the pregnancy calendar your 40 guide to prenatal care and fetal development
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the pregnancy calendar your 40 guide to prenatal care and fetal development
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Methods Electronic searching of the PubMed, Medline, EMBASE, Cochrane Library, Web of Science and CINAHL databases was used to conduct the search up to November 2018. Study designs included in the systematic review were randomised control trials, quasi-experimental studies, cohort studies and case-control studies. The studies were required to include an intervention or report of pregnant women performing vigorous exercise during gestation, with a comparator group of either lower intensity exercise or standard care. Further research is needed on the effects of vigorous intensity exercise in the first and second trimester, and of exercise intensity exceeding 90 of maximum heart rate. Trial registration PROSPERO trial registration CRD42018102109. The combination of these adaptations challenges the greater demands required by the fetus during pregnancy. It seems likely that the increasing physiological demands during each trimester of pregnancy require variation in exercise training accordingly. However, current guidelines for pregnancy are not trimester-specific. This range is lower than the target heart rate of non-pregnant populations. The haemodynamic variances throughout the stages of pregnancy, which are also dependent on age and fitness, provides insight to the lack of guidance behind vigorous intensity exercise prescription in pregnant populations. It is currently recommended that if patients are completing vigorous intensity exercise before pregnancy they should be able to continue throughout pregnancy, but with caution. The current understanding of the benefits of vigorous intensity exercise during pregnancy lie predominantly in decreased maternal weight gain. Despite vigorous intensity exercise having potential benefits in minimising maternal weight gain, trimester-specific evidence needs to be pooled for an improved synthesis of existing evidence before vigorous intensity exercise can safely be prescribed throughout pregnancy.
More specific guidelines are needed on vigorous intensity exercise in each trimester; and particularly in the final trimester, as this appears to be the most controversial within the literature. This is the first analysis of its kind to pool the evidence for studies reporting vigorous intensity exercise specifically in the third trimester. The primary aim of the study was to investigate the effects of vigorous intensity exercise during pregnancy on birth weight. The secondary aim was to investigate the effects on incidence of small for gestational age (SGA), low birth weight (LBW), prematurity, gestational age at delivery and maternal weight gain. Search strategy Electronic searching of the PubMed, Medline, EMBASE, Cochrane Library, Web of Science and CINAHL databases was used to conduct the search up to November 2018. The Medical Subject Heading (MeSH) database, Boolean operators and truncation were employed to establish all related articles on exercise and pregnancy. The complete search strategy for each of the databases is available in Additional file 1. Only publications in English were included. Eligibility criteria Studies included in the systematic review were randomised control trials (RCTs), quasi-experimental studies, cohort studies and case-control studies. The studies were required to include 1) an intervention or report of pregnant women (of any maternal age) performing vigorous exercise during gestation, 2) vigorous exercise reported in any trimester of pregnancy, 3) a comparator group of either lower intensity exercise or standard care, and 4) at least one of the following infant or maternal outcomes: birth weight, SGA, LBW, gestational age at delivery, preterm birth, or gestational weight gain. Studies reporting any type of vigorous physical activity were included in the review, including but not limited to: running, swimming, circuit training, interval training, weight lifting, or plyometrics.
However, studies reporting gestational diabetes as an outcome were included in the study. Definitions The methodology of all articles on the effects of exercise in pregnancy on birth weight was reviewed in detail, to assess whether they met the definition of vigorous intensity exercise (regardless of the wording of the exercise intensity reported by the authors in the study). The reported incidence for SGA, preterm birth, gestational weight gain, birth weight and gestational age at delivery was based on the diagnosis provided by each study. For the Cochrane Risk of Bias for Randomized Controlled Trials, bias in each study is assessed as low, high or unclear risk across the domains of selection bias (random sequence generation and allocation concealment), reporting bias, other bias, performance bias, detection bias, and attrition bias. From these scores an overall quality assessment of low, unclear, or high-risk was provided. For the Newcastle-Ottawa Scale, quality is assessed from eight questions (one question which includes two parts) based on selection, comparability, as well as outcome for the cohort studies, and exposure for the case-control studies. From these scores an overall quality assessment is determined by the total of the scores out of nine. Two reviewers (CG and KB) conducted the evaluation separately. When there was a discrepancy, a third reviewer provided an evaluation (MN). Data collection process Results of the searches were exported to EndNote X9 for removal of duplicates. Titles and abstracts were screened by CG, with any uncertainties verified by KB. The full-text of included studies were retrieved for data extraction and were reviewed in full by CG and KB. Data from the included studies were screened separately by two reviewers (CG and KB).
