A comparison of cardiopulmonary adaptations to exercise in pregnancy at sea level and altitude

Environmental Exposures and Risks During Pregnancy

The Women in Wilderness Medicine Research Committee of the Wilderness Medical Society conducted a narrative review to address considerations for pregnant individuals in wilderness environments. There is limited evidence behind many opinion-based recommendations on the safety of various environmental exposures in pregnancy. The authors reviewed the literature for the best available evidence, including observational studies, case series, limited controlled trials, and extrapolation from physiological data, as well as evaluating expert consensus statements. The benefits of exposure to natural environments include better pregnancy outcomes and improved maternal mental and physical health. Risks are similar to nonpregnant individuals with the added risks associated with maternal-fetal physiology in wilderness environments and difficulties of evacuation. This narrative review discusses pregnancy-specific concerns in extreme environments, including high altitude, hypothermia, hyperthermia, lightning strikes, envenomations, and common outdoor exposures.

Pregnancy and Exercise in Mountain Travelers

ABSTRACT

Pregnant women are traveling to high altitude and evidence-based recommendations are needed. Yet, there are limited data regarding the safety of short-term prenatal high-altitude exposure. There are benefits to prenatal exercise and may be benefits to altitude exposure. Studies evaluating maternofetal responses to exercise at altitude found the only complication was transient fetal bradycardia, a finding of questionable significance. There are no published cases of acute mountain sickness in pregnant women, and data suggesting an increase in preterm labor are of poor quality. Current recommendations across professional societies are overly cautious and inconsistent. Non-evidence-based restrictions to altitude exposure can have negative consequences for a pregnant women's physical, social, mental, and economic health. Available data suggest that risks of prenatal travel to altitude are low. Altitude exposure is likely safe for women with uncomplicated pregnancies. We do not recommend absolute restrictions to high altitude exposure, but rather caution and close self-monitoring.

Can Maternal Exercise Prevent High-Altitude Pulmonary Hypertension in Children?

Leslie, Eric, Ann L. Gibson, Laura V. Gonzalez Bosc, Christine Mermier, Sean M. Wilson, and Michael R. Deyhle. Review: can maternal exercise prevent high-altitude pulmonary hypertension in children? High Alt Med Biol. 24:1-6, 2023.-Chronic high-altitude exposure reduces oxygen delivery to the fetus during pregnancy and causes pathologic pulmonary artery remodeling, This increases the risk of high-altitude pulmonary hypertension (PH), which is a particularly fatal disease that is difficult to treat. Therefore, finding ways to prevent high-altitude PH, including during the neonatal period, is preferable. Cardiorespiratory exercise can improve functional capacity and quality of life in patients with high-altitude PH. However, similar to other treatments and surgical procedures, the benefits are not enough to cure the disease after a diagnosis. Cardiorespiratory exercise by mothers during pregnancy (i.e., maternal exercise) has not been previously evaluated to prevent the development of high-altitude PH in children born and living at high altitude. This focused review describes the pathophysiology of high-altitude PH and the potential benefit of maternal exercise for preventing the disease caused by high-altitude pregnancies.

Assessment of physical fitness during pregnancy: validity and reliability of fitness tests, and relationship with maternal and neonatal health - a systematic review

Objectives

To systematically review studies evaluating one or more components of physical fitness (PF) in pregnant women, to answer two research questions: (1) What tests have been employed to assess PF in pregnant women? and (2) What is the validity and reliability of these tests and their relationship with maternal and neonatal health?

Design

A systematic review.

Data sources

PubMed and Web of Science.

Eligibility criteria

Original English or Spanish full-text articles in a group of healthy pregnant women which at least one component of PF was assessed (field based or laboratory tests).

Results

A total of 149 articles containing a sum of 191 fitness tests were included. Among the 191 fitness tests, 99 (ie, 52%) assessed cardiorespiratory fitness through 75 different protocols, 28 (15%) assessed muscular fitness through 16 different protocols, 14 (7%) assessed flexibility through 13 different protocols, 45 (24%) assessed balance through 40 different protocols, 2 assessed speed with the same protocol and 3 were multidimensional tests using one protocol. A total of 19 articles with 23 tests (13%) assessed either validity (n=4), reliability (n=6) or the relationship of PF with maternal and neonatal health (n=16).

Conclusion

Physical fitness has been assessed through a wide variety of protocols, mostly lacking validity and reliability data, and no consensus exists on the most suitable fitness tests to be performed during pregnancy.

PROSPERO registration number

CRD42018117554.

Integrative Review of Exercise at Altitude during Pregnancy

Many competitive and elite athletes continue to train throughout their pregnancies and many visit or live at altitude. The purpose of this integrative review is to synthesize, analyze and critique published studies regarding the safety of serious recreational or elite athletes exercising at altitude while pregnant. Seven databases were searched, and 157 documents were located, which were screened for appropriateness and reduced to seven articles that met the criteria. The studies were analyzed based on maternal and fetal outcomes. Current recommendations for exercising at altitude were based on sedentary individuals who frequently did not have the expected physiological responses based on research on pregnancy and altitude. It is unknown whether competitive and elite athletes would have similar responses to exercise at altitude. More research on exercise at altitude on individuals with a variety of fitness levels is needed.

