The pregnant athlete is defined as a woman with established levels of fitness who continues participation in regular exercise throughout pregnancy including the prenatal and postpartum periods. This includes recreational exercisers who perform regular strenuous exercise for fitness and competition as well as elite athletes who are a member of any national team or other high-level team overseen by a national sports federation.1
Since the passing of Title IX of the educational amendments in 1972, there has been substantial growth of women’s sports in the United States and around the world.2,3 Women are participating in athletics throughout their lifetime, many during their prime reproductive years.1,4 As of 2016, there were at least 17 athletes who completed at the Olympic Games while pregnant and many women returning to elite competition after delivery.5
Epidemiology including risk factors and primary prevention
Most athletes and non-athletes will exercise during pregnancy, however less than one-third of women will meet recommendations from the American College of Obstetricians and Gynecologists (ACOG). Approximately 85% of surveyed elite master level rowers exercised during pregnancy, however only 51.3%, 42.4%, and 15.7% met or exceeded guidelines in the first, second, and third trimesters respectively.6 This is similar to a 2006 survey, reported in 2009, that found 88% of pregnant women participated in moderate and/or vigorous physical activity within 30 days. However only 29% were classified as meeting ACOG guidelines for physical activity in pregnancy.7 This is an overall increase from the 42% of pregnant women doing some exercise in 1996.8 The National Health and Nutrition Examination Survey (NHANES), collected from 2007 to 2014, showed 60% of women did no leisure time physical activity and 12.7% to 45% met the 2015 ACOG guidelines.9 A survey in Brazil, found that of women who participated in exercise pre-pregnancy, 55.2% stopped, 29.3% maintained their current level of exercise, and 15.5% decreased their exercise amount during pregnancy.10 Details regarding the intensity, frequency, and duration of such exercise are limited. The most commonly reported activity is walking, followed by swimming and aerobics. Characteristics of women less likely to report physical activity include having less than a high school education, Hispanic ethnicity, low income, single relationship status, and beyond the first trimester.7
Pregnancy results in many anatomic and physiologic changes. Cardiovascular adaptations include an initial 15% decrease in systemic vascular tone and subsequent decrease in blood pressure.11,12 One-quarter of maternal blood flow is diverted to the uterus and fetus. Increasing estrogen levels in pregnancy lead to 30 to 50% increase in total blood volume which increases preload, stroke volume, and ultimately cardiac output.13 Average heart rate will increase by 10 to15 bpm.12 With the decreased venous return, there is increased risk of dependent edema, varicose veins, hemorrhoids, and venous thromboembolism. Increased progesterone during the 1st trimester stimulates increased respiratory drive.14 The tidal volume increases by 40% and without a change in respiratory rate, the minute ventilation increases by 30 to 50% due to the increased oxygen consumption.15 As the fetus grows, it elevates the intra-abdominal viscera and, ultimately, the diaphragm. This results in a 5% decrease in total lung capacity and 10 to 25% decrease in functional residual capacity that is further decreased when supine.15 Pregnancy results in weight gain, which alters the center of gravity and gait.16 The gravid uterus also results in increased lumbar lordosis.17 There are many benefits to regular exercise during pregnancy, in addition to those seen in the general population. Women can maintain or improve their physical fitness level.1 The absolute capacity of the aerobic system remains similar to nonpregnant cohorts, however maximal oxygen uptake (VO2max) may be approximately 10% lower during pregnancy.18 There is a decrease in gestational diabetes and a 40% decrease in pre-eclampsia with regular exercise.19,20 Exercise can decrease resting diastolic blood pressure more than systolic blood pressure during pregnancy, with lower than expected increase in blood pressure during physical activity in early pregnancy.21 Kardel 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.22
Exercise during pregnancy may also decrease the risk of Cesarean section and shorten the duration of vaginal delivery.23 Exercise may prevent excessive weight gain during pregnancy, in turn decreasing chronic disease risk for mother and child.24,25 General endurance and strengthening exercises, water aerobics, balance training, and spine and pelvic floor muscle strengthening programs have been shown to decrease disability, decrease pain, decrease incontinence, reduce lower limb edema, and improve overall function.26-28
