Pregnant Athlete

Author(s): Rakhi G Sutaria, MD, Roshni Durgam, MD

Originally published:11/10/2011

Last updated:05/05/2016

1. DISEASE/DISORDER:

Definition

The term “pregnant athlete” refers to a pregnant female during any stage of pregnancy, from the prenatal to postpartum period, with established pre-pregnancy fitness, who chooses to continue participation in a regular physical activity program.

Etiology

Many physiologic changes occur in pregnancy predisposing women participating in athletics to hyperthermia, dehydration, and hypoglycemia. Two main benefits of continued participation in physical activity are: (1) optimizing cardiopulmonary fitness and strength for improved tolerance of labor and (2) decreased time to achieve peak athletic performance postpartum.

Epidemiology including risk factors and primary prevention

Approximately 42% of women report participating in some form of exercise during their pregnancy 1. Details regarding the intensity, frequency, and duration of such exercise are limited. The most commonly reported activity is walking, followed by swimming and aerobics. Starting a high-intensity exercise program for the first time during pregnancy is not recommend because of the risk of harm to both the woman and fetus 2. Most significant risks to the fetus include hyperthermia, oxygen deficit and trauma. Risks to the pregnant woman and fetus vary slightly depending on the stage of pregnancy. In the first trimester, the fetus has increased protection from trauma because of its position within the pelvis.

Patho-anatomy/physiology

Physiologic changes during pregnancy include increased resting metabolic rate, increased cardiac output, increased circulating blood volume, and splenic enlargement 3. Some women may develop transient osteoporosis (most frequently of the hips and spine during the third trimester) and iron deficiency anemia, which may negatively impact participation in weight bearing and endurance sports, respectively. Common musculoskeletal conditions resulting from ligamentous and joint laxity related to increased circulating relaxin levels include pregnancy related pelvic girdle pain (PRPGP), pregnancy related lower back pain (PRLBP) and sacroiliac (SI) joint pain.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Musculoskeletal injury can occur in the pregnant athlete, just as in the non-pregnant athlete. Evaluation and diagnosis relies largely on physical examination findings.

PRLBP and PRPGP are among the most commonly reported musculoskeletal complaints in pregnant women.  Incidence rates are estimated around 50% 4. PRLBP is described as pain in and around the lumbar spine, generally above the sacrum. PRPGP is a specific term used to describe low back pain between the posterior iliac crests and gluteal folds, particularly involving the sacroiliac joints. As the gravid uterus displaces the patient’s center of gravity anteriorly creating an excessive lumbar lordosis and weak abdominal muscles, thereby placing additional strain on the lower back and pelvis. Biomechanics are further altered with the release of the hormone relaxin, which functions to loosen the ligaments of the pelvis and sacroiliac joints in preparation for childbirth 5,6.

Low back pain may also be caused by disc, facet joint, or hip pathology.  If clinically warranted, magnetic resonance imaging (MRI) may be obtained at the clinician’s discretion.  To date, there are no identified adverse effects of MRI on the developing fetus, although long-term effects have not yet been fully evaluated.

To help reduce symptoms of both PRLBP and PRPGP, pregnant patients can engage in pelvic tilt exercises, core muscle strengthening, and stretching the lower extremity muscles.  Aerobic water exercises have been shown to reduce pain and disability in PRLBP 7. Further, acupuncture and pelvic belts can help alleviate symptoms of lumbopelvic pain in pregnancy 8. Patients should be instructed to lift by bending at the knees and pushing up with the thighs.

Specific secondary or associated conditions and complications

Intensive exercises in pregnancy risk dehydration, hyperthermia, hypoglycemia, and traumatic injury to the patient. Improved health perceptions, however, have been documented in physically active versus inactive pregnant women 9. While uncommon, fetal hyperthermia, traumatic injury (highest risk occurs later in pregnancy, when fetus is outside of the protective pelvis.), and oxygen deficit can occur. Some harm can be avoided by advising against participation in contact sports such as hockey, boxing, wrestling and football, as well as high velocity sports such as skating, skiing and horseback riding. The pregnant athlete should avoid exercising in a supine position after the first trimester to reduce the risk of developing a supine hypotensive syndrome, which is related to increased mechanical pressure of the gravid uterus on the inferior vena cava 10.