The secret enemy during a flight: Economy class syndrome

Deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) are the major causes of morbidity and mortality in immobile patients. There is observational evidence that intercontinental air travel is associated with a high incidence of DVT and PTE during or within 48 hours of long-distance flights. This situation is known as the economy class syndrome and can affect both the cabin crew and passengers. The term "economy class syndrome" refers to the occurrence of thrombotic events that mainly occur in passengers in the economy class of the aircraft during long-haul flights. This syndrome results from several factors related to the aircraft cabin and the passenger, acting together to predispose to excessive blood coagulation, which can result in venous thromboembolism. In this review, we have shared the relationship between air travel and the formation of DVT and PTE.

Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804

Exercise, defined as physical activity consisting of planned, structured, and repetitive bodily movements done to improve one or more components of physical fitness, is an essential element of a healthy lifestyle, and obstetrician-gynecologists and other obstetric care providers should encourage their patients to continue or to commence exercise as an important component of optimal health. Women who habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period. Observational studies of women who exercise during pregnancy have shown benefits such as decreased gestational diabetes mellitus, cesarean birth and operative vaginal delivery, and postpartum recovery time. Physical activity also can be an essential factor in the prevention of depressive disorders of women in the postpartum period. Physical activity and exercise in pregnancy are associated with minimal risks and have been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to continue or to initiate safe physical activities. This document has been revised to incorporate recent evidence regarding the benefits and risks of physical activity and exercise during pregnancy and the postpartum period.

Cardiopulmonary exercise testing during pregnancy

The goal of this review is to examine practical considerations when conducting cardiopulmonary exercise testing during pregnancy. In a clinical and research setting, cardiopulmonary exercise testing during pregnancy is valuable in identifying underlying cardiopulmonary conditions, stratifying the risk of adverse pregnancy outcomes, as well as establishing exercise tolerance/limitations. This review encompasses information regarding the unique physiological adaptations that occur throughout gestation (e.g., changes in resting heart rate, blood pressure, glucose, etc.) and how these adaptations impact the interpretation of physiological measurements. There are also key concerns that are unique to pregnant populations that should be considered when participating in exercise (i.e., fetus, ventilation, thermoregulation, urinary incontinence, low back pain, and pelvic girdle pain). This step-by-step review of cardiopulmonary exercise testing outlines pregnancy related adjustments to standardized methods (i.e., screening/documentation, pre- and post-test measurements, protocol specifics, modality selection, and fetal monitoring) which should be considered for the safety of both the participant and fetus. Currently, pregnancy specific exercise testing guidelines are lacking. Therefore, we will be discussing the limitations of current recommendations such as a safe cut off for resting heart rate and pregnancy specific test termination criteria.

Air travel during pregnancy and the risk of adverse pregnancy outcomes as gestational age and weight at birth: A retrospective study among 284,069 women in Israel between the years 2000 to 2016

Objective

The American College of Gynecology (ACOG) recommendation does not limit air travel during pregnancy, yet the evidence for air travel effect on adverse pregnancy outcomes is limited and debatable. Study objectives were to examine the association between air travel during pregnancy and preterm birth together with decreased birth weight.

Study design

A retrospective cohort study.

Methods

The study evaluated 628,292 women who gave birth to singleton infants from 9/2000 to 9/2016 and classified them into “air travel during pregnancy” or not, based on flight insurance as proxy. Multiple linear regression models were utilized to examine the relationship between air travel during pregnancy and newborn's gestational age and birth weight, while accounting for socioeconomic status, diabetes, high-risk pregnancies, and smoking.

Results

A total of 41,677 (6.6%) births of women who air traveled during pregnancy was included, and 586,615 (93.4%) births of women who did not. Air travel during pregnancy was associated with a statistically significant (p<0.0001) but negligible increase in birth weight (9 gr. 95% CI: 4.8 to 14.5 gr.) and gestational age (0.36 days. 95% CI: 0.24–0.48).

Conclusion

The study results provide no evidence that air travel during pregnancy is related to adverse effects on gestational age or birth weight. These findings corroborate the current recommendations of ACOG.

ACOG Committee Opinion No. 746: Air Travel During Pregnancy

In the absence of obstetric or medical complications, occasional air travel is safe for pregnant women. Pregnant women can fly safely, observing the same precautions for air travel as the general population. Because severe air turbulence cannot be predicted and the subsequent risk for trauma is significant should this occur, pregnant women should be instructed to use their seat belts continuously while seated. Despite a lack of evidence associating lower extremity edema and venous thrombotic events with air travel during pregnancy, certain preventive measures can be used to minimize these risks, including use of support stockings and periodic movement of the lower extremities, avoidance of restrictive clothing, occasional ambulation, and maintenance of adequate hydration. For most air travelers, the risks to the fetus from exposure to cosmic radiation are negligible. However, aircrew or frequent flyers may exceed these limits. The Federal Aviation Administration and the International Commission on Radiological Protection consider aircrew to be occupationally exposed to ionizing radiation and recommend that they be informed about radiation exposure and health risks.