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
There are theoretical risks to fetal development associated with exercise in pregnancy, though many have not been demonstrated in human studies. During exercise, the fetus experiences transient hypoxia and deceleration of fetal heart rate (FHR) without lasting effects on the fetus.1,16,29,30 Fetal cardiovascular changes during strenuous exercise have also been shown to be transient without lasting detrimental consequences in very limited studies.19 Light to moderate resistance training during pregnancy generally has no adverse effects.1 Caution should be used with heavy weight lifting to avoid Valsalva maneuver which rapidly increases blood pressure and intraabdominal pressure, potentially decreasing blood flow to the fetus.1
Other prior concerns about fetal health included risk of miscarriage and growth retardation. There are inconsistent results from heterogenic reviews on the effects of exercise during the first trimester and risk of spontaneous abortion.31 There may be an increased risk of miscarriage associated with high intensity exercise at time of fetal implantation but not after 18 weeks.30 Light to moderate physical activity may actually decrease risk of miscarriage, decrease rate of Cesarean delivery, and increase chance of normal delivery.1 When there is adequate maternal caloric intake, the birthweight of the child is unaffected by increased physical activity.32 Women who exercise may have lower risk for having large-for-gestational age babies.1 There are theoretical fetal risks associated with exercise in pregnancy, however it is overwhelmingly more beneficial than inactivity.1,16
Generally, exercise increases body temperature 1.5°C in the first 30 minutes of exercise and reaches a steady state for the next 30 minutes of exercise for an average non-pregnant female.33 This temperature change is dependent on several environmental factors. In a hot and humid environment, there is less dissipation of heat. Higher intensity of exercise and dehydration can also lead to greater rise in core body temperature.33,34 Rat studies have demonstrated teratogenicity of hyperthermia (>1.5°C increase) early in gestation, however this has not been shown in humans.16 Accordingly, pregnant women should avoid exercising in hot, humid environments, such as in hot yoga, and stay well hydrated before and during exercise.1,16,35
Exercise in the postpartum period is also recommended.1,16 There is no evidence that postpartum exercise negatively impacts composition or amount of breast milk.36
Specific secondary or associated conditions and complications
In the active pregnant female, there may be secondary conditions that are experienced including perceived performance, pelvic floor dysfunction, incontinence, and musculoskeletal conditions. Given the substantial respiratory changes during pregnancy, an individual’s level of perceived exertion may increase and maximal exercise performance may decrease.16
Musculoskeletal injury can occur in pregnancy just as in those who are not pregnant. Low back pain is reported in 45 to 75% of pregnant women and 30 to 45% in the post-partum period.16,36 Pregnancy-related pelvic girdle pain is reported in between 23 and 65% of women.1 Women may also have pubic symphysis separation, osteitis pubis, rectus abdominis diastasis, and pelvic floor myofascial pain and dysfunction. Valsalva maneuver should be avoided for fetal protection and because it can also weaken or stretch the pelvic floor muscles increasing the risk of pelvic organ prolapse and incontinence.1 The prevalence of urinary incontinence (UI) in female elite athletes is high (28-80%).37 The only study assessing UI in pregnant athletes demonstrated an increased prevalence of UI in Norwegian elite athletes after giving birth.29 Pregnancy is associated with increased prevalence of DeQuervain’s tenosynovitis, carpal tunnel syndrome, lateral femoral cutaneous neuropathy, and lumbosacral plexopathies.1,16,36
Transient osteoporosis of pregnancy (TOP) is a typically self-limited and rare but serious condition that can predispose women to insufficiency fractures during pregnancy and postpartum.38 The exact mechanism is unknown but may be due to abnormal mechanical stress, history of low bone mineral density, microvascular injury, venous stasis causing reversible ischemia, maternal calcium demands, and hormonal factors.39,40 Conservative treatment for TOP includes physical therapy, protected weight bearing, and analgesics.40
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. Relative and absolute contraindications for exercise in pregnancy are listed in Table 1.
