Downloaded from https://iranpaper.

ir

CHAPTER 26

Exercise Considerations Before, During,

and After Pregnancy
STEPHANIE CHU, DO • SARAH WEINSTEIN, DO • KELSEY ANDREWS, BS

INTRODUCTION PATHOPHYSIOLOGY
Over the past decade, there has been an increased inter- Pregnancy has a profound effect on multiple body sys-
est in the topic of physical activity during pregnancy. tems, and the subsequent physiologic adaptations can
This is likely due to the increasing number of studies be a large factor in determining the level of participa-
that have shown what benefits exercise can have during tion in physical activity for a pregnant woman. In the
this unique time in a woman’s life. Physicians and pa- section, we will discuss the relevant adaptations and
tients often express uncertainty regarding physical activ- physiologic changes during pregnancy.
ity during pregnancy out of concern for the safety of
both the mother and fetus. Previous studies have shown Anatomic/Musculoskeletal Considerations
that physical activity is not associated with critical out- There are various anatomic changes that occur
comes such as miscarriage, neonatal death, preterm throughout pregnancy that may affect a woman’s ability
birth, or birth defects.1 The dramatic rise in obesity, hy- to participate in certain activities or sports, of which the
pertension, and diabetes over the past few decades is most obvious and noticeable is gestational weight gain.
well-documented in the literature. Subsequently there For a female with a normal prepregnancy body mass in-
has been a similar increase in pregnancy complications dex (BMI) (18.5e24.9 kg/m2), the optimal weight gain
such as gestational diabetes, gestational hypertension, is between 25 and 35 pounds, with an average of 1
and preeclamspsia.1 For this reason, there is an pound per week in the second and third trimesters.7
emphasis on using physical activity to help decrease Increased mass may transfer significant force across
the risk of these complications and optimize the larger weight-bearing joints such as the knees and
maternal-fetal health during pregnancy.1 hips.4 Over time, this may cause discomfort and limit
Pregnancy no longer needs to be thought of as a the ability to participate in activities or sports requiring
time to cease all activity, and it is important to counsel full load bearing, such as running.
patients that there can be more complications by not Throughout pregnancy, both the expanding uterus
exercising. Exercise throughout all three trimesters of and enlarging breasts will displace the center of gravity.
pregnancy is safe, does not lead to an increase in major Increased lumbar lordosis and subsequent anterior pel-
complications, and improves overall pregnancy out- vic rotation on the femur occur in pregnancy, changing
comes.5 While the benefits almost always outweigh a woman’s center of gravity.3 This is important for activ-
the risks for the general pregnant population, it is ities that require optimal balance such as cycling on a
important to be aware of contraindications and to nonstationary bike or walking on uneven ground.1
know when to refrain from certain activities. The Finally, ligamentous laxity increases throughout
goal of this chapter is to discuss the specific consider- pregnancy, secondary to the effects of increased levels
ations and recommendations for exercise during preg- of estrogen and relaxin, which can predispose a female
nancy and the peripartum period based on the most to joint instability and the theoretic risk of increased
updated guidelines, explain how the physiologic strains and sprains.3,4,6
changes throughout pregnancy may impact the ability
to perform physical activity, and describe appropriate Hemodynamic Adaptations
precautions to take before engaging in physical Significant hemodynamic changes occur during preg-
activity. nancy, including increased cardiac output, increased

The Female Athlete. https://doi.org/10.1016/B978-0-323-75985-4.00012-X

Copyright © 2022 Elsevier Inc. All rights reserved. 311
 Downloaded from https://iranpaper.ir