2019 Canadian guideline for physical activity throughout pregnancy

The objective is to provide guidance for pregnant women and obstetric care and exercise professionals on prenatal physical activity. The outcomes evaluated were maternal, fetal or neonatal morbidity, or fetal mortality during and following pregnancy. Literature was retrieved through searches of MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection, CINAHL Plus with Full Text, Child Development & Adolescent Studies, Education Resources Information Center, SPORTDiscus, ClinicalTrials.gov and the Trip Database from inception up to 6 January 2017. Primary studies of any design were eligible, except case studies. Results were limited to English-language, Spanish-language or French-language materials. Articles related to maternal physical activity during pregnancy reporting on maternal, fetal or neonatal morbidity, or fetal mortality were eligible for inclusion. The quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation methodology. The Guidelines Consensus Panel solicited feedback from end users (obstetric care providers, exercise professionals, researchers, policy organisations, and pregnant and postpartum women). The development of these guidelines followed the Appraisal of Guidelines for Research and Evaluation II instrument. The benefits of prenatal physical activity are moderate and no harms were identified; therefore, the difference between desirable and undesirable consequences (net benefit) is expected to be moderate. The majority of stakeholders and end users indicated that following these recommendations would be feasible, acceptable and equitable. Following these recommendations is likely to require minimal resources from both individual and health systems perspectives.

Effects of prenatal exercise on fetal heart rate, umbilical and uterine blood flow: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis examining the influence of acute and chronic prenatal exercise on fetal heart rate (FHR) and umbilical and uterine blood flow metrics.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Online databases were searched up to 6 January 2017.

STUDY ELIGIBILITY CRITERIA

Studies of all designs were included (except case studies) if published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcomes (FHR, beats per minute (bpm); uterine and umbilical blood flow metrics (systolic:diastolic (S/D) ratio; Pulsatility Index (PI); Resistance Index (RI); blood flow, mL/min; and blood velocity, cm/s)).

RESULTS

'Very low' to 'moderate' quality evidence from 91 unique studies (n=4641 women) were included. Overall, FHR increased during (mean difference (MD)=6.35bpm; 95% CI 2.30 to 10.41, I²=95%, p=0.002) and following acute exercise (MD=4.05; 95% CI 2.98 to 5.12, I²=83%, p<0.00001). The incidence of fetal bradycardia was low at rest and unchanged with acute exercise. There were no significant changes in umbilical or uterine S/D, PI, RI, blood flow or blood velocity during or following acute exercise sessions. Chronic exercise decreased resting FHR and the umbilical artery S/D, PI and RI at rest.

CONCLUSION

Acute and chronic prenatal exercise do not adversely impact FHR or uteroplacental blood flow metrics.

N° 367-2019 Lignes Directrices Canadiennes Sur L'activité Physique Durant La Grossesse

OBJECTIF

L'objectif est de guider les femmes enceintes et les professionnels de l'obstétrique et de l'exercice en ce qui concerne l'activité physique prénatale. RéSULTATS: Les issues évaluées étaient la morbidité maternelle, fœtale ou néonatale et la mortalité fœtale pendant et après la grossesse. DONNéES: Nous avons interrogé MEDLINE, Embase, PsycINFO, la Cochrane Database of Systematic Reviews, le Cochrane Central Register of Controlled Trials, Scopus et la Web of Science Core Collection, CINAHL Plus with Full Text, Child Development & Adolescent Studies, ERIC, SPORTDiscus, ClinicalTrials.gov de leur création jusqu'au 6 janvier 2017. Les études primaires de tous types étaient admissibles, à l'exception des études de cas. Seules les publications en anglais, en espagnol et en français ont été retenues. Les articles liés à l'activité physique durant la grossesse qui abordaient la morbidité maternelle, fœtale ou néonatale ou la mortalité fœtale étaient admissibles. La qualité des données probantes a été évaluée au moyen de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation).