ESSENTIALS OF ASSESSMENT
Obstetrician–gynecologists (OB/GYN), primary care physicians, and sports medicine physicians need to carefully evaluate women for medical or obstetric complications prior to recommending participation in physical activity and exercise during pregnancy.16 Preparticipation evaluation should be done in accordance with the 5th edition of Preparticipation Physical Evaluation and the American College of Sports Medicine recommendations. 41,42 In addition to taking a thorough medical history, the physician should inquire about the patient’s exercise tolerance, duration, frequency, and intensity prior to pregnancy.
For athletes, it is important to inquire about life and athletic goals, including upcoming events, competitions, and long-term priorities (retirement, Olympics, World Cup, etc). Also, all female athletes, especially those who are pregnant, should be screened for disordered eating and Relative Energy Deficiency in Sport (RED-S) and managed approrpiately.1,43-45 Athletes have a higher rate (20-22%) than non-athletes (3-9%) of eating disorders.1 Higher rates of disordered eating were found when using conversational interviewing as compared to self-reported surveys.43 Women who struggle with disordered eating have increased rates of hyperemesis gravidum, anemia, spontaneous abortion, preterm birth, Cesarean section, and postpartum hemorrhage.1
Per the ACOG recommendations, a thorough evaluation should be completed prior to clearance for participation in an exercise program during pregnancy. This should be done in conjunction with the athlete’s obstetrician.16
A general neuromusculoskeletal examination should be performed with specific attention to the patient’s axial spine, pelvis, and hips. When evaluating pregnant women for pelvic girdle pain the FABER and Posterior Pelvic Pain Provocation (P4) tests are the most specific provocative maneuvers.46,47 FABER is performed with the participant supine, their leg flexed, abducted, and externally rotated so that the heel rests on the opposite knee. This test is positive with production of pain in the sacroiliac joint. P4 starts with the patient supine, the femur is flexed to 90 degrees and the knee is flexed at 90 degrees. A gentle force is applied to the femur in the direction of the examination table. The test is positive when the participant experiences pain in the gluteal region of that limb. The Active Straight Leg Raise Test (ASLR) is a functional assessment that is more sensitive than the P4 test for pregnancy related pelvic girdle pain.48,49 The ASLR is performed with the participant supine with straight legs extended on the table 20 cm apart. The participant raises each leg one at a time 20 cm above the table without bending the knee. The test is positive when the participant describes a heaviness or difficulty in performing the task. In the second part of the maneuver, posterior pelvic compression is applied by the clinician and the participant is then asked to repeat the ASLR. If there is greater ease in lifting the leg this is considered a positive test. The participant will be asked to score impairment without and with posterior pelvic compression. Importantly, the score measures their difficulty raising the leg (but does not measure pain) on a 6-point scale: not difficult at all = 0, minimally difficult = 1, somewhat difficult = 2, fairly difficult = 3, very difficult = 4, unable to do = 5). The scores of both sides are summed so that the total score can range from 0-10, with a higher score meaning greater impairment. Impairment is considered severe if the summed bilateral score is at least 4.46,49
Additional tests to evaluate pelvic girdle pain in pregnancy include the long dorsal sacroiliac ligament (LDL) palpation test, pubic symphysis palpation test, and modified Trendelenburg’s test. The LDL is palpated directly caudomedially from the posterior iliac spine to the lateral dorsal border of the sacrum while the patient lies on her side with slight flexion in both hip and knee joints.46 If palpation causes pain that persists five seconds after removal of the examiner’s hand, it is considered pain. If the pain disappears within five seconds, it is recorded as tenderness. When the identical pain is felt directly in the vicinity, but outside the borders of the ligament, the test is not deemed as positive. When palpating the pubic symphysis, the patient will be lying supine.46 If palpation causes pain that persists five seconds after removal of the examiner’s hand, it is recorded as pain. If the pain disappears within five seconds, it is recorded as tenderness. Modified Trendelenburg’s test is considered positive if the woman experiences pain in the symphysis while standing on one leg and flexes the other at 90° (hip and knee).46 Other joints may be examined in response to patients’ complaints.
