William M. Gilbert, MD Regional Medical Director, Womens Services - - PowerPoint PPT Presentation

William M. Gilbert, MD Regional Medical Director, Women’s Services Sutter Health, Valley Region & Clinical Professor, Department of OB/GYN, University of California, Davis

 Physical Activity (PA) restrictions including

bed rest

• Evidence for these restrictions

 Examine normal PA levels in pregnancy.

• What level of PA is safe, if any?
• Is too much (marathon runner) PA bad?

 PA and the effect on pregnancy outcomes.

• Potentially bad: SGA/IUGR, PTD, LGA
• Potentially good: C/S rates, DM, preeclampsia

 Many myths about maternal activity levels in

pregnancy

• Bed rest with first trimester bleeding
• Too much exercise causes bad things:

 PTL, PTD, SGA

• Bed rest with incompetent cervix
• Increased activity may put you into labor

• A. Go back to work
• B. Off work until the bleeding stops or an

SAB

• C. Give progesterone injections

Go back to work Off work until the bleedi.. Give progesterone inject...

81% 2% 17%

 Regular physical activity (PA) in all stages of

life, including pregnancy, promotes health benefits.

 Most Americans do not reach this goal  Most pregnant women decrease PA once

pregnant.

 Obese patients more likely to decrease PA

than normal weight patients

 150 min/week at moderate intensity.

• 5 -30 min sessions

 International Physical Activity Questionnaire

short form (IPAQ-SF)

• Good test-retest reliability for PA
• Inactive or low (< 150 min/week)
• Active (> 150min/week),

 Moderate, Moderate to vigorous, vigorous

 Metabolic Equivalents (MET)

• Amount of calories burned at complete rest
• 1 MET- About 70 kcal

 Sousa Rego et al., 2016 1,380 women  Surveyed PA in the second trimester

• All levels of PA including High PA was not

associated with LBW, PTD, IUGR

 Owe et al. 2012 – 61,0908 Norwegian

Mother and Child Cohort study

• Surveyed at 17 and 30 weeks gestation on PA
• 3-5 times per week at both gestational ages

 Decreased risk of PTD aOR 0.82 (0.73, 0.91)  Slight increase in post term delivery

 aOR 1.14 (1.04, 1.24)  Committee Opinion Number 650 2015

• Reaffirmed 2017
• Exercise recommendations

 Basically any/all PA is good in normal women

• Absolute contraindications
• Relative contraindications
• Examples of safe and unsafe PA during pregnancy

 Often women unable to get exercise due to

exhaustion or N/V

 Bleeding and decreasing PA

• Poor, limited data but no benefit
• Cochrane review –Aleman et al 2005

 Two studies of 84 women  No difference in SAB – RR 1.54 (0.92, 2.58)  Insufficient evidence supporting use of bed rest

 Bed rest – loss of physical conditioning,

economic loss, psychological stress.

 Can lead to MORE stress!!  Pre Term Delivery

• Poor, limited data but no benefit
• Cochrane review -Sosa et al. 2015

 One study of 1266 women  No difference in PTD – RR 0.92 (0.6, 1.6)  No evidence supporting or refuting use of bed rest

 Bed rest – loss of physical conditioning,

economic loss, psychological stress, increase in DVT/PE

• A. IV hydration
• B. IV hydration and bed rest in the hospital
• C. Send the patient home and come back

for 2nd beta in 24 hours.

• D. None of the above

I V h y d r a t i

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I V h y d r a t i

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a n d b e d r e s t . . . S e n d t h e p a t i e n t h

• m

e a . . N

• n

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t h e a b

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47% 7% 34% 13%

 “ Although bedrest and hydration have been

recommended to women with symptoms of PTL to prevent PTD, these measures have not been shown to be effective for the prevention

• f preterm birth and should not be routinely

recommended”

 ACOG Practice Bulletin #171 2018

 Practice Bulletin Number 142 2014

• Reaffirmed 2019

 Cerclage for the Management of Cervical

Insufficiency

• Much controversy about cerclage use without

proper indications

• Recommendation Level B
• “Certain non surgical approaches, including activity

restriction, bed rest, and pelvic rest, have not been proved to be effective for the treatment of CI and their use is discouraged”

  Hispanic population 2006 – 2011

• Proyecto Buena Salud prospective cohort -1313
• Pregnancy Physical Activity Questionnaire

 Sedentary activity Increase in C/S rates

• OR 1.54 (1.02-3.33)

 When planned C/S removed

• High PA pre-pregnancy OR 0.61, (0.38-0.99)
• Moderate intensity mid/late pregnancy 50%

reduction in C/S rates



Russo et al 2019

 Pastorino et al., 2018  Meta-analysis of 8 population based studies

with 72,694 patients

 Examined early and late PA on birth outcomes

• Leisure time PA (LTPA) - Moderate to vigorous or

Vigorous

• Outcomes BW, LGA, Macrosomia, SGA

 Late but not early LTPA

• Lower risk of LGA, macrosomia
• No increase in SGA

 Sanda Et al. 2017  Effect of a prenatal lifestyle intervention on

PA level in late pregnancy and the first year postpartum

 Norwegian Fit for Delivery (NFFD) RCT  Healthy primips, BMI > 19 two groups

• Intervention group: twice weekly group exercises
• Control: standard prenatal care
• IPAQ-SF at 16, 36 weeks and 6 and 12 months PP

 Sanda Et al. 2017  Results

• Intervention group maintained PA levels at 36

weeks in normal weight and physically active.