VALEURS

Le groupe d'experts responsable des lignes directrices a recueilli les commentaires d'utilisateurs finaux (fournisseurs de soins obstétricaux, professionnels de l'exercice, chercheurs, organismes responsables de politiques, et femmes enceintes et en période postpartum). La directive clinique a été élaborée au moyen de l'outil Appraisal of Guidelines for Research Evaluation (AGREE) II. AVANTAGES, INCONVéNIENTS, ET COûTS: Les avantages de l'activité physique prénatale sont modérés, et aucun inconvénient n'a été relevé; la différence entre les conséquences désirables et indésirables (avantage net) devrait donc être modérée. La majorité des intervenants et des utilisateurs finaux ont indiqué qu'il serait faisable, acceptable et équitable de suivre ces recommandations, qui nécessitent généralement des ressources minimes de la part des personnes et des systèmes de santé. PRÉAMBULE: Les présentes lignes directrices contiennent des recommandations fondées sur des données probantes au sujet de l'activité physique durant la grossesse visant à favoriser la santé maternelle, fœtale et néonatale. En l'absence de contre-indications (voir la liste détaillée plus loin), le fait de suivre ces lignes directrices est associé à : 1) moins de complications pour le nouveau-né (p. ex., gros par rapport à l'âge gestationnel); et 2) des bienfaits pour la santé maternelle (p. ex., diminution du risque de prééclampsie, d'hypertension gravidique, de diabète gestationnel, de césarienne, d'accouchement opératoire, d'incontinence urinaire, de gain de poids excessif durant la grossesse et de dépression; amélioration de la glycémie; diminution du gain de poids total durant la grossesse; et diminution de la gravité des symptômes dépressifs et de la douleur lombo-pelvienne). L'activité physique n'est pas associée à la fausse couche, à la mortinaissance, au décès néonatal, à l'accouchement prématuré, à la rupture prématurée préterme des membranes, à l'hypoglycémie néonatale, au poids insuffisant à la naissance, aux anomalies congénitales, au déclenchement du travail, ou aux complications à la naissance. En général, une augmentation de l'activité physique (fréquence, durée ou volume) est liée à une augmentation des bienfaits. Cependant, nous n'avons pas trouvé de données probantes concernant l'innocuité ou l'avantage accru de l'exercice à des niveaux considérablement supérieurs aux recommandations. L'activité physique prénatale devrait être vue comme un traitement de première ligne pour réduire le risque de complications de la grossesse et améliorer la santé physique et mentale de la mère. Pour les femmes enceintes qui n'atteignent actuellement pas le niveau recommandé, nous recommandons une augmentation progressive pour l'atteindre. Les femmes déjà actives peuvent continuer de l'être tout au long de la grossesse. Elles pourraient devoir modifier le type d'activité à mesure que leur grossesse avance. Il peut devenir impossible de suivre les lignes directrices pendant certaines périodes en raison de la fatigue ou des inconforts de la grossesse; nous encourageons les femmes à faire ce qu'elles peuvent et à revenir aux recommandations lorsqu'elles en sont capables. Les recommandations qui suivent reposent sur une revue systématique approfondie de la littérature, l'opinion d'experts, la consultation d'utilisateurs finaux et des considérations de faisabilité, d'acceptabilité, de coût et d'équité.

RECOMMANDATIONS

Les recommandations des Lignes directrices canadiennes sur l'activité physique durant la grossesse 2019 sont fournies ci-dessous avec des énoncés indiquant la qualité des données probantes utilisées et la force des recommandations (des explications suivent).

CONTRE-INDICATIONS

Toutes les femmes enceintes peuvent faire de l'activité physique durant la grossesse, sauf celles qui présentent des contre-indications (voir ci-dessous). Celles présentant des contre-indications absolues peuvent poursuivre leurs activités quotidiennes habituelles, mais ne devraient pas faire d'activités plus vigoureuses. Celles présentant des contre-indications relatives devraient discuter des avantages et des inconvénients de l'activité physique d'intensité modérée à vigoureuse avec leur fournisseur de soins obstétricaux avant d'y prendre part.

CONTRE-INDICATIONS ABSOLUES

Contre-indications relatives  FORCE DES RECOMMANDATIONS: Nous avons utilisé le système GRADE pour évaluer la force des recommandations. Les recommandations sont jugées fortes ou faibles en fonction de : 1) l'équilibre entre les avantages et les inconvénients; 2) la qualité globale des données probantes; 3) l'importance des issues (valeurs et préférences des femmes enceintes); 4) l'utilisation de ressources (coût); 5) l'incidence sur l'équité en matière de santé; 6) la faisabilité et 7) l'acceptabilité. Recommandation forte : La majorité ou la totalité des femmes enceintes auraient avantage à suivre la recommandation. Recommandation faible : Les femmes enceintes n'auraient pas toutes avantage à suivre la recommandation; il faut tenir compte d'autres facteurs comme la situation, les préférences, les valeurs, les ressources et le milieu de chaque personne. La consultation d'un fournisseur de soins obstétricaux peut faciliter la prise de décisions. QUALITé DES DONNéES PROBANTES: La qualité des données probantes fait référence au degré de confiance dans les données et va de très faible à élevée. Qualité élevée : Le groupe d'experts responsable des lignes directrices est très convaincu que l'effet estimé de l'activité physique sur l'issue de santé est près de l'effet réel. Qualité moyenne : Le groupe d'experts responsable des lignes directrices a moyennement confiance en l'effet estimé de l'activité physique sur l'issue de santé; l'effet estimé est probablement près de l'effet réel, mais il est possible qu'il soit très différent. Qualité faible : Le groupe d'experts responsable des lignes directrices a peu confiance en l'effet estimé de l'activité physique sur l'issue de santé; l'effet estimé pourrait être très différent de l'effet réel. Qualité très faible : Le groupe d'experts responsable des lignes directrices a très peu confiance en l'effet estimé de l'activité physique sur l'issue de santé; l'effet estimé est probablement très différent de l'effet réel. ^a Il s'agit d'une recommandation faible parce que la qualité des données probantes était faible et que l'avantage net entre les femmes qui étaient physiquement actives et celles qui ne l'étaient pas était petit. ^b Il s'agit d'une recommandation forte parce que, malgré le fait que les données probantes appuyant l'activité physique durant la grossesse pour les femmes en surpoids ou obèses étaient de qualité faible, des données tirées d'essais cliniques randomisés démontraient une diminution du gain de poids durant la grossesse et une amélioration de la glycémie. ^c On parle d'intensité modérée lorsque l'activité est assez intense pour augmenter la fréquence cardiaque de façon perceptible; une personne peut parler, mais pas chanter durant les activités de cette intensité. Pensons par exemple à la marche rapide, à la gymnastique aquatique, au vélo stationnaire (effort modéré), à l'entraînement musculaire, au port de charges modérées et aux travaux ménagers (p. ex., jardinage, lavage de fenêtres). ^d Il s'agit d'une recommandation faible parce que l'incontinence urinaire n'était pas jugée comme étant une issue « critique » et que les données étaient de qualité faible. ^e Il s'agit d'une recommandation faible parce que : 1) la qualité des données probantes était très faible; et 2) bien que nous ayons étudié les inconvénients, il y avait peu de renseignements disponibles sur l'équilibre entre les avantages et les inconvénients. Cette recommandation était principalement fondée sur l'opinion d'experts.