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.
The use of radiologic imaging in pregnant patients has increased 107% from 1997-2006.50 While generally safety and technology is improving, use of imaging in pregnancy should follow the principle of As Low As Reasonably Achievable (ALARA) regardless of the modality.51 For low-risk, suspected benign musculoskeletal complaints, ultrasound should be the first line modality.51-54 Ionizing radiation exposure from common imaging modalities including X-rays and computed tomography (CT) pose substantial risk to developing embryos and fetuses depending on gestational age and dose of radiation.51,53,54 Radiation doses greater than 100 mGy (10 rad) during the first trimester are associated with spontaneous abortion, growth retardation, and developmental delay.51-54 There is a 1.5 to 2 factor increase in leukemia in the fetus with 10 to 20mGy exposure.51 Generally the radiation exposure from X-rays, CT scans, and nuclear medicine studies is lower than the exposure associated with fetal injury and should not be withheld in emergent situations.51-54 Magnetic resonance imaging (MRI) is considered to be safe in pregnancy but carries theoretical risks of miscarriage, teratogenesis, and acoustic damage in the fetus.51,53 Ray et al found that while there was no significant difference in fetal outcomes in pregnant women exposed to MRI in the 1st trimester, there was an associated increased risk of rheumatological, inflammatory, and infiltrative skin conditions, still birth, or neonatal death in women who had MRI with gadolinium contrast compared to those without any MRI exposure.51,54,55 Both gadolinium and iodinated contrast are known to cross the placenta.51,54 There is little known about their effects on the embryo or fetus other than that there is speculation that iodinated contrast cause neonatal hypothyroidism though no human studies have demonstrated this.51 Contrast agents should only be used in emergent situations if it significantly improves diagnostic performance of the test and improves the outcome for mother and child.51
During lactation, only 0.4 to 0.5% and 0.01% of iodinated and gadolinium, respectively, is excreted in breast milk, of which the child will absorb less than 1% in their gastrointestinal system.51,53,54 Therefore ACOG recommends not interrupting breastfeeding after maternal exposure to contrast.51 Radionuclide compounds have much more variability with regards to rates and duration of excretion in breast milk, and their use should only be done in conjunction with an expert on breast feeding.51
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. During pregnancy, athletes may be concerned about direct trauma to the fetus as well as concerns about not performing to the standards of their teammates.6 During the postpartum period, athletes may struggle with re-establishing their role within the team and as an athlete.4 The patient may benefit psychologically by continuing to participate in athletics aside from the benefits of exercise on mood and sleep. All of these should be considered when making recommendations and modifications to the athlete’s participation in sport.
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. An athlete may have a large network of professionals and teammates. It is important to remain in compliance with privacy laws and the patient’s wishes. When prescribing medications to treat common symptoms during pregnancy, the physician and athlete should ensure the medication is written in accordance to their sport governing body, national anti-doping agency, and the World Anti-Doping Association (WADA) list of banned substances.1
REHABILITATION MANAGEMENT AND TREATMENTS
Physical Exercise Guidelines for Pregnant Women
The 2nd edition of Physical Activity Guidelines for Americans released by the U.S. Department of Health and Human Services in 2018 recommends that pregnant women of any fitness level should participate in preferably moderate intensity aerobic activity at least 150 minutes throughout a week. If women habitually participate in vigorous aerobic activity, they are able to continue that level of exercise during pregnancy.56 The American College of Obstetricians and Gynecologists (ACOG) committee opinion in 2015, which was reaffirmed in 2017, further expanded the benefits greatly outweighing the risks of exercise during pregnancy.16 A thorough clinical evaluation should be completed prior to recommending an exercise program. For uncomplicated pregnancies, aerobic and strength conditioning is safe and encouraged. For women with obstetric and medical comorbidities recommendations for physical activity should be individualized.16 For women who were previously inactive, ACOG identifies pregnancy as an ideal time to adopt an active lifestyle as there is more access to medical supervision than other times in a woman’s life. Activity should start at mild and progress to moderate intensity with gradual progression of frequency and duration. There are several absolute and relative contraindications for women to participate in exercise during pregnancy as listed in Table 1.
