Birth Defects Research ( IF 2.1 ) Pub Date : 2020-09-17 , DOI: 10.1002/bdr2.1800 Justin J Fiutem 1, 2
The Barakat model (Guideline entitled “An exercise program throughout pregnancy: Barakat model” by Barakat, in this issue) presents an interesting program for professionally supervised exercise for pregnant women. It is a good supplement to what we already know is recommended and works for women who are pregnant. Women do not necessarily need supervised exercise programming unless there are known risks or they prefer to have a trainer. In those cases, their obstetrician could work with an American College of Sports Medicine (ACSM) certified personal trainer or an ACSM Certified Clinical Exercise Physiologist to carry out the training sessions. These would be rare occasions at least in the United States. Pregnant women should always consult with their obstetrician before beginning an exercise program anyway.
Exercise is known to be beneficial to women who are pregnant and improve birth outcomes both in reducing complications during pregnancy, birth, and postnatal periods (Downs, Chasan‐Taber, Evenson, Leiferman, & Yeo, 2012; Ferraro, Gaudet, & Adamo, 2012; Pivarnik et al., 2006; Tobias, Zhang, van Dam, Bowers, & Hu, 2011) and in the health of children born to these women (Prather, Spitznagle, & Hunt, 2012). In fact, exercise recommendations for women who are pregnant are the same for the healthy adult (150 min/week of moderately intense aerobic exercise on most days of the week) as long as there are no medical complications or concerns (ACSM, 2013 report https://www.acsm.org/docs/default‐source/files‐for‐resource‐library/pregnancy‐physical‐activity.pdf?sfvrsn=12a73853_4; Centers for Disease Control, https://www.cdc.gov/physicalactivity/basics/pregnancy/index.htm; and U.S. Department of Health and Human Services, 2008, https://health.gov/sites/default/files/2019-09/paguide.pdf).
There are some modifications depending on the week of pregnancy. Exercise should always be modified for women who are pregnant based on symptoms, discomforts, and changes in ability across the course of pregnancy (ACSM's Guidelines for Exercise Testing and Prescription, 10th edition, 2018). A physical activity readiness questionnaire for pregnant women should be given before beginning an exercise program (https://www.chp.gov.hk/archive/epp/files/PARmed-X.pdf).
- Vaginal bleeding or (amniotic) fluid leakage
- Shortness of breath prior to exertion
- Dizziness, feeling faint, or headache
- Chest pain
- Muscle weakness
- Calf pain or swelling
- Decreased fetal movement
- Preterm labor
- Physical activity in the supine position (lying your back) should be avoided or modified after week 16 of pregnancy. Due to the weight of the growing fetus, exertion or prolonged periods in the supine position may reduce venous return and subsequent cardiac output.
- Women who are pregnant should avoid exercising in a hot and humid environment, be well hydrated at all times (preferably with water), and dress appropriately to avoid heat stress. Please also refer to ACSM's position stand on exercise and fluid replacement from 2007.
- During pregnancy, the metabolic demand increases by ~300 kcal/day. Women should increase caloric intake to meet the caloric costs or pregnancy and exercise. Intake above or below recommended levels with concomitant changes in weight gain during pregnancy may be associated with adverse maternal and fetal outcomes. In order to avoid excessive weight gain during pregnancy, consult appropriate weight gain guidelines based on pre‐pregnancy BMI, available from the Institute of Medicine and the National Research Council (https://www.nationalacademies.org/news/2009/05/report‐updates‐guidelines‐on‐how‐much‐weight‐women‐should‐gain‐during‐pregnancy‐calls‐on‐health‐care‐providers‐to‐help‐women‐achieve‐a‐healthy‐weight‐before‐and‐during‐pregnancy).
- Physical activity may help regulate weight gain during pregnancy. However, women who exercise above recommended levels should be monitored to ensure adequate caloric intake and weight gain.
- Women who are pregnant and severely obese or have gestational diabetes mellitus or hypertension should consult their physician before beginning an exercise program, and their exercise program should be adjusted to their medical condition, symptoms, and physical fitness level. Exercise may be beneficial as an adjunct therapy for weight control and in primary prevention of preeclampsia and gestational diabetes, especially for women who are obese.
- Women who are pregnant should avoid contact sports and sport/activities that may cause loss of balance or trauma to the mother or fetus. Examples of sports/activities to avoid include soccer, basketball, ice hockey, roller blading, horseback riding, skiing/snowboarding, scuba diving, and vigorously intense racquet sports.
- In any activity, avoid using the Valsalva maneuver, prolonged isometric contractions, and motionless standing.
- Physical activity can be resumed after pregnancy but should be done so gradually because of normal deconditioning in the initial postpartum period. Generally, gradual exercise may begin ~4–6 weeks after a normal vaginal delivery or about 8–10 weeks after a cesarean section delivery with medical clearance. Women with higher cardiorespiratory fitness levels and more rigorous exercise routines prior to and during pregnancy may be able to resume exercise sooner. Light to moderate intensity exercise in the postpartum period is important for return to pre‐pregnancy BMI and does not interfere with breast feeding.
- Other online resources: http://www.acog.org and http://www.csep.ca/english/view.asp?x=698
Consistent with the letter to the editor by Dr. Antoine‐Jonville (in this issue), a trainer is not necessarily needed and an autonomous exercising program would reach more people. Pregnant women might be more likely to start an exercise program if they knew that they can do it on their own and if they knew that just walking is great exercise by itself especially during pregnancy. Recommendations and practices in other parts of the world may differ.
Exercise during pregnancy, for the most part, positively impacts maternal and fetal health and well‐being. Even if initiating physical activity during pregnancy, that can set the stage for lifelong exercise habits that would benefit the mother, child, and family. The prenatal period is a valuable time for counseling regarding physical activity and discussing barriers to physical activity in order to promote healthy exercise levels during pregnancy and afterwards.