No. 367-2019 Canadian Guideline for Physical Activity throughout Pregnancy

OBJECTIVE

The objective is to provide guidance for pregnant women, and obstetric care and exercise professionals, on prenatal physical activity.

OUTCOMES

The outcomes evaluated were maternal, fetal, or neonatal morbidity or fetal mortality during and following pregnancy.

EVIDENCE

Literature was retrieved through searches of Medline, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection, CINAHL Plus with Full-text, Child Development & Adolescent Studies, ERIC, Sport Discus, ClinicalTrials.gov, and the Trip Database from database inception up to January 6, 2017. Primary studies of any design were eligible, except case studies. Results were limited to English, Spanish, or French language materials. Articles related to maternal physical activity during pregnancy reporting on maternal, fetal, or neonatal morbidity or fetal mortality were eligible for inclusion. The quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

VALUES

The Guidelines Consensus Panel solicited feedback from end-users (obstetric care providers, exercise professionals, researchers, policy organizations, and pregnant and postpartum women). The development of this guideline followed the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument.

BENEFITS, HARMS, AND COSTS

The benefits of prenatal physical activity are moderate, and no harms were identified; therefore, the difference between desirable and undesirable consequences (net benefit) is expected to be moderate. The majority of stakeholders and end-users indicated that following these recommendations would be feasible, acceptable, and equitable. Following these recommendations is likely to require minimal resources from both individual and health systems perspectives.

PREAMBLE

This guideline provide evidence-based recommendations regarding physical activity throughout pregnancy in the promotion of maternal, fetal, and neonatal health. In the absence of contraindications (see later for a detailed list), following this guideline is associated with: (1) fewer newborn complications (i.e., large for gestational age); and (2) maternal health benefits (i.e., decreased risk of preeclampsia, gestational hypertension, gestational diabetes, Caesarean section, instrumental delivery, urinary incontinence, excessive gestational weight gain, and depression; improved blood glucose; decreased total gestational weight gain; and decreased severity of depressive symptoms and lumbopelvic pain). Physical activity is not associated with miscarriage, stillbirth, neonatal death, preterm birth, preterm/prelabour rupture of membranes, neonatal hypoglycemia, low birth weight, birth defects, induction of labour, or birth complications. In general, more physical activity (frequency, duration, and/or volume) is associated with greater benefits. However, evidence was not identified regarding the safety or additional benefit of exercising at levels significantly above the recommendations. Prenatal physical activity should be considered a front-line therapy for reducing the risk of pregnancy complications and enhancing maternal physical and mental health. For pregnant women not currently meeting this guideline, a progressive adjustment toward them is recommended. Previously active women may continue physical activity throughout pregnancy. Women may need to modify physical activity as pregnancy progresses. There may be periods when following the guideline is not possible due to fatigue and/or discomforts of pregnancy; women are encouraged to do what they can and to return to following the recommendations when they are able. This guideline were informed by an extensive systematic review of the literature, expert opinion, end-user consultation and considerations of feasibility, acceptability, costs, and equity.

RECOMMENDATIONS

The specific recommendations in this 2019 Canadian Guideline for Physical Activity Throughout Pregnancy are provided below with corresponding statements indicating the quality of the evidence informing the recommendations and the strength of the recommendations (explanations follow).

CONTRAINDICATIONS

All pregnant women can participate in physical activity throughout pregnancy with the exception of those who have contraindications (listed below). Women with absolute contraindications may continue their usual activities of daily living but should not participate in more strenuous activities. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider prior to participation. Absolute contraindications to exercise are the following: Relative contraindications to exercise are the following: STRENGTH OF THE RECOMMENDATIONS: The GRADE system was utilized to grade the strength of the recommendations. Recommendations are rated as strong or weak based on the: (1) balance between benefits and harms; (2) overall quality of the evidence; (3) importance of outcomes (i.e., values and preferences of pregnant women); (4) use of resources (i.e., cost); (5) impact on health equity; (6) feasibility, and (7) acceptability. Strong recommendation: Most or all pregnant women will be best served by the recommended course of action. Weak recommendation: Not all pregnant women will be best served by the recommended course of action; there is a need to consider other factors such as the individual's circumstances, preferences, values, resources available, or setting. Consultation with an obstetric care provider may assist in decision-making.

