11 b Exercise and High risk pregnancy Flashcards
Historical view of exercise in pregnancy Early to Mid 1900’s
Pregnancy regarded as a state of confinement
ACOG: Position Statement 1985 (exercise in pregnancy)
» Do not exercise > 15min
» Maternal HR < 140bpm
» Core Temp < 38 deg Celsius
ACOG: Position Statement 1994 (exercise in pregnancy)
- 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
Current exercise in pregnancy position statement
• 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.
Exercise in pregnancy Implications for physiotherapists
- Most health professionals are now in support of exercise during pregnancy
- 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 - Exercise is even now regarded as beneficial in some circumstances where it was
previously contra-indicated
General Suggestions for Exercise in
Pregnancy (ACOG 2002)
• 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)
Contra-indications*
ACOG (2002)
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
WHAT IS “INCOMPETENT CERVIX”
• 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
Medical Mx of Incompetent Cervix
OPTION 1 Prophylactic Cerclage (at 12-16/40)
OPTION 2 Emergency Cerclage (at 18-24/40)
OPTION 3 Watch and Wait (Conservative Management)
When is Prophylactic Cerclage (at 12-16/40) indicated?
– Suggested in women with 3 or more previous unexplained 2nd trimester miscarriages
– Performed at beginning of 2nd trimester
Risks with Prophylactic Cerclage (at 12-16/40) ?
– Does pose a risk of inducing preterm delivery
due to chorioamnionitis, suture displacement, ROM
Birht after Prophylactic Cerclage (at 12-16/40)?
Usually removed at 37/40 (if unable caesarean)
When is Emergency Cerclage indicated?
– 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
When is Watch and wait indicated in incompetent cervix?
Identified with a short cervix at/after 20 weeks
• Fewer than 3 previous 2nd trimester losses
3 Main Components to Conservative Management incompetent cervix?
- Serial Transvaginal Ultrasound Ax of Cervix
- Labour Prevention / Fetal Maturation
- Activity Restriction
WHAT IS PHYSIOTHERAPISTS ROLE IF REFERRED A
Patient with severe incompetent cervix ON BED REST?
– 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
Placenta Praevia
• 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
Pre - eclampsia
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 ’
• Untreated pre-eclampsia can cause
– Liver damage – Kidney damage – Convulsions / seizures – Clotting problems – Death
Pre-eclampsia - treatment
- The only way to cure pre-eclampsia is delivery of foetus and placenta.
- Maternal and foetal risks of preterm delivery.
Exercise and Pre-Eclampsia
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%
Diabetes in Pregnancy
Can be classified as
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
Gestational Diabetes
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.
GDM • Risk factors
• 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
