11 b Exercise and High risk pregnancy

Question 1

Historical view of exercise in pregnancy Early to Mid 1900’s

Answer 1

Pregnancy regarded as a state of confinement

Question 2

ACOG: Position Statement 1985 (exercise in pregnancy)

Answer 2

» Do not exercise > 15min
» Maternal HR < 140bpm
» Core Temp < 38 deg Celsius

Question 3

ACOG: Position Statement 1994 (exercise in pregnancy)

Answer 3

• Women who have previously exercised can continue mild – moderate exercise
• Regular (3/week) is preferable to intermittent
• Avoid exercising in supine after 1st trimester
• Avoid prolonged periods of motionless standing
• Should not exercise to fatigue / exhaustion
• Avoid any exercises with potential for even mild abdominal trauma

Question 4

Current exercise in pregnancy position statement

Answer 4

• 30min or more of moderate intensity exercise on most if not all days is
recommended for all pregnant women in the absence of medical or
obstetric complications.
• Exercise can be safe and beneficial in previously sedentary individuals.
• Following medical review, exercise may still be recommended in women
in the presence of medical or obstetric complications.
• Exercise can play an important role in the prevention and management of
gestational diabetes mellitus.

Question 5

Exercise in pregnancy Implications for physiotherapists

Answer 5

1. Most health professionals are now in support of exercise during pregnancy
2. Not all health professionals are aware that heart rate and time restrictions have
   been removed from the ACOG guidelines for exercises in healthy pregnant women
3. Exercise is even now regarded as beneficial in some circumstances where it was
   previously contra-indicated

Question 6

General Suggestions for Exercise in

Pregnancy (ACOG 2002)

Answer 6

• Avoid exercise in supine (after 19 weeks)
• Avoid Periods of Motionless standing.
• Avoid activities which pose a risk for falls or direct trauma
\• Ensure adequate diet and hydration (see notes later on water based
exercise)

Question 7

Contra-indications*

ACOG (2002)

Answer 7

General Medical
Haemodynamically significant heart disease
Restrictive Lung Disease
Obstetric
Premature labour during current pregnancy
Ruptured membranes (ie waters broken)
Multiple gestation at risk for premature delivery
Incompetent cervix / cerclage
Placenta Praevia after 26/40
Pregnancy induced hypertension / Pre-Eclampsia

Question 8

WHAT IS “INCOMPETENT CERVIX”

Answer 8

• Dilation of the cervix in the absence of labour/contractions, usually in the
2nd trimester –
“
Silent Dilatation
” • Thought to be the cause of 20-25% of second trimester stillbirths / losses.
• Affects ~1% of pregnant women to some degree
• Diagnosis by digital Ax or ultrasound

Question 9

Medical Mx of Incompetent Cervix

Answer 9

OPTION 1 Prophylactic Cerclage (at 12-16/40)

OPTION 2 Emergency Cerclage (at 18-24/40)

OPTION 3 Watch and Wait (Conservative Management)

Question 10

When is Prophylactic Cerclage (at 12-16/40) indicated?

Answer 10

– Suggested in women with 3 or more previous unexplained 2nd trimester miscarriages
– Performed at beginning of 2nd trimester

Question 11

Risks with Prophylactic Cerclage (at 12-16/40) ?

Answer 11

– Does pose a risk of inducing preterm delivery

due to chorioamnionitis, suture displacement, ROM

Question 12

Birht after Prophylactic Cerclage (at 12-16/40)?

Answer 12

Usually removed at 37/40 (if unable caesarean)

Question 13

When is Emergency Cerclage indicated?

Answer 13

– Suggested in women found to have short cervix at 18/40 Morphology scan
– Performed later in pregnancy (18-24/40), but not usually performed if > 25/40 (after
– Higher risk than prophylactic cerclage
– Requires at least 10-15mm of cervical length and at least 24hrs of pre-operative broad
spectrum antibiotics

Question 14

When is Watch and wait indicated in incompetent cervix?

Answer 14

Identified with a short cervix at/after 20 weeks

• Fewer than 3 previous 2nd trimester losses

Question 15

3 Main Components to Conservative Management incompetent cervix?

Answer 15

1. Serial Transvaginal Ultrasound Ax of Cervix
2. Labour Prevention / Fetal Maturation
3. Activity Restriction

Question 16

WHAT IS PHYSIOTHERAPISTS ROLE IF REFERRED A

Patient with severe incompetent cervix ON BED REST?