QUALITY OF THE EVIDENCE

The quality of the evidence refers to the level of confidence in the evidence and ranges from very low to high. High quality: The Guideline Consensus Panel is very confident that the estimated effect of physical activity on the health outcome is close to the true effect. Moderate quality: The Guideline Consensus Panel is moderately confident in the estimated effect of physical activity on the health outcome; the estimate of the effect is likely to be close to the true effect, but there is a possibility that it is substantially different. Low quality: The Guideline Consensus Panel's confidence in the estimated effect of physical activity on the health outcome is limited; the estimate of the effect may be substantially different from the true effect. Very low quality: The Guideline Consensus Panel has very little confidence in the estimated effect of physical activity on the health outcome; the estimate of the effect is likely to be substantially different from the true effect. ^aThis was a weak recommendation because the quality of evidence was low, and the net benefit between women who were physically active and those who were not was small. ^bThis was a strong recommendation because, despite low quality evidence supporting physical activity during pregnancy for women categorized as overweight or obese, there was evidence from randomized controlled trials demonstrating an improvement in gestational weight gain and blood glucose. ^cModerate-intensity physical activity is intense enough to noticeably increase heart rate; a person can talk but not sing during activities of this intensity. Examples of moderate-intensity physical activity include brisk walking, water aerobics, stationary cycling (moderate effort), resistance training, carrying moderate loads, and household chores (e.g., gardening, washing windows). ^dThis was a weak recommendation because urinary incontinence was was not rated as a "critical" outcome and the evidence was low quality. ^eThis was a weak recommendation because: (1) the quality of evidence was very low; and (2) although harms were investigated there was limited available information to inform the balance of benefits and harms. This recommendation was primarily based on expert opinion.

Economy class syndrome: what is it and who are the individuals at risk?

The term ‘economy class syndrome’ refers to the occurrence of thrombotic events during long-haul flights that mainly occur in passengers in the economy class of the aircraft. This syndrome results from several factors related to the aircraft cabin (immobilization, hypobaric hypoxia and low humidity) and the passenger (body mass index, thrombophilia, oral contraceptives or hormone replacement therapy, cancer), acting together to predispose to excessive blood coagulation, which can result in venous thromboembolism. Several risk factors, both genetic and acquired, are associated with venous thromboembolism. The most important genetic risk factors are natural anticoagulant deficiencies (antithrombin, protein C and protein S), factor V Leiden, prothrombin and fibrinogen gene mutations and non-O blood group individuals. Acquired risk factors include age, pregnancy, surgery, obesity, cancer, hormonal contraceptives and hormone replacement therapy, antiphospholipid syndrome, infections, immobilization and smoking. People who have these risk factors are predisposed to hypercoagulability and are more susceptible to suffer venous thromboembolism during air travel. For these individuals, a suitable outfit for the trip, frequent walks, calf muscle exercises, elastic compression stockings and hydration are important preventive measures. Hence, it is essential to inform about economic class syndrome in an attempt to encourage Brazilian health and transport authorities to adopt measures, in partnership with the pharmaceutical industry, to prevent venous thromboembolism.

Outdoor Activity and High Altitude Exposure During Pregnancy: A Survey of 459 Pregnancies

OBJECTIVE

To evaluate whether women engage in outdoor activities and high altitude travel during pregnancy; the health care advice received regarding high altitude during pregnancy; and the association between high altitude exposure and self-reported pregnancy complications.

METHODS

An online survey of women with at least 1 pregnancy distributed on websites and e-mail lists targeting mothers and/or mountain activities. Outcome measures were outdoor activities during pregnancy, high altitude (>2440 m) exposure during pregnancy, and pregnancy and perinatal complications.

RESULTS

Hiking, running, and swimming were the most common activities performed during pregnancy. Women traveled to high altitude in over half of the pregnancies (244/459), and most did not receive counseling regarding altitude (355, 77%), although a small proportion (14, 3%) were told not to go above 2440 m. Rates of miscarriage and most other complications were similar between pregnancies with and without travel above 2440 m. Pregnancies with high altitude exposure were more likely to have preterm labor (odds ratio [OR] 2.3; 95% CI 0.97-5.4; P = .05). Babies born to women who went to high altitude during pregnancy were more likely to need oxygen at birth (OR 2.34; 95% CI 1.04-5.26; P < .05) but had similar rates of neonatal intensive care unit admission (P = not significant).

CONCLUSIONS

Our results suggest pregnant women who are active in outdoor sports and travel to high altitude have a low rate of complications. Given the limitations of our data, further research is necessary on the risks associated with high altitude travel and physical activity and how these apply to the general population.

Travel During Pregnancy: Considerations for the Obstetric Provider

Importance

Travel among US citizens is becoming increasingly common, and travel during pregnancy is also speculated to be increasingly common. During pregnancy, the obstetric provider may be the first or only clinician approached with questions regarding travel.