• Control group all decreased their PA
• The intervention effect on obese or inactive patients

depended upon level of PA

 Conclusion:

• 1.Group exercise intervention maintained PA

through 36 weeks.

• 2. No postpartum effect was seen

 Abenhaim et al. 2008  Retrospective cohort study of 36,140 patients  Examined hospitalized patients (677) with:

• PTL (71%), PROM (18%), incompetent cervix (8%)

 Bed rest reduction in Preeclampsia

• OR 0.27 (0.16, 0.48)

 Delivery prior to 34 weeks

• OR 0.12 (0.03, 0.5)

 Reduction in IUGR

• OR 0.38 (0.18, 0.84)

 McCall et al. O&G 2013  “Therapeutic” bed rest in pregnancy:

unethical and unsupported by data.

 Cochrane reviews do not support:

• Threatened AB, Hypertension, PTD, Multiples or

IUGR

 If bed rest is to be used, it should be only

within a formal clinical trial

 Evidence does not appear to support bed rest

for MOST obstetrical complications:

• First trimester bleeding, IC, PTL, IUGR, PE

 In fact, may cause more harm:

• Loss of physical condition, financial loss, increase in

Stress, DVT/PE.

 Increasing physical activity:

• Panacea for most obstetrical problems!

 Lower C/S, LGA, Macrosomia, SGA, PTD

• Intervention works to increase PA but at acceptable

cost?

 Understanding this evidence, how do we

educate our patients?

• Bleeding in the first trimester?
• Short cervix on 2nd trimester ultrasound

 Increasing physical activity to improve

• utcome
• Stress maintaining PA! 150 min/week
• Increasing activity in those who are inactive
• Focus on benefits of PA in pregnancy

 We have much research and work to do!!

References

1. Sanda, B., Vistad, I., Reme Sagedal, L., Hagen Haakstad, LA., Lohne- Seiler, H., Klungland Torstveit, M. Effect of a prenatal lifestyle intervention on physical activity level in late pregnancy and the first year postpartum. PLOS ONE November 27, 2017; https://doi.org/10.1371/journal.pone.0188102 2. Sousa Rego, A., Seabra Soares de Britto e Alves, M., Lucena Batista, RF., Costa Ribeiro, CC. (2016). Physical activity in pregnancy and adverse birth

• utcomes. Cad.Saude Publica Health 2016; 32(11):e00086915 /

www.ensp.fiocruz.br/csp DOI: 10.1590/0102-311X00086915 3. Cerclage for the management of cervical insufficiency. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians. Practice Bulletin. Number 142, February 2014 (Reaffirmed 2019). 4. Pastorino, S., Biship, T., Crozier, SR., et al. Associations between maternal physical activity in early and late pregnancy and offspring birth size: remote federated individual level meta-analysis from eight cohort studies. BJOB: An International Journal of Obstetrics and Gynaecology. Epidemiology. October 16, 2018; www.bjog.org DOI: 10.1111/1471-0528.15476 5. Management of preterm labor. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians. Interim Update Practice Bulletin. Number 171, October 2016 (Reaffirmed 2018). 6. Aleman, A., Althabe, F., Belizan J., Bergel, E. Bedrest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003576. https://www.ncbi.nlm.nih.gov/pubmed/15846669 7. Russo, LM., Harvey, MW., Pekow, P., Chasan-Taber, L. Physical activity and risk of cesarean delivery in hispanic women. J Phys Act Health. 2019 Feb 1;16(2):116-124. DOI: 10.1123/jpah.2018-0072. Epub 2019 Jan 9 8. Sosa, CG., Althabe, F., Belizan, JM., Bergel, E. Bed rest in singleton pregnancies for preventing preterm birth. Cochran Database Syst Rev. 2015 Mar 30;(3):CD003581. DOI: 10.1002/14651858.CD003581.pub3 9. Physical activity and exercise during pregnancy and the postpartum period. The American College of Obstetricians and Gynecologists Women’s Health Care

• Physicians. Committee Opinion. Number 650, December 2015 (Reaffirmed 2017)

10. Sanda, B., Vistad, I., Hagen Haakstad, LA., Bernstsen, S., Reme Sageal, L., Lohn-Seller, H., Klungland Torstveit, M. Reliability and concurrent validity of the internal physical activity questionnaire short form among pregnant women. BMC Sports Science, Medicine and Rehabilitation. (2017)9:7 DOI: 10.1186/s13102-017-0070-4