312 The Female Athlete

resting heart rate, increased stroke volume, and consumption in pregnant women. To meet the greater
decreased systemic vascular resistance.3,4 Cardiac oxygen demand during physical activity, pregnant
output may increase by as much as 50% in the third women will have an increase in respiratory frequency
trimester.3,9 These changes are to supply sufficient and oxygen consumption with just mild
blood to the placenta and the growing fetus.3,8 During exercise.3,4,13,16 Studies have demonstrated that during
exercise, there can be up to a 50% decrease in pregnancy, the subjective effort to perform aerobic exer-
splanchnic blood flow and subsequently blood flow cise is increased and maximum voluntary exercise per-
to the uterus, as blood is redirected to the exercising formance is decreased.3,4,13
muscles.13 This raises the hypothetical risk of fetal hyp-
oxemia during exercise, which has been the subject of Thermoregulatory Adaptations
multiple reports. However, flow velocity profiles in Metabolic rate increases throughout pregnancy subse-
the fetal aorta and umbilical circulation in various quently increasing heat production.4,13 In the first
studies resulted in contradictory and inconclusive trimester, core temperatures above 39 C (103 F)
results.4,14,15 At this time, the general consensus is should be avoided because of an increased risk of neural
that an increase in fetal heart rate between 10 and 30 tube defects.3,4,13 In the second and third trimesters,
beats per minute (bpm) over baseline during maternal thermoregulatory control improves, during which fetal
exercise does not have a negative sequela on the fetus temperature is maintained approximately 1 C above
and that overall fetal injuries are unlikely during a maternal core temperature, due to fetoplacental
normal uncomplicated pregnancy.4 metabolism.3,4,13 Core temperature does not increase
An important consideration is the effect of supine significantly with steady-state moderate exercise, which
positioning on the fetus, both at rest and during exer- is approximately 60%e70% VO2max.3,4 It is critical that
cise. Primarily after the first trimester, compression of heat dissipation remains greater than heat production
the inferior vena cava by the enlarged uterus reduces to protect the fetus and ensure adequate uterine blood
cardiac output.3,4 A similar phenomenon has been flow. For this reason, exercising in hot, humid environ-
seen with motionless standing for prolonged periods, ments or engaging in strenuous and high-intensity ac-
which leads to decreased venous return and a subse- tivities should be avoided.3
quent increased risk of hypotension.10e12 For this
reason, it is best to assume a right or left lateral side
lying position and avoid motionless standing as preg- BENEFITS OF EXERCISE IN PREGNANCY
nancy progresses, especially if one is experiencing hypo- Exercise during pregnancy has been shown to have
tensive episodes. Equally important is avoiding supine immense cardiac, metabolic, and mental health benefits.
exercises such as bench press or sit-ups. According to the 2019 Canadian guidelines for physical
activity in pregnancy, there is a strong recommendation
Respiratory Adaptations for all females without contraindications to be physically
Along with the cardiovascular adaptations during preg- active throughout pregnancy.1 Contraindications will be
nancy, significant respiratory changes occur. As the discussed in another section of this chapter. Contrary to
uterus enlarges, the diaphragm displaces superiorly, certain myths that have prevailed over the years, recent
which ultimately causes a profound increase in tidal research has shown that there is no association between
volume and subsequently minute ventilation, physical activity and increased risk of miscarriage, pre-
decreasing arterial carbon dioxide.3,4,16 All these adap- term birth/rupture of membranes, low birth weight,
tations protect the fetus from an acidic environment, congenital defects, neonatal death, hypoglycemia, or
which may significantly affect the function of various birth complications.1,30 Some of the many maternal ben-
organ systems, such as the cardiovascular and central efits of physical activity during pregnancy include
nervous systems, ultimately lowering APGAR (appear- reduced risk of gestational diabetes, gestational hyperten-
ance, pulse, grimace, activity, and respiration) scores. sion, preeclampsia, and excessive gestational weight
The pressure of the enlarged uterus on the dia- gain.1 There has also been shown to be a reduced risk
phragm causes a decrease in oxygen availability and of cesarean and assisted vaginal delivery.1,27 Another
thereby increased work of breathing and feelings of res- very important benefit of exercise during pregnancy is
piratory discomfort late in pregnancy.3,4 In response to the reduction of prenatal depressive symptoms, as well
increased oxygen requirements of the fetus, there are as reduction of stress and anxiety and feelings of overall
mild increases in tidal volume and oxygen improved quality of life.1,28,29
 Downloaded from https://iranpaper.ir