In healthy pregnancies, womens’ hemodynamic function changes. Blood is diverted from the uterus to exercising muscles during exercise. An overall increase in blood volume and cardiac output works to optimize blood flow to the placenta 11,12 making moderate exercise safe for the mother and baby.

There is a paucity of literature on high-intensity exercise training in pregnant athletes. Kardel 13 found that vigorous exercise in top competitive athletes, with uncomplicated pregnancies, can facilitate quicker return to sport without posing a health risk to mother or fetus.  In a separate study involving nulliparous women, Kardel 14 found that duration of labor was inversely associated with maximal oxygen uptake, suggesting that increased aerobic fitness may be associated with shorter labor.

Exercise is contraindicated in patients at risk for preterm labor, or those with a history of pregnancy-induced hypertension, premature rupture of membranes, incompetent cervix, intrauterine growth retardation, or persistent bleeding in the second or third trimester.  Pregnant patients with heart disease should be evaluated by a cardiologist prior to beginning an exercise program.

Patients should be advised to stop exercising if they develop dizziness, chest pain, increasing shortness of breath, headaches, uterine contractions, vaginal bleeding, or fluid leaking from the vagina.

2. ESSENTIALS OF ASSESSMENT

History

The physician should inquire about the patient’s tolerance of exercise, as well as its duration, frequency and intensity. Bleeding, pain, headaches, gastrointestinal distress, or fevers should be noted if present.

Physical examination

A general neuromusculoskeletal examination should be performed with specific attention to the patient’s axial spine, pelvis, and hips.  As no gold standard for diagnosing sacroiliac joint pain exists, several provocative tests may be performed together to increase the sensitivity and specificity of detecting SIJ dysfunction. Specifically, Gaenslen’s test, Patrick’s or FABER’s test (flexion, abduction, and external rotation), thigh thrust test, ASIS (anterior superior iliac spine) distraction and the sacral compression test may be used. In Gaenslen’s test, the patient is placed in a supine position with one leg dropped off the table and the other leg flexed at the hip and knee. The pelvis is stressed when force is applied to both knees. The test is positive for SI joint pain if pain is elicited at the SI joint on either side. In Patrick’s or FABER’s test, the patient lies supine with their hip flexed, abducted and externally rotated.   The foot of the tested leg rests on the opposite knee. The test is positive for pelvic girdle pain if pain is elicited in the contralateral sacroiliac joint and positive for hip pathology if pain is elicited at the ipsilateral anterior hip. In the thigh thrust test, the patient lies in the supine position with their hip and knee flexed to 90 degrees while pressure is applied to the femur. In the ASIS distraction test, force is applied vertically to the bilateral ASIS with the patient in the supine position. In the sacral compression test, force is applied vertically to the iliac crest towards the floor with the patient in a side lying position. When 3 out of 5 tests are positive, there is a 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain 15,16. Other joints may be examined in response to patients’ complaints.

Laboratory studies

The patient’s obstetric provider should be managing all laboratory studies. If clinical concern warrants further diagnostic testing (eg, thyroid hormone levels, electrolytes, hematologic studies), these should be performed as part of and with the guidance of the primary provider.

Imaging

Diagnostic ultrasound is an excellent first-line modality for joint and soft tissue evaluation. X-rays and computed tomography scans carry risks related to radiation exposure to the fetus and should be avoided unless an unforeseen emergency requires it. The risks and benefits of any proposed study should be reviewed and discussed in detail with the patient. Acute lower back pain with new neurologic deficit, for example, may warrant magnetic resonance imaging as the results may change the patient’s management.