Objective

In this review, we discuss the reasons women travel during pregnancy, medical considerations for long-haul air travel, destination-specific medical complications, and precautions for pregnant women to take both before travel and while abroad. To improve the quality of pretravel counseling for patients before or during pregnancy, we have created 2 tools: a guide for assessing the pregnant patient's risk during travel and a pretravel checklist for the obstetric provider.

Evidence Acquisition

A PubMed search for English-language publications about travel during pregnancy was performed using the search terms "travel" and "pregnancy" and was limited to those published since the year 2000. Studies on subtopics were not limited by year of publication.

Results

Eight review articles were identified. Three additional studies that analyzed data from travel clinics were found, and 2 studies reported on the frequency of international travel during pregnancy. Additional publications addressed air travel during pregnancy (10 reviews, 16 studies), high-altitude travel during pregnancy (5 reviews, 5 studies), and destination-specific illnesses in pregnant travelers.

Conclusions and Relevance

Travel during pregnancy including international travel is common. Pregnant travelers have unique travel-related and destination-specific risks. We review those risks and provide tools for obstetric providers to use in counseling pregnant travelers.

Adaptation of Maternal-Fetal Physiology to Exercise in Pregnancy: The Basis of Guidelines for Physical Activity in Pregnancy

Only 50 years ago obstetric care providers and women had many concerns regarding whether exercise during pregnancy created a harmful competition for substrate resources between the fetus and the mother. Animal and human research in the past 50 years, which includes acute and chronic aerobic exercise during pregnancy, has a reassuring margin of safety throughout gestation in women. Maternal physiology adapts to pregnancy changes involving the cardiorespiratory and glucometabolic alterations. Due to these changes, pregnant women have slight differences in response to acute exercise sessions. Chronic exposure to aerobic exercise before and during pregnancy is associated with numerous maternal and neonatal adaptations which may have short- and long-term benefits to maternal and child health. On the basis of the consistent evidence of safety of exercise during pregnancy, multiple nations and health care organizations, including the American College of Obstetrics and Gynecology, recommend moderate exercise for 20 to 30 minutes most days of the week. Despite the 15 to 20 years since the first recommendations were made, only 10% to 15% of pregnant women meet this recommendation. It seems there may be 2 foci for failure to achieve these exercise recommendations: patient specific and culturally driven and/or obstetric provider not recommending regular exercise due to lack of knowledge or motivation. This article addresses the provider knowledge by a review of the normal (at rest) physiologic adaptation to pregnancy. Then, we provide a detailed description of the type and intensity of controlled experiments that document the safety of exercise during pregnancy. The short- and long-term benefits are reviewed, including the safety in moderate-risk women.

Travel to high altitude during pregnancy: frequently asked questions and recommendations for clinicians

The effects of altitude on pregnancy have been extensively studied in high altitude residents, but there is a lack of knowledge concerning the pregnant altitude visitor. Exposure to hypoxia results in physiologic responses which act to preserve maternal and fetal oxygenation. However, these reactions are limited and maternal/fetal complications may be observed, especially in association with exercise. Certain pre-existing conditions or risk factors of hypertension/preeclampsia and/or fetal growth restriction are contra-indications for traveling to high altitude, especially after 20 weeks. The acclimatization process has to be respected to avoid acute mountain sickness without taking drugs, and at least a few days of acclimatization are required before exercising.

A literature review of air medical work hazards and pregnancy

An increased percentage of miscarriages among coworkers at one air medical transport company in 2008 prompted a literature review of selected hazards relevant to the profession of rotor wing air medical flight crew. Because of a lack of known research specific to this population, relevant studies from 1990 to 2008 were chosen to investigate pregnancy risks associated with exposure to vibration, jet fuel, noise, altitude, and fatigue in other occupations. Findings were summarized and recommendations made for future research.

Adverse outcome of pregnancy following air travel: A myth or a concern?

OBJECTIVE

To assess whether air travel elevates the risk of adverse pregnancy outcomes in essentially healthy women with single non-anomalous fetuses at a gestational age greater than 20 weeks.

METHODS

A retrospective analysis of air travel during the current pregnancy and pregnancy outcome was undertaken in 992 women admitted for delivery over a 12-month period. The study group of 546 (55%) women, of whom 57% were primigravidae, travelled at least once during pregnancy, and were compared with a control group of 447 women (45%), of whom 54% were primigravidae, who did not travel by air.

RESULTS

The primigravidae in the study group showed an increased risk of preterm birth, and this risk was statistically significant between the gestations of 34 and 37 weeks (adjusted odds ratio 1.5, 95% confidence intervals 1.2, 1.8); this risk remained elevated after adjustment for covariates. These women's pregnancies were appreciably shorter than those of primigravidae who did not fly (36.1 +/- 0.8 vs. 39.2 +/- 2.1 weeks) and their babies had lower birthweights (2684 +/- 481 vs. 3481 +/- 703 g). and were more likely to be admitted to the neonatal intensive care unit. This group of air travellers is unusual for the uncommonly long and frequent duration of air travel, which is not routinely undertaken in most parts of the world. There were no thromboembolic events complicating any pregnancies.