CHAPTER 26 Exercise Considerations Before, During, and After Pregnancy 313

GENERAL RECOMMENDATIONS of media reporting on high-profile athletes.18 It is of

Similar to the general population, females without con- utmost importance for any female who wishes to exer-
traindications to exercise should aim for 150 min of cise, especially at a high intensity, to have a conversa-
moderate intensity exercise per week, accumulated tion with a trained medical professional to
over a minimum average of 3 days per week.1,17 It is individualize her exercise program during pregnancy.
best however to be active daily, if possible. Unfortu-
nately, less than 15% of pregnant women achieve the
goal of 150 min of moderate intensity activity per EXERCISE PRESCRIPTION
week.1 Intensity can best be assessed via the “talk With any exercise prescription and fitness counseling,
test.” Moderate-intensity exercise raises the heart rate the main factors that should be discussed are frequency,
enough that an individual is still able to carry on a con- intensity, time, and type of exercise. The same concepts
versation but would not be able to sing a song.1,21 Ex- apply to pregnant women as with the general popula-
amples of moderate-intensity exercises include tion; however, the provider must be aware of the con-
resistance training, brisk walking, stationary cycling, traindications of exercise during pregnancy. In this
and water aerobics.1 Heart rate ranges have also been section, the focus will be on the different types of exer-
established by the American College of Sports Medicine cise that can be done safely in pregnancy. In general, a
and the Canadian Guidelines to help better define combination of aerobic and resistance exercises has
moderate-intensity activity, based on age, fitness level, shown greater benefit than just aerobic exercise alone
and BMI (Table 26.1).17,34,38 and adding yoga and/or stretching may provide added
There remains a paucity of information related to the benefits.1
effects of more vigorous activity levels during preg-
nancy, which is challenging for medical professionals
FIRST STEPS AND HOW TO START
caring for elite athletes and high-intensity recreational
EXERCISING DURING PREGNANCY
athletes. A study revealed vigorous intensity exercise
during the third trimester in uncomplicated pregnancies Given all the benefits of exercise during pregnancy are
did not result in increased poor birth outcomes.18 previously discussed, it is important to know appro-
Studies are still limited on vigorous intensity activity priate resources and how to safely engage in an exercise
in the first and second trimesters and primarily consist program during pregnancy for females who may be
naïve to routine physical activity. A resource for both
clinicians and pregnant women is PARmed-X for Preg-
nancy, also known as the Physical Activity Readiness
TABLE 26.1
Medical Examination (available through the Canadian
Heart Rate Ranges Defining Moderate-Intensity Society for Exercise Physiology’s (CESP) website at
Activity, Based on Age, Fitness Level, and BMI. www.csep.ca/forms.asp). PARmed-X for Pregnancy
HEART RATE RANGES FOR PREGNANT WOMEN was established by CSEP and has since been adopted
by other institutions to help medical professionals
Maternal Age Fitness Level Heart Rate Range
provide individualized counseling to their patients on
(Years) or BMI (beats/min)
exercise during pregnancy.1,34 Further research is still
Less than 20 e 140e155 needed on the effects of high-intensity activity during
20e29 Low 129e144 pregnancy, but it can be said with confidence that un-
Active 135e150 less there are contraindications, all pregnant women
Fit 145e160 should be engaging in moderate-intensity physical
BMI >25 kg/m2 102e124 activity most days of the week.4,17,33
30e39 Low 128e144
Active 130e145 Aerobic Exercises
Fit 140e156 Aerobic exercises that are advisable in pregnancy
BMI > 25 kg/m2 101e120 include those that focus on the larger muscle groups
>40 No written guidelines due to insufficient and those in which intensity is easily modified based
information on the goal heart rate or the talk test, as mentioned in
the section General Recommendations. Brisk walking,
Target heart rate ranges were derived from peak exercise tests in
medically prescreened low-risk pregnant females (established by the
jogging, swimming, cycling, rowing, dancing, and
American College of Sports Medicine and the Canadian Guidelines). cross-country skiing are all examples of aerobic activ-
BMI, body mass index. ities that one can partake in while pregnant.4 Again,
 Downloaded from https://iranpaper.ir