Social role and social support system

The pregnant athlete may have a well-established pre-pregnancy social support system consisting of fellow athletes, coaches, and trainers. The patient’s identity as an athlete may play an integral role in the patient’s life and should not be discounted. As a provider, one should consider this factor when making recommendations and possible modifications to the athlete’s participation in her sport. The patient may benefit psychologically by continuing to participate in athletics aside from the benefits of exercise on mood and sleep.

Professional Issues

All recommendations on exercise in the pregnant athlete should be evidence-based if possible and discussed in the context of risks and benefits for both the patient and fetus.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Physical Exercise Guidelines for Pregnant Women

The American College of Obstetrics and Gynecology (ACOG) 17recommends at least 30 minutes of exercise daily to help reduce backaches, constipation, and improve overall energy. Regular exercise may also help prevent and treat gestational diabetes. Individual differences in fitness level, health status and pregnancy should dictate the exercise prescription. A recent systematic review by Nascimento et al. concluded that exercise intensity for previously sedentary pregnant women should be mild or moderate, while previously active pregnant women should engage in moderate to high intensity exercise, at least three times per week 18.

Aerobic exercise is recommended to maintain cardiovascular fitness as well as to help prevent chronic disease. Aerobic exercises may include walking, jogging, using a stationary bicycle, treadmill, swimming, water aerobics, aerobic dance, or low-impact aerobics. Recent recommendations also add strength training and muscle conditioning exercises to improve body strength and posture, which may reduce low back pain, prevent urinary incontinence, and control weight.  Additionally, pelvic floor exercises may be added to help prevent urinary incontinence in late pregnancy and during the post-partum period 17.

Coordination of care

As in other areas of rehabilitation medicine, treatment of the pregnant athlete must be coordinated across all areas of care. Specifically, care must be coordinated with the patient’s obstetrician or primary care provider.  Involving physical therapists experienced in treating pelvic floor disorders in pregnant women may also be helpful.

Patient & family education

Patient and family education enhances understanding of several key points: (1) 30 minutes or more of moderate exercise on most days, avoiding exercise in supine position (after fourth month of pregnancy), with strength training limited to light to moderate resistance is recommended for most patients; (2) benefits of exercise include decreased back pain, less constipation, bloating and swelling, prevention or treatment of gestational diabetes, and improved energy, mood, posture, and sleep, (3) the patient should not start any new exercise program after becoming pregnant without first consulting her physician.

Emerging/unique Interventions

As more high-level athletes continue to perform while pregnant, the International Olympic Committee (IOC) made the following formal statement regarding female participation in the Olympics in April 2011:

No female athlete should be denied the opportunity to participate in any Olympic sport on the basis that she might sustain an injury to her reproductive organs. A survey of injury data has failed to find any evidence of an increased risk for acute or chronic damage to the female reproductive organs occurring as a direct result from participation in sport.” 19.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Encourage the pregnant patient to maintain or increase physical activity within recommended guidelines. Carefully review risks and benefits of exercise during pregnancy, providing informed consent for participation. When addressing acute musculoskeletal complaints in the pregnant athlete, offer reassurance that most issues resolve after delivery. Acute diagnosis and treatment of musculoskeletal complaints requires detailed history, physical examination, and avoidance of unnecessary and possibly harmful radiologic exposures. Conservative management with skilled therapies, modalities, and a home exercise program is often most appropriate in managing musculoskeletal complaints.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

In France, all postpartum women may receive government sponsored pelvic floor rehabilitation therapy (PFRT) paid for by the French Social Security. Pelvic floor rehabilitation has been shown to prevent urinary incontinence 20, pelvic pain and pelvic organ prolapse after delivery. France’s pelvic floor re-education program can be used as a model to treat postpartum women in the U.S.. With increased evidence that PFRT can help treat PRPGP, women with persistent pain can seek clinicians skilled in these therapies.

Data are emerging on the health perceptions of women who participate in regular physical activity, with outcomes indicating that exercise during pregnancy improves maternal health perceptions 21.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

Limited data is available on musculoskeletal injury prevalence in the pregnant athlete.