|Absolute Contraindications||Relative Contraindications|
|Hemodynamically significant heart disease||Anemia|
|Restrictive lung disease||Unevaluated maternal cardiac arrhythmia|
|Incompetent cervix or cerclage||Chronic bronchitis|
|Multiple gestation at risk of premature labor||Poorly controlled type 1 diabetes|
|Persistent 2nd or 3rd trimester bleeding||Extreme morbid obesity|
|Placenta previa after 26 weeks gestation||Extremely underweight (BMI < 12)|
|Rupture of membranes||History of extremely sedentary lifestyle|
|Preeclampsia or pregnancy induced hypertension||Intrauterine growth restriction in current pregnancy|
|Severe anemia||Poorly controlled hypertension|
|Poorly controlled seizure disorder|
|Poorly controlled hyperthyroidism|
Table 1. Absolute and relative contraindications to aerobic exercise during pregnancy per American College of Obstetricians and Gynecologists (ACOG).16
Information adapted from motor vehicle accidents indicates that maternal blunt trauma may result in acute or chronic fetal hypoxia or death. Thus, pregnant women should generally avoid participating in collision and fall risk sports such as ice hockey, luge, equestrian, and downhill skiing.1,2,16 It is recommended that pregnant women should not SCUBA dive because the fetus is at risk of malformation and gas embolism after decompression disease as demonstrated in few human cases and animal studies.1,16,57,58 While there is no evidence to support the theoretical risk of fetal hypoxia, it is advisable to avoid training at high altitudes greater than 1500-2000 m.59
Individuals should stop exercise and notify a physician if they develop vaginal bleeding, regular painful contractions, dyspnea at rest, dizziness, headache, chest pain, calf pain or swelling, or muscle weakness affecting balance.16
Rehabilitation Management and Treatments
Poorly managed pain during pregnancy is a risk factor for developing chronic pain, increased maternal stress, depression, sleep deprivation, and hypertension.60 Initial treatment of musculoskeletal pain during pregnancy should be with non-pharmacologic options. A Cochrane review in 2013 found moderate level evidence for exercise and acupuncture as treatment for low back and pelvic girdle pain.61 Other options include core stabilizing exercises, cognitive behavioral therapy, pelvic belts, and TENS units.60 A diagnosis specific physical therapy regimen can be beneficial.1,61 Additionally, pelvic floor exercise may be added to help prevent incontinence in late pregnancy and postpartum.16 Black et al proposed an algorithm for pharmacologic treatment of pain in pregnancy.60 Acetaminophen/paracetamol is the first line option as it is generally regarded as safe.62,63 Several observational studies have found a significant association between prenatal acetaminophen exposure and early childhood asthma, neurodevelopmental delays, and behavioral problems.60,62-67 If pain is not relieved, NSAIDs and aspirin may be added during the 1st and 2nd trimesters with the theoretical but unproven risk of miscarriage with 1st trimester use, however these should be strictly avoided in the 3rd trimester due to risk for premature closure of the ductus arteriosus and oligohydramnios.60 Short term use of atypical or low dose opioids may be considered for patients with severe pain.60 Medical management of pain during pregnancy and postpartum should always be done in close coordination with the patient’s obstetrician.