Answer 16

– Pregnant women on bed rest are highly susceptible to DVT due to
progesterone softening blood vessels:
• Circulatory exercise (ankle, calf)
• Compression stockings (not over abdomen)
• Upper limb exercises
• ??? Gentle non –WB lower limb strengthening exercises
?? In side lying with slide board
• AVOID all ABDOMINAL EXERCISE

Question 17

Placenta Praevia

Answer 17

• Placenta normally attaches in upper uterus (anterior, lateral or
posterior wall)
• Can attach low near or across cervix
• Higher Risk of antepartum haemorrhage
• Can’t labour cervical dilation haemorrhage

Question 18

Pre - eclampsia

Answer 18

Diagnosis
– Persistent Hypertension >140/90

 PLUS 1 or more of:
• Proteinuria
• Persistent Headaches
• Visual Disturbance eg flashing lights
• High level of swelling in hands and feet
• Epigastric pain
• Thrombocytopenia
• Elevated liver enzyme activity
’

Question 19

• Untreated pre-eclampsia can cause

Answer 19

– Liver damage
– Kidney damage
– Convulsions / seizures
– Clotting problems
– Death

Question 20

Pre-eclampsia - treatment

Answer 20

• The only way to cure pre-eclampsia is delivery of foetus and placenta.
• Maternal and foetal risks of preterm delivery.

Question 21

Exercise and Pre-Eclampsia

Answer 21

Exercise in the first 20/40:
– Regular moderate intensity physical activity decreased the risk of PE by 24%
– Regular vigorous physical activity decreased the risk of PE by 54%

Question 22

Diabetes in Pregnancy

Can be classified as

Answer 22

Pre-Gestation Diabetes Mellitis (Pre-GDM)
A woman with Type 1 or 2 Diabetes who then falls pregnant
Gestational Diabetes Mellitis (GDM)
A woman who develops diabetes during pregnancy

Question 23

Gestational Diabetes

Answer 23

Diabetes restricted to pregnant women in whom the onset or recognition of
glucose intolerance first occurs during pregnancy
”

Usually doesn’t occur until late 2nd or 3rd trimester when placenta
is creating sufficient placental lactogen to increase insulin
resistance.
• Usually resolves after birth with removal of placenta and cessation
of placental lactogen hormone.

Question 24

GDM • Risk factors

Answer 24

• Risk factors
– Maternal age >40yrs OR = 6.13
– Family history of diabetes
– Previous pregnancy with GD
– BMI > 29
– Previous stillbirth or spontaneous miscarriage
– Ethnicity (in Australia)
• Chinese 13.9%, Other Asian 10.9%, Africa 9.4%, Vietnam 7.3%
– Previous level of activity

Question 25

GDM: Risk for baby

Answer 25

Macrosomia
Neonatal Hypoglycaemia
Increased Risk of Premature birth
• Increased risk of Hyperbilirubinemia / Prolonged jaundice
Increased risk of Respiratory distress syndrome
• Increased risk of Neonatal death / stillbirth

Question 26

Risks for Mother GDM

Answer 26

• Increased risk of Caesarean Section
– Macrosomia CPD
• Increased risk of pre-eclampsia
• Hypertension
• Future Type 2 Diabetes Mellitus
– 5-10% immediately after pregnancy

Question 27

Management of GDM

Answer 27

Diet
Insulin therapy
– Cut-offs for commencement of insulin:
• Fasting > 5.8mM
• 1hr postprandial > 8.6mM
• 2hr postprandial > 7.2mM

Question 28

WHAT IS THE PHYSIOTHERAPIST’S ROLE

IN GESTATIONAL DIABETES?

Answer 28

• Exercise is now acknowledged as an effective way to
– decrease insulin resistance and thus help control blood glucose levels.
– Prevent GDM if performed through entire pregnancy at least 3/week

Question 29

Considerations when exercising GDM women

Answer 29

Carbohydrates are preferentially used in non-weight bearing

exercise

Question 30

Hypoglycemia cont….

• Symptoms

Answer 30

– Confusion
– Dizziness
– Feeling shaky
– Headaches
– Sudden hunger
– Sweating
– Weakness

Question 31

Warning signs to cease exercise in any woman during

pregnancy

Answer 31

• Vaginal bleeding
• Dyspnoea before commencing exercise
• Dizziness
• Headache
• Chest pain
• Calf pain or swelling
• Preterm labour
• Decreased foetal movement
• Amniotic fluid leakage