中文翻译：
本期特刊“孕期锻炼”致编辑的信
Barakat 模型（本期 Barakat 撰写的题为“整个孕期的锻炼计划：Barakat 模型”的指南）为孕妇提供了一个在专业监督下锻炼的有趣计划。这是对我们已经知道的推荐的很好的补充，并且适用于怀孕的女性。女性不一定需要有人监督的锻炼计划，除非存在已知风险或她们更喜欢有教练。在这些情况下，他们的产科医生可以与美国运动医学学院 (ACSM) 认证的私人教练或 ACSM 认证的临床运动生理学家合作进行培训课程。至少在美国，这种情况很少见。无论如何，孕妇在开始锻炼计划之前应该始终咨询她们的产科医生。
众所周知，锻炼对怀孕妇女有益，并能改善分娩结果，减少怀孕、分娩和产后期间的并发症（Downs、Chasan-Taber、Evenson、Leiferman 和 Yeo，2012 年；Ferraro、Gaudet 和 Adamo，2012 年；Pivarnik 等人，2006 年；Tobias、Zhang、van Dam、Bowers 和 Hu，2011 年）以及这些妇女所生孩子的健康（Prather、Spitznagle 和 Hunt，2012 年））。事实上，只要没有医疗并发症或顾虑，孕妇的运动建议与健康成人相同（一周中的大多数日子进行 150 分钟/周的中等强度有氧运动）（ACSM，2013 年报告 https ://www.acsm.org/docs/default-source/files-for-resource-library/pregnancy-physical-activity.pdf?sfvrsn=12a73853_4；疾病控制中心，https://www.cdc.gov/ physicalactivity/basics/pregnancy/index.htm；以及美国卫生与公共服务部，2008 年，https://health.gov/sites/default/files/2019-09/paguide.pdf）。
根据怀孕周数有一些修改。应始终根据怀孕期间的症状、不适和能力变化对怀孕妇女的运动进行调整（ACSM 的运动测试和处方指南，第 10 版，2018 年）。在开始锻炼计划之前，应提供孕妇身体活动准备问卷 (https://www.chp.gov.hk/archive/epp/files/PARmed-X.pdf)。
- 阴道出血或（羊水）渗漏
- 运动前呼吸急促
- 头晕、头晕或头痛
- 胸痛
- 肌肉无力
- 小腿疼痛或肿胀
- 胎动减少
- 早产
- 怀孕 16 周后应避免或改变仰卧位（仰卧）的体力活动。由于生长中胎儿的重量，仰卧位的劳累或长时间可能会减少静脉回流和随后的心输出量。
- 孕妇应避免在炎热潮湿的环境中运动，随时补充水分（最好是水），并适当着装以避免热应激。另请参阅 ACSM 2007 年关于运动和补液的立场。
- 在怀孕期间，代谢需求增加约 300 kcal/天。女性应增加热量摄入以满足热量成本或怀孕和锻炼。摄入量高于或低于推荐水平并伴随怀孕期间体重增加的变化可能与不利的母体和胎儿结局有关。为了避免怀孕期间体重过度增加，请参考医学研究所和国家研究委员会提供的基于孕前 BMI 的适当体重增加指南 (https://www.nationalacademies.org/news/2009/05/报告-更新-指南-关于-女性在怀孕期间应该增加多少体重-呼叫医疗保健提供者-帮助-女性-达到健康的体重之前-和怀孕期间）。
- 身体活动可能有助于调节怀孕期间的体重增加。然而，应监测运动量超过推荐水平的女性，以确保足够的热量摄入和体重增加。
- 孕妇、严重肥胖或妊娠期糖尿病或高血压的女性在开始运动计划前应咨询医生，并根据自身的身体状况、症状和身体健康水平调整运动计划。运动作为控制体重和预防先兆子痫和妊娠糖尿病的辅助疗法可能是有益的，尤其是对肥胖女性而言。
- 孕妇应避免接触性运动和可能导致母亲或胎儿失去平衡或创伤的运动/活动。要避免的运动/活动的例子包括足球、篮球、冰球、轮滑、骑马、滑雪/单板滑雪、水肺潜水和剧烈的球拍运动。
- 在任何活动中，避免使用 Valsalva 动作、长时间的等长收缩和静止站立。
- 怀孕后可以恢复体力活动，但由于产后初期身体状况正常，因此应逐渐进行。一般来说，逐渐锻炼可以在正常阴道分娩后约 4-6 周开始，或在剖宫产手术后约 8-10 周开始，并获得医学证明。心肺健康水平较高且孕前和孕期锻炼规律的女性可能能够更快地恢复锻炼。产后轻到中等强度的运动对于恢复到孕前 BMI 很重要，并且不会干扰母乳喂养。
- 其他在线资源：http://www.acog.org 和 http://www.csep.ca/english/view.asp?x=698
与 Antoine-Jonville 博士（在本期中）给编辑的信一致，不一定需要培训师，自主锻炼计划将惠及更多人。如果孕妇知道自己可以进行锻炼，并且知道步行本身就是很好的锻炼，尤其是在怀孕期间，那么她们可能更有可能开始锻炼计划。世界其他地区的建议和做法可能有所不同。
在大多数情况下，怀孕期间的锻炼对母婴健康和福祉产生积极影响。即使在怀孕期间开始体育锻炼，也可以为终生锻炼习惯奠定基础，这将使母亲、孩子和家庭受益。产前期是进行体力活动咨询和讨论体力活动障碍的宝贵时间，以促进怀孕期间和之后的健康运动水平。
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