Coordination of care
For all pregnant women, it is important that the decision to exercise is made in conjunction with an obstetrician and their primary care physician. For recreational and even more so, elite athletes, there may be more people involved in their care. The team physician typically takes a leadership role to coordinate assessment and management of injuries and illness including final clearance to participate.68 This is coordinated with athletic trainers, physical therapists, strength and conditioning specialists, dieticians, coaches, and agents. As the field of women’s sports evolves, this team is expanding to include endocrinologist and OB/GYNs.69 It is vital to work cohesively and with open communication with each team member to best support the athlete’s wishes.
Patient & family education
Women indicate that their doctor has the most influence on their beliefs about exercise during pregnancy. Those who are encouraged to exercise by their doctor are more likely to exercise.70 Krans and colleagues also found strong correlation (P=0.005) between patient beliefs regarding benefits of prenatal exercise and whether or not they exercised during pregnancy. 41.3% of patients report initiating conversations about exercise during pregnancy. For patients who exercised during the 1st and 2nd trimester, 25% and 32.4% of obstetricians, respectively, recommend decreasing intensity or duration of aerobic and resistance exercise during the 3rd trimester.71 Key points of education include the benefits of exercise, what types of exercise are acceptable, duration and frequency of exercise, importance of gradual progression, and when they should stop with regards to their pregnancy course in accordance with the ACOG guidelines listed above.16 It is especially important that physicians caring for recreational and elite athletes counsel patients on how body positions, environment, and types of exercise may need to be altered given specific risks previously discussed.4
After identifying that more high-level athletes continue to train and compete while pregnant, the International Olympic Committee (IOC) created a summary of evidence, published in 5 parts from 2016 to 2018 to better guide practices and future research on exercise in the pregnant recreational or elite athlete. 1,4,30,35,72
Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
- In the absence of contraindications as determined by an OB/GYN and after thorough screening, women should engage in aerobic and strength conditioning exercise before, during, and after pregnancy.
- Women should be encouraged to engage in 150 minutes or more of moderate intensity exercise weekly. avoiding exercise in supine position after 28 weeks gestation, contact sports, sports with high risk of falls, SCUBA diving, and exercise in hot environments.
- Benefits of exercise include maintaining and improving physical fitness, decreased back pain, less constipation, bloating and swelling, prevention or treatment of gestational diabetes, and improved energy, mood, posture, and sleep.
- Exercise should be stopped and the person’s physician notified if a person develops vaginal bleeding, regular painful contractions, dyspnea at rest, dizziness, headache, chest pain, calf pain or swelling, and muscle weakness affected balance.
- Acute diagnosis and treatment of musculoskeletal complaints requires a detailed history, physical examination, and avoidance of unnecessary radiologic exposures.
- Conservative management with skilled therapies, modalities, and a home exercise program is often most appropriate in managing musculoskeletal complaints.
- Understand that there is little evidence with regards to how pregnancy may be different in elite level athletes.
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, 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. 73 With increased evidence that PFRT can help treat pregnancy related pelvic girdle pain,women with persistent pain can seek clinicians skilled in these therapies.
A randomized controlled trial of usual prenatal care vs twice weekly supervised exercise with nutrition counselling in Norway demonstrated that a community sponsored group exercise program is safe, feasible, and saw 71.7% of participants exercise outside of the class.74
GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
There is generally a lack of high-quality evidence of how high intensity exercise in large doses affects maternal and neonatal health and outcomes. There needs to be more information on the effects of pregnancy and return to sport. Additionally, exploration of the longer-term effects of RED-S on fertility would be beneficial. For a more comprehensive list of areas of opportunity for further research, please refer to Part 4 of the IOC expert group meeting in Lausanne summary of evidence on exercise in pregnancy for athletes.35
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Original Version of the Topic:
Devon Shuchman, MD, Colleen Fitzgerald, MD. Pregnant Athlete. Publication Date: 2011/11/10.
Previous Revision(s) of the Topic
Rakhi G Sutaria, MD, Roshni Durgam, MD. Pregnant Athlete. Publication Date. 05/05/2016
Stacey A. Bennis, MD
Nothing to Disclose
Ann Hulme, MD
Nothing to Disclose