314 The Female Athlete

this must be catered to each patient and pregnancy uncomplicated pregnancies. It is essential to be aware
based on individual risk factors, previous experience, of both relative and absolute contraindications, as
and preferences. well as warning signs for when to stop exercising. For
this reason, there is a need to emphasize individualized
Strength Training exercise programs for each patient and have a discus-
Overall, there is much less evidence with regard to sion regarding risks and benefits. Table 26.2 has been
strength training, especially heavy lifting, during preg- adopted by the 2019 Canadian guidelines for exercise
nancy. Based on findings from recent studies, lower in pregnancy and outlines the absolute and relative con-
weights and higher repetitions did not have negative traindications. Table 26.3 demonstrates the warning
impacts on pregnancy outcomes.4,19,22,23 Although evi- signs to terminate exercise during pregnancy, as detailed
dence is lacking regarding heavier weight strength by the American College of Obstetricians and Gynecol-
training or Olympic lifts, it is advisable to refrain ogists (ACOG).
from any lifts that require a Valsalva maneuver. The Val-
salva maneuver increases intra-abdominal pressure and
in turn hypothetically reduces blood flow and oxygen HIGH-RISK SPORTS TO AVOID
supply to the fetus, in addition to the potential of It is advised to avoid contact sports with an increased
damaging pelvic floor muscles.2,4,20 Pelvic floor muscle risk of blunt abdominal trauma during pregnancy;
training, if done correctly, has been shown to treat and this includes but is not limited to boxing, soccer, basket-
prevent urinary incontinence both during pregnancy ball, ice hockey, wrestling, and football.4 Additionally,
and after delivery. Females should aim to perform these sports with an increased risk of falls such as skiing
exercises at least three times per day on most days of the (downhill and water), horseback riding, gymnastics,
week for the greatest benefit.2,31 It may be prudent to and ice skating should be avoided because of changes
avoid heavy lifts or physical strain during the in the center of gravity as pregnancy progresses.1,13
6e9 days after estimated ovulation; limited evidence Scuba diving should be avoided throughout pregnancy,
has shown a slightly increased risk of miscarriage during as this places the fetus at an increased risk of decom-
this time of implantation.26 If done in the appropriate pression sickness and gas embolism.1,32
manner, weight lifting during pregnancy can have bene-
ficial effects on the mother without negatively impact-
ing the health of the baby. ALTITUDE TRAINING
Exercising at altitudes less than 2500 m (8200 feet) has
Flexibility not been shown to have any adverse effects on the fetus
Recent studies have shown that prenatal yoga is a prom- in an otherwise uncomplicated pregnancy.1,4,32 Exer-
ising treatment for maternal depression, providing cising at altitudes over 2500 m carries a hypothetical
beneficial effects on maternal comfort during labor, as risk of hypoxia and decreased uteroplacental perfusion,
well as reduced stress, reduced anxiety, and overall especially in those who are not acclimatized or who
improved quality of life.24,25 Increased ligamentous have high-risk pregnancies.2,32 Uncomplicated preg-
laxity during pregnancy causes pelvic instability and nant women who are not acclimatized should limit ex-
misalignment of the spine, which can result in pain ercise to altitudes less than 2000 m (6500 feet).2
and discomfort. Maintaining flexibility during preg-
nancy enables a female to adapt effectively, efficiently,
and safely to pregnancy-associated changes in align- EXERCISE CONSIDERATIONS DURING THE
ment, joints, tendons, and ligaments. Stretching during POSTPARTUM PERIOD AND RETURN TO
pregnancy should focus on maintaining a normal range SPORT
of motion required for activity, stretching the muscle Similar to exercise prescriptions during pregnancy,
belly rather than at the tendon or ligament, and per- returning to sport during the postpartum period must
forming stretches in a slow and controlled manner for be individualized and the exact time to return is influ-
maximum effectiveness.4 enced by several factors. It is important for patients to
be aware that regardless of prior activity level, resump-
tion of activity after pregnancy should be gradual and
CONTRAINDICATIONS TO EXERCISE should progress along a continuum. Return to sport
DURING PREGNANCY can begin as soon as it is medically and physically
Although the benefits of exercise during pregnancy far safe, which is variable, and often depends on the type
outweigh the risks, this primarily applies to of delivery (cesarean section, instrumental delivery, or
 Downloaded from https://iranpaper.ir

CHAPTER 26 Exercise Considerations Before, During, and After Pregnancy 315

TABLE 26.2
Contraindications to Exercise During Pregnancy.
Absolute Contraindications Relative Contraindications
• Ruptured membranes, premature labor • Recurrent pregnancy loss
• Unexplained persistent vaginal bleeding • History of spontaneous preterm birth
• Placenta previa after 28 weeks gestational age • Gestational hypertension
• Preeclampsia • Symptomatic anemia
• Incompetent cervix • Malnutrition
• Intrauterine growth restriction • Eating disorder
• High-order multiple pregnancy (i.e., triplets) • Twin pregnancy after 28th week
• Uncontrolled type I diabetes, uncontrolled • Mild/moderate cardiovascular or respiratory
hypertension, or uncontrolled thyroid disease disease
• Other serious cardiovascular, respiratory, or • Other significant medical conditions
systemic disorders

TABLE 26.3 BREASTFEEDING

Warning Signs to Discontinue Exercise in Breastfeeding and return to exercise are also important
Pregnancy. topics. The World Health Organization recommends
• Vaginal bleeding breastfeeding for at least the first 6 months of pregnancy
due to the numerous benefits for both mother and in-
• Regular painful contractions
fant.35 For mothers who want to engage in moderate-
• Amniotic fluid leakage to high-intensity activity post partum, it is best to nurse
• Dyspnea before exertion just prior to exercise.2,4 This will allow for increased
• Dizziness comfort from decreased engorgement, as well as
decreased risk of acidity in breast milk, as lactic acid
• Headaches
builds with prolonged exercise.4 While some mothers
• Chest pain may be concerned about reduced production of breast
• Muscle weakness affecting balance milk with increased activity, some studies show per-
• Calf pain or swelling forming high-volume aerobic exercises during breast-
feeding resulted in both slightly greater quality and
quantity of breast milk.36,37

vaginal delivery), extent of damage to the pelvic floor

muscles, or any type of incision that may have been CONCLUSIONS
made.4 Pregnancy is a critical time in a woman’s life and is
Low-impact endurance training such as brisk characterized by numerous physiologic and anatomic
walking or cross-country skiing can begin soon after changes. Physical activity is highly beneficial during
birth, as this does not place excessive pressure on the pregnancy and is recommended for all patients with
healing pelvic floor muscles.2 Higher impact endurance uncomplicated pregnancies. Engaging in physical ac-
training as well as strength training should be resumed tivity has shown a variety of benefits for the mother
in a step-by-step manner, initially focusing on regaining and the fetus, including reduced risk of gestational hy-
pelvic floor muscle strength.2 Following strengthening pertension, gestational diabetes, and preeclampsia, as
of the pelvic floor, emphasis should be on core strength- well as a reduction in prenatal depressive symptoms,
ening, specifically the abdomen and back.2 If a female all without increasing adverse effects. Exercise pro-
exercised at a moderate- to high-intensity level during grams should be tailored to each pregnancy based on
pregnancy, she can expect her VO2max to return to pre- patient-specific risk factors and should include a com-
pregnancy levels, or possibly even increase.2 bination of aerobic and resistance training for
 Downloaded from https://iranpaper.ir