The following information was extracted: study setting; population and participant demographics and baseline characteristics; intervention and control condition details; methodology; recruitment and study completion rates; outcomes and times of measurement; and information for assessment of the risk of bias. Statistical analysis The primary outcome was the impact of vigorous intensity exercise on infant birth weight. Secondary outcomes were the impact of vigorous intensity on SGA, LBW, prematurity, gestational age at delivery and maternal weight gain. We planned to assess the influence of vigorous exercise in each trimester, but sufficient data were only available for the third trimester. Meta-analyses were conducted separately for each outcome. For continuous outcomes, unstandardised mean differences were calculated (e.g., birth weight in grams) to preserve the clinical significance of outcomes. For dichotomous outcomes (e.g., prematurity), a risk ratio was calculated. These approximations have been shown to reduce biases introduced from alternative approaches (e.g., list-wise deletion of studies). Where possible, planned moderation analyses were conducted for different study designs (prospective, retrospective, RCT) and different comparison conditions (vigorous vs.In moderation analyses, standardised mean difference (Hedges’ g) were used for parsimony so multiple outcomes could be presented on the same forest plot. Results Study selection In total, 12,316 articles were initially screened for inclusion in the study (Fig. 1 ). After filters were applied and duplicates were removed, 5792 articles were screened by title and abstract. The full texts of 176 articles were reviewed for eligibility criteria, and 15 studies met the criteria for inclusion in the systematic review. For this reason, they were not included in the meta-analysis. The overall risk of bias of the RCTs were mixed.
All studies were considered low risk for reporting bias, performance bias blinding and detection blinding. However, attrition bias was poorly reported. The cohort studies scored higher in the quality assessment than the case-control studies. As expected in observational studies, there were mixed scores for the representativeness of the cohort, with instances of convenience sampling. However, all but one study used controls from the same representative cohort as the exposure group. The number of studies controlling for confounding factors was mixed, with four studies including no confounding variables in their statistical analyses (two cohort studies and two case-control studies). Table 3 Cochrane Risk of Bias for Randomized Control Trials Full size table Table 4 Newcastle-Ottawa Scale for cohort studies Full size table Table 5 Newcastle-Ottawa Scale for case-control studies Full size table Intensity The use of exercise intensity terminology was varied. Three studies reported moderate intensity exercise, but the description indicated it was vigorous intensity exercise. As such, it was deemed that all three studies met the criteria for vigorous intensity and were included in the systematic review and meta-analysis. In all studies, women who performed vigorous exercise were compared with those who did light or no exercise (i.e., there was no moderate intensity comparison group). Adverse events All studies were conducted in low-risk women, with exclusion criteria which included conditions such as cervical insufficiency, presence of chronic disease, or any contraindication to exercise. The five RCT’s included in this review suggest no increased risk of an adverse event occurring as a result of vigorous exercise training. The main reason was attributed to an unwillingness to participate further. However, four women in the vigorous intensity exercise group had miscarriages, and there were three miscarriages and one fetal death in utero for women in the standard care group.
As such, miscarriage and fetal death in utero was not different between the exercise and control group. Discussion The findings from the meta-analysis indicated no significant difference in birth weight from mothers who completed vigorous intensity exercise in the third trimester compared with controls. Further, no significant mean difference was observed between vigorous intensity exercise and control groups on incidence of SGA, LBW, or maternal weight gain. However, women undertaking vigorous intensity to third trimester did have a small, but significant, increase in gestational age at delivery and decreased risk of prematurity. As such, vigorous intensity exercise in the first and second trimesters can result in a healthier placenta. Indeed, the findings from this meta-analysis indicate an absence of detrimental effects of vigorous intensity exercise in the third trimester on markers which may reflect outcomes of reduced blood flow, such as incidence of SGA, LBW and prematurity. There also appeared to be no difference between groups in the women who suffered miscarriages in the RCTs. However, there is a lack of detail in the reporting of adverse events in the cohort and case-control studies, and caution is required. However, the weight loss was insufficient to be considered as a diagnosis of SGA. Notably, only one of these studies provided exercise descriptions that were considered adequate to be defined as vigorous intensity exercise. However, it would seem pertinent to suggest that women who are carrying fetuses on the lower end of the weight chart in the later stages of pregnancy should be cautious about undertaking vigorous exercise in the third trimester, as, although not significant, the pooled results from the RCTs demonstrated slightly lower birth weight than controls. Every paper reported vigorous intensity exercise in a different way, making it difficult to compare studies.
It is hard to differentiate if it is intensity, frequency, duration, or volume (total exercise workload which can be a factor of intensity, frequency and duration) of exercise sessions, that contributes to the lower birth weight reported in some of the studies. The equation for met-hours per week uses a weighting for intensities, therefore looking at volumes of exercise rather than specific intensities. However, this study found no detrimental effects of high-volume exercise on infant outcomes. Conversely, a significant increase was reported in prematurity in the very low volume exercise group. This is in line with our own findings, which found a reduction in prematurity in women undertaking vigorous intensity exercise. It is important to note that most studies in this systematic review reported intensities below 90 MHR (or equivalent). Only two of the seven athletes reached an intensity greater than 90 MHR, and in both of these athletes the mean uterine artery blood flow was less than 50 of the initial value with fetal bradycardia occurring (indicating fetal distress). However, fetal heart rate returned to normal upon cessation of the exercise. It is not clear what the long-term impact of this transient fetal bradycardia from acute strenuous exercise is. It could be that this extreme high-intensity exercise undertaken by some women is what is driving the tendency to lower birth weight in some studies. However, the results from these measures are not reported in the article. As both studies were conducted with a small sample size, the impact of exercising at levels above 90 MHR warrants further investigation. However, the purpose of this meta-analysis is to demonstrate the safety of an intensity that is likely prescribed as vigorous intensity exercise in research and clinical practice. As such, the lack of adverse events using non-pregnant vigorous intensity guidelines (i.e. the upper limit) provides reassurance of the safety of this intensity of exercise.