CONCLUSIONS

Primigravid women who travel by air appear to be at higher risk for preterm birth. Multicentre large studies are required to confirm or repute these findings.

Physiological Basis for Recommendations Regarding Exercise during Pregnancy at High Altitude

Although exercise during pregnancy has been shown to be safe and is now recommended by the American College of Obstetricians and Gynecologists and the Society of Obstetricians and Gynaecologists of Canada for all healthy women, little is known about the combined effects of high altitude and exercise during pregnancy. Due to a paucity of experimental data, recommendations regarding exercise during pregnancy at elevations >/=1600 m must be based on synthesis of available information regarding the independent effects of high altitude and exercise on uteroplacental oxygen delivery. Maternal hyperventilation and elevated blood hemoglobin concentration maintain resting arterial oxygen content at or above sea-level values. During exercise, however, arterial hemoglobin saturation falls, lowering the oxygen content. Resting uterine artery blood flow is lower in residents at 3100 m than at 1600 m, and flow is likely to decrease further during exercise, in proportion to the intensity and duration. The combined reduction in arterial oxygen content and uterine artery flow suggest that fetal oxygen delivery is compromised during exercise at altitude. Anemia, which should be defined according to altitude-adjusted criteria, will further diminish oxygen delivery. Clinicians may wish to monitor patient hemoglobin concentration more frequently and adopt a more conservative stance regarding exercise during pregnancy for both residents and visitors of altitudes >/=1600 m.

Exercise during pregnancy and the postpartum period

The physiologic and morphologic changes of pregnancy may interfere with the ability to engage safely in some forms of physical activity. A woman's overall health, including obstetric and medical risks, should be evaluated before prescribing an exercise program. Generally, participation in a wide range of recreational activities appears to be safe during pregnancy; however, each sport should be reviewed individually for its potential risk, and activities with a high risk of falling or those with a high risk of abdominal trauma should be avoided during pregnancy. Scuba diving also should be avoided throughout pregnancy because the fetus is at an increased risk for decompression sickness during this activity. In the absence of either medical or obstetric complications, 30 minutes or more of moderate exercise a day on most, if not all, days of the week is recommended for pregnant women.

ACOG committee opinion. Exercise during pregnancy and the postpartum period. Number 267, January 2002. American College of Obstetricians and Gynecologists

The physiologic and morphologic changes of pregnancy may interfere with the ability to engage safely in some forms of physical activity. A woman's overall health, including obstetric and medical risks, should be evaluated before prescribing an exercise program. Generally, participation in a wide range of recreational activities appears to be safe during pregnancy; however, each sport should be reviewed individually for its potential risk, and activities with a high risk of abdominal trauma should be avoided during pregnancy. Scuba diving also should be avoided throughout pregnancy because the fetus is at an increased risk for decompression sickness during this activity. In the absence of either medical or obstetric complications, 30 minutes or more of moderate exercise a day on most, if not all, days of the week is recommended for pregnant women.

ACOG committee opinion. Air travel during pregnancy

In the absence of obstetric or medical complications, pregnant women can observe the same general precautions for air travel as the general population and can fly safely up to 36 weeks of gestation. In-craft environmental conditions, such as low cabin humidity and changes in cabin pressure, coupled with the physiologic changes of pregnancy, do result in maternal adaptations, which could have transient effects on the fetus. Pregnant air travelers with medical problems that may be exacerbated by a hypoxic environment, but who must travel by air, should be prescribed supplemental oxygen during air travel. Pregnant women at significant risk for preterm labor or with placental abnormalities should avoid air travel. Because air turbulence cannot be predicted and the risk for trauma is significant, pregnant women should be instructed to continuously use their seat belts while seated, as should all air travelers. Pregnant air travelers may take precautions to ease in-flight discomfort, and although no hard evidence exists, preventive measures can be employed to minimize risks.

Exercise during pregnancy. A clinical update

Research dealing with exercise during pregnancy continues to demonstrate marked benefits for mother and fetus. The type, intensity, frequency, and duration of the exercise seem to be important determinants of its beneficial effects. Maternal benefits include improved cardiovascular function, limited weight gain and fat retention, improved attitude and mental state, easier and less complicated labor, quick recovery, and improved fitness. Fetal benefits may include decreased growth of the fat organ, improved stress tolerance, and advanced neurobehavioral maturation. Currently, the offspring are leaner at 5 years of age and have a slightly better neurodevelopmental outcome. Postpubertal effects are still unknown. In the absence of medical contraindications, women should be encouraged to maintain their prepregnancy activity level.

The pregnant altitude visitor

The human fetus develops normally under low-oxygen conditions. Exposure of a pregnant woman to the hypoxia of high altitude results in acclimatization responses which act to preserve the fetal oxygen supply. The fetus also utilizes several compensatory mechanisms to survive brief periods of hypoxia. While fetal heart rate monitoring data during air travel suggest no compromise of fetal oxygenation, exercise at high altitude may place further stress on oxygen delivery to the fetus. The limited data on maternal exercise at high altitude suggest good tolