercise elicited adaptations in nutrient partitioning to the fetus → leading to decreased endocrine stimulation of fetal growth.

20. Discussion • When considering current observations, there exists a potential for a link between • i)maternal exercise and the • ii)developmental origins of obesity, • Thus if you have a small reduction in birth weight in babies that would be in the upper normal range or in the large for gestational age range → exercise might reduce their overall risk for childhood obesity. • What is the most reliable method to determine a baby’s sex?~Childbirth.

21. Discussion • However, a significant reduction in a babies weight, that would have been at the bottom normal range could result in: →SGA babies →↑ incidence of SGA babies →long term metabolic sequelae (↑coronary artery disease + ↑DM2 in adult life) The more pregnant I get, the more often strangers smile at me. Why?~‘Cause you’re fatter than they are.

22. EFFECT OF EXERCISE ON FETAL GROWTH • Studies examining the effects of maternal exercise on fetal growth primarily have focused on offspring birth weight - not considering other concomitant factors (nutrition, amount of exercise, environmental factors). • Different patterns of exercise during pregnancy have diverse effects on the relationship between exercise and pregnancy outcomes (Clapp et al 2002.)

23. EFFECT OF EXERCISE ON FETAL GROWTH • Clapp looked at lean, previously fit, individual who continued to exercise (aerobic, weight baring) into late pregnancy Controls (also lean previously fit mothers) →compared to the controls the babies were an avgof 350g lighter. The reduction in BW caused entirely by ↓in fat mass + NO difference in lean mass

24. EFFECT OF EXERCISE ON FETAL GROWTH • He then looked at previously unfit and moderately over weight ladies →made them exercise in pregnancy →260g increase in birth weight. →The increase in birth weight was caused by a proportional increase in lean body mass and fat mass. →may relate to long-term effects of an active lifestyle on body composition, because maternal adiposity is linked strongly to offspring birth weight (Catalano et al 1998).

25. EFFECT OF EXERCISE ON FETAL GROWTH • An effect of nonweight-bearing exercise (such as cycling or swimming) on birth size has not been documented clearly • But it is suggested that a predominantly nonweight-bearing exercise program may be sufficient to elicit adaptations leading to alterations in fetal growth. • What’s the difference between a nine-month pregnant woman and a model?~Nothing, if the pregnant woman’s husband knows what’s good for him.

26. TIME-SPECIFIC EFFECTS ON FETAL GROWTH • ↑Volumeof exercise in Early pregnancy + ↓ Volume in 2nd Half pregnancy = offspring significantlyheavierand taller at birth. →↑birth weight = due to Balanced increase in Fat and Lean tissue, →resulting in significantly higher percentage of body fat (fetal body fat is laid down primarily in the last third of gestation). • ↓Volume of exercise in Early pregnancy + ↑Volume in2ndHalf pregnancy → ↓ birth weight (compared to group who maintained a moderate volume of exercise for the entire duration of pregnancy). →In comparison these neonates had a similar percentage of fat mass, suggesting a symmetrical decrease in body size.

27. TIME-SPECIFIC EFFECTS ON FETAL GROWTH • These findings suggest that fetoplacental adaptations are dependent on the • 1)Period of gestation in which exercise training is initiated and maintained, as well as the • 2)Intensity or Volume of exercise performed. • Under what circumstances can sex at the end of pregnancy bring on labor?~When the sex is between your husband and another woman

28. LONG-TERM HEALTH CONSEQUENCES FOR THE OFFSPRING • The long-term effects of fetal growth on adult health are thought to be the consequences of: PROGRAMMING →A stimulus occurring at a critical sensitive period of early life having permanent effects on the growth and metabolism of the infant. My childbirth instructor says it’s not pain I’ll feel during labor, but pressure. Is she right?~Yes, in the same way that a tornado might be called an air current.

29. LONG-TERM HEALTH CONSEQUENCES FOR THE OFFSPRING • These stimuli may lead to: • Alterations in Birth Size and • Metabolic changes, such as: • Reduced insulin sensitivity and • Increased susceptibility to disease in later life • Size at birth has a well-known and studied link to the development of : • Type 2 diabetes mellitus, Metabolic syndrome, • Hypertension, Cerebrovascular disease, • Coronary heart disease.