316 The Female Athlete

maximum benefit. It is important as healthcare pro- 17. American College of Sports Medicine. In: Riebe D,
viders and medical professionals to reassure our preg- Ehrman JK, Liguori G, Magal M, eds. American College of
nant patients that not only will exercise improve Sports Medicine’s Guidelines for Exercise Testing and Prescrip-
overall health but also it has been shown to improve tion. 10th ed. Philadelphia: Wolters Kluwer; 2018.
18. Beetham KS, Giles C, Noetel M, Clifton V, Jones JC,
pregnancy outcomes.
Naughton G. The effects of vigorous intensity exercise in
the third trimester of pregnancy: a systematic review and
meta-analysis. BMC Pregnancy Childbirth. 2019;19:281.
REFERENCES 19. Hall DC, Kaufmann DA. Effects of aerobic and strength
1. Mottola MF, Davenport MH, Ruchat S-M, et al. 2019 Cana- conditioning on pregnancy outcomes. Am J Obstet Gynecol.
dian guideline for physical activity throughout pregnancy. 1987;157:1199e1203.
Br J Sports Med. 2018;52:1339e1346. 20. Johnson J. Exercise in pregnancy. Sport Med Today; 2016.
2. Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in https://www.sportsmedtoday.com/exercise-in-pregnancy-
recreational and elite athletes: 2016/2017 evidence sum- va-126.htm.
mary from the IOC expert group meeting, Lausanne. Part 21. Nascimento S, Surita F, Cecatti J. Physical exercise during
5. Recommendations for health professionals and active pregnancy: a systematic review. Curr Opin Obstet Gynecol.
women. Br J Sports Med. 2018;52:1080e1085. 2012;24:387e394.
3. Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in 22. Barakat R, Lucia A, Ruiz JR. Resistance exercise training
recreational and elite athletes: 2016/2017 evidence sum- during pregnancy and newborn’s birth size: a randomised
mary from the IOC expert group meeting, Lausanne. Part controlled trial. Int J Obes. 2009;33:1048e1057.
1 - exercise in women planning pregnancy and those 23. Zavorsky G, Loongo L. Adding strength training, exercise
who are pregnant. Br J Sports Med. 2018;50:571e589. intensity, and caloric expenditure to exercise guidelines
4. Artal R, O’Toole M. Guidelines of the American College of in pregnancy. Obstet Gynecol. 2011;117:1399e1402.
Obstetricians and Gynecologists for exercise during preg- 24. Babbar S, Agatha C, Parks-Savage S. Yoga during preg-
nancy and the postpartum period. Br J Sports Med. 2003; nancy: a review. Am J Perinatol. 2012;29:459e464.
37:6e12. 25. Ng QX, Venkatanarayanan N, Loke W, et al. A meta-
5. Davies G, Artal R. It’s time to treat exercise in pregnancy as analysis of the effectiveness of yoga-based interventions
therapy. Br J Sports Med. 2019;53:81. for maternal depression during pregnancy. Compl Ther
6. Dumas GA, Reid JG. Laxity of knee cruciate ligaments dur- Clin Pract. 2019;34:8e12.
ing pregnancy. J Orthop Sports Phys Ther. 1997;26:2e6. 26. Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in
7. ACOG Committee opinion no. 548: weight gain during recreational and elite athletes: 2016 evidence summary
pregnancy. Obstet Gynecol. 2013;121:210e212. from the IOC expert group meeting, Lausanne. Part 2 -
8. Morris EA, Hale SA, Badger GJ, et al. Pregnancy induces the effect of exercise on the fetus, labour and birth. Br J
persistent changes in vascular compliance in primiparous Sports Med. 2016;50:1297e1305.
women. Am J Obstet Gynecol. 2015;212, 633. E1e6. 27. Tinloy J, Chuang CH, Zhu J, et al. Exercise during preg-
9. Pivarnik J. Cardiovascular responses to aerobic exercise nancy and risk of late preterm birth, cesarean delivery,
during pregnancy and postpartum. Semin Perinatol. 1996; and hospitalizations. Wom Health Issues. 2014;24:
20:242e249. e99e104.
10. Ibrahim S, Jarefors E, Nel DG, et al. Effect of maternal po- 28. Davenport MH, McCurdy AP, Mottola MF, et al. Impact of
sition and uterine activity on periodic maternal heart rate prenatal exercise on both prenatal and postnatal anxiety
changes before elective cesarean section at term. Acta and depressive symptoms: a systematic review and meta-
Obstet Gynecol Scand. 2015;94:1359e1366. analysis. Br J Sports Med. 2018;52:1376e1385.
11. Avery ND, Stocking KD, Tranmer JE, et al. Fetal responses 29. Kolomanska D, Zarawski M, Mazur-Bialy A. Physical activ-
to maternal strength conditioning exercises in late ity and depressive disorders in pregnant womenda sys-
gestation. Can J Appl Physiol. 1999;24:362e376. tematic review. Medicina. 2019;55:212.
12. Jeffreys RM, Stepanchak W, Lopez B, et al. Uterine blood 30. Barakat R, Pelaez M, Menotejo R, et al. Exercise during
flow during supine rest and exercise after 28 weeks of pregnancy does not cause preterm delivery: a randomized,
gestation. Br J Obstet Gyneacol. 2006;113:1239e1247. controlled trial. J Phys Activ Health. 2014;11:1012e1017.
13. Wang TW, Apgar BS. Exercise during pregnancy. Am Fam 31. Boyle R, Hay-Smith EJ, Code JD, et al. Pelvic floor muscle
Physician. 1998;57:1846e1852. training for prevention and treatment of urinary and faecal
14. Collings CMS, Curet LB, Mullin JP. Maternal and fetal re- incontinence in antenatal and postnatal women. Cochrane
sponses to a maternal aerobic exercise program. Am J Database Syst Rev. 2012;10:CD007471.
Obstet Gynecol. 1983;145:702e707. 32. Artal R, Fortunato V, Welton A, et al. A comparison of car-
15. Carpenter MW, Sady SP, Hoegsberg B, et al. Fetal heart rate diopulmonary adaptations to exercise in pregnancy at sea
response to maternal exertion. J Am Med Assoc. 1988;259: level and altitude. Am J Obstet Gynecol. 1995;172:
3006e3009. 1170e1180.
16. LoMauro A, Aliverti A. Respiratory physiology of preg- 33. Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in
nancy: Physiology masterclass. Breathe. 2015;11:297e301. recreational and elite athletes: 2016/2017 evidence
 Downloaded from https://iranpaper.ir