REFERENCES

  1. Nascimento SL, Surita FG, Cecatti JG. Physical exercise during pregnancy: a systematic review. Current opinion in obstetrics & gynecology. Dec 2012;24(6):387-394.
  2. Wolfe LA, Brenner IK, Mottola MF. Maternal exercise, fetal well-being and pregnancy outcome. Exercise and sport sciences reviews. 1994;22:145-194.
  3. Maymon R, Zimerman AL, Strauss S, Gayer G. Maternal spleen size throughout normal pregnancy. Seminars in ultrasound, CT, and MR. Feb 2007;28(1):64-66.
  4. Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low Back Pain and Pelvic Girdle Pain in Pregnancy. J Am Acad Orthop Surg. Sep 2015;23(9):539-549.
  5. Borg-Stein J, Dugan SA, Gruber J. Musculoskeletal aspects of pregnancy. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. Mar 2005;84(3):180-192.
  6. Sneag DB, Bendo JA. Pregnancy-related low back pain. Orthopedics. Oct 2007;30(10):839-845; quiz 846-837.
  7. Pennick V, Liddle SD. Interventions for preventing and treating pelvic and back pain in pregnancy. The Cochrane database of systematic reviews. 2013;8:Cd001139.
  8. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Jun 2008;17(6):794-819.
  9. Sternfeld B, Quesenberry CP, Jr., Eskenazi B, Newman LA. Exercise during pregnancy and pregnancy outcome. Medicine and science in sports and exercise. May 1995;27(5):634-640.
  10. Hammer RL, Perkins J, Parr R. Exercise during the childbearing year. The Journal of perinatal education. Winter 2000;9(1):1-14.
  11. Wang TW, Apgar BS. Exercise during pregnancy. American family physician. Apr 15 1998;57(8):1846-1852, 1857.
  12. Gilson GJ, Samaan S, Crawford MH, Qualls CR, Curet LB. Changes in hemodynamics, ventricular remodeling, and ventricular contractility during normal pregnancy: a longitudinal study. Obstetrics and gynecology. Jun 1997;89(6):957-962.
  13. Kardel KR. Effects of intense training during and after pregnancy in top-level athletes. Scandinavian journal of medicine & science in sports. Apr 2005;15(2):79-86.
  14. Kardel KR, Johansen B, Voldner N, Iversen PO, Henriksen T. Association between aerobic fitness in late pregnancy and duration of labor in nulliparous women. Acta obstetricia et gynecologica Scandinavica. 2009;88(8):948-952.
  15. Laslett M, Aprill CN, McDonald B. Provocation sacroiliac joint tests have validity in the diagnosis of sacroiliac joint pain. Arch Phys Med Rehabil. Vol 87. United States2006:874; author reply 874-875.
  16. van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Archives of physical medicine and rehabilitation. Jan 2006;87(1):10-14.
  17. Committee Opinion No. 650: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstetrics and gynecology. Dec 2015;126(6):e135-142.
  18. Nascimento SL, Surita FG, Godoy AC, Kasawara KT, Morais SS. Correction: Physical Activity Patterns and Factors Related to Exercise during Pregnancy: A Cross Sectional Study. PLoS One. Vol 10. United States2015:e0133564.
  19. IOC Medical Commission Statement on female reproductive system in sport. Medical and Scientific Commission: Olympic Movement; 2011.
  20. Boyle R, Hay-Smith EJ, Cody JD, Morkved S. Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short version Cochrane review. Neurourology and urodynamics. Mar 2014;33(3):269-276.
  21. Barakat R, Pelaez M, Montejo R, Luaces M, Zakynthinaki M. Exercise during pregnancy improves maternal health perception: a randomized controlled trial. American journal of obstetrics and gynecology. May 2011;204(5):402.e401-407.

Original Version of the Topic:

Devon Shuchman, MD, Colleen Fitzgerald, MD. Pregnant Athlete. Publication Date: 2011/11/10.

Author Disclosure

Rakhi G Sutaria, MD
Nothing to Disclose

Roshni Durgam, MD
Nothing to Disclose

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