30. LONG-TERM HEALTH CONSEQUENCES FOR THE OFFSPRING • The consequences of being small at birth (<10th centile) • Increased rates of: • Cardiovascular disease, Type 2 diabetes, and Metabolic syndrome • Short pre-pubertal children born SGA demonstrated • ↓ insulin sensitivity + ↑ insulin response to glucose.

31. LONG-TERM HEALTH CONSEQUENCES FOR THE OFFSPRING • The consequences of being large at birth (>90th centile / >4.5kg) • Children born at both the lower and upper ends of the birth weight spectrum are at risk of: • Obesity and a range of adult diseases in later life • Infants > 4.5kg at birth have • ↑ risk of infant mortality and birth trauma

32. HEALTH RISKS IN OFFSPRING OF EXERCISERSDuring pregnancy • Sustained moderate- or high-intensity aerobic exercise initiates a redistribution of blood flow to working muscles and results in an: • ↑core temperature and • ↓ maternalsubstrate levels. • Recent investigations have suggested that regular exercise does not result in • an increase in early pregnancy loss, stillbirth, or neonatal death • Physiological changes in maternal insulin sensitivity in a healthy pregnancy are regulated to achieve optimal fetal growth and are NOT sensitive to modest increases in energy expenditure through exercise. This supports the safety of maternal exercise for fetal well-being.

33. HEALTH RISKS IN OFFSPRING OF EXERCISERSPostnatal • NWBexercise program in 2ndhalf of pregnancy →avg BW reduction of 143 g • Vigorous WB exercise for duration of pregnancy →Mean reduction in BW of 310 g (compared with offspring of women who reduced physical activity levels from early gestation) Exercise offspring remained lighter and leaner than controls, but there were no differences in height.

34. HEALTH RISKS IN OFFSPRING OF EXERCISERSLater life of infant • Potential long-term consequences of maternal exercise may not be caused by • →a reduction in fetal growth • →BUT ↑ risk of postnatal catch-up growth, →predisposing to adult obesity and subsequent comorbidities. • No catch-up growth was observed at 5 yr of age in offspring of women who continued vigorous exercise in pregnancy.

35. POSTNATAL HEALTH BENEFITS IN THE OFFSPRING OF EXERCISERS • 1) Modest ↓ in BW in the offspring of women who exercise during their pregnancy →may lead to a long-term reduction in the risk of obesity in childhood • There is general trend of increasing mean BW in recent generations →Phenomenon that may be contributing to the ever-increasing global obesity epidemic. →Thus a reduction of say 143-310g in BW (compared to controls) may actually be MORE NORMAL than the “normal” controls!

36. POSTNATAL HEALTH BENEFITS IN THE OFFSPRING OF EXERCISERS • Exercise offspring demonstrated slightly advanced neurodevelopmental scores compared with their control counterparts (although they did not control for maternal IQ.) So maybe only clever moms exercise!! • The potential health benefits of maternal exercise for offspring could be greater in ↓ →overweight and obese mothers, who have a ↑risk of delivering a large baby.

37. Lessons learnt OR Advice to be given to Pregnant patients • Exercise in woman of child baring age is important • →PRIOR to pregnancy as your body composition and fitness level is important prior to falling pregnant • The potential health benefits of maternal exercise for offspring may thus be the greatest in • →overweight and obese mothers, who have an ↑risk of delivering a large baby with an ↑risk of obesity in childhood. • Dietary intervention may be an essential part of a lifestyle modification program during pregnancy in overweight and obese women.

38. Lessons learnt OR Advice to be given to Pregnant patients • Note that • Only few studies examining postnatal growth outcomes in exercise offspring. • Two studies to date provide NO evidence of adverse outcomes in childhood. • No studies examined postnatal growth in the offspring of overweight or obese women who engage in regular aerobic exercise IN pregnancy. • The most favorable long-term health outcomes for offspring (of exercising mothers) are to result from a : • Modest reduction in mean BW • OR a ↓ incidence of LGA, without a significant increase in the incidence of SGA. • Thus exercise may decrease your chance of having a LGA baby.