CHAPTER 26 Exercise Considerations Before, During, and After Pregnancy 317

summary from the IOC expert group meeting, Lausanne. FURTHER READING
Part 4. Recommendations for future research. Br J Sports 1. Barakat R, Pelaez M, Montejo R, et al. Exercise during preg-
Med. 2018;51:1724e1726. nancy improves maternal health perception: a randomized
34. PARmed-X for Pregnancy: Canadian Society for Exercise Phys- controlled trial. Am J Obstet Gynecol. 2011;204:
iology. 2013. 402.e1e402.e7.
35. World Health Organization (WHO). Recommendations on 2. Campolong K, Jenkins S, Clark MM, et al. The association of
Exclusive Breast Feeding. 2017. exercise during pregnancy with trimester-specific and post-
36. Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in partum quality of life and depressive symptoms in a cohort
recreational and elite athletes: 2016/17 evidence summary of healthy pregnant women. Arch Womens Ment Health.
from the IOC expert group meeting, Lausanne. Part 3 - ex- 2018;21:215e224.
ercise in the postpartum period. Br J Sports Med. 2017;51: 3. Mottola M. Chapter 12: Performance in the pregnant
1516e1525. woman: maternal and fetal considerations. In: Taylor N,
37. Lovelady CA, Lonnerdal B, Dewey KG. Lactation perfor- Groeller H, eds. Physiological Bases of Human Performance
mance of exercising women. Am J Clin Nutr. 1990;52: During Work and Exercise. USA: Elsevier; 2008:225e237.
103e109. 4. Jean D, Moore LG. Travel to high altitude during pregnancy:
38. Mottola MF, Davenport MH, Brun CR, et al. VO2 peak pre- frequently asked questions and recommendations for
diction and exercise prescription for pregnant women. Med clinicians. High Alt Med Biol. 2012;13:73e81.
Sci Sports Exerc. 2006;38:1389e1395.