39. Advice to be given on Exercise Program: • To achieve a: • Modest reduction in mean birth weight • OR a reduction in the incidence of LGA.

40. Typeof exercise: Weight-bearing aerobic exercise training (favored) • NWB exercise, which may be more tolerable for overweight and obese women (may also be sufficient to elicit feto-placental adaptations). • Resistance training in pregnancy (currently there is scant evidence on the efficacy and safety) • Addition of modified resistance training to aerobic exercise programs (may have different or additional benefits for both mothers and offspring).

41. Timingof exercise training. Early pregnancy exercise has: • Stimulatory effects on placental growth and function. • Physically active women • →May be a beneficial adaptation in BUT • Overweight and Obese mothers. • →May have the less desirable effect of promoting excess fetal growth in Initiating a moderate exercise programat 20 wk • May be more beneficial in preventing excess fetal growth. (Further studies in overweight and obese women are required)

42. Volume of exercise training • Exercise should be frequent • (fetoplacental adaptations are caused by the repeated acute stimulus of each exercise session) • 30 min of moderate exercise on most, if not all, days of the week. (Based on the current evidence of the ACOG) • Above recommendations should be safe for healthy pregnant women in the absence of medical or obstetric complications

43. Learning experience • I think my main learning experience or ‘take home’ message with this particular patient was that: • When you are in the business of sport and exercise medicine you must be ready and prepared to field any exercise related enquiries. • Every person and every situation needs a tailor made solution and it is our duties to help in these circumstances to the best of our learnt knowledge

44. Thank you

45. References • Hopkins SA, Baldi JC, Cutfield WS, McCowan LS, Hofman PL. Exercise training in pregnancy reduces offspring size without changes in maternal insulin sensitivity. J. Clin. Endocrinol. Metab. 2010; 95(5):2080Y8. • Cutfield WS, Hofman PL, Vickers M, Breier B, Blum WF, Robinson EM. IGFs and binding proteins in short children with intrauterine growth retardation. J. Clin. Endocrinol. Metab. 2002; 87(1):235Y9. • Hofman PL, Cutfield WS, Robinson EM, et al. Insulin resistance in short children with intrauterine growth retardation. J. Clin. Endocrinol. Metab. 1997; 82(2):402Y6. • Clapp JF 3rd. Maternal carbohydrate intake and pregnancy outcome. Proc. Nutr. Soc. 2002; 61(1):45Y50. • Clapp JF 3rd, Kim H, Burciu B, Schmidt S, Petry K, Lopez B. Continuing regular exercise during pregnancy: Effect of exercise volume on fetoplacental growth. Am. J. Obstet. Gynecol. 2002; 186(1):142Y7. • Clapp JF 3rd, Capeless EL. Neonatal morphometrics after endurance exercise during pregnancy. Am. J. Obstet. Gynecol. 1990; 163:1805Y11. • Clapp JF 3rd, Kim H, Burciu B, Lopez B. Beginning regular exercise in early pregnancy: Effect on fetoplacental growth. Am. J. Obstet. Gynecol. 2000; 183:1484Y8. • Catalano PM, Thomas AJ, Huston LP, Fung CM. Effect of maternal metabolism on fetal growth and body composition. Diabetes Care 1998; 21(Suppl. 2):B85Y90. • Hopkins SA, Baldi JC, Cutfield WS, McCowan LS, Hofman PL. Exercise training in pregnancy reduces offspring size without changes in maternal insulin sensitivity. J. Clin. Endocrinol. Metab. 2010; 95(5):2080Y8. • Barker DJ. In utero programming of chronic disease. Clin. Sci. 1998; 95(2):115Y28. • Oken E, Gillman MW. Fetal origins of obesity. Obes. Res. 2003; 11(4): 496Y506. • SpellacyWN, Miller S,Winegar A, Peterson PQ. Macrosomia V Maternal characteristics and infant complications. Obstet. Gynecol. 1985; 66(2): 158Y61. • Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst. Rev. 2006; 3:CD000180. • Ananth CV, Wen SW. Trends in fetal growth among singleton gestations in the United States and Canada, 1985 through 1998. Semin. Perinatol. 2002; 26(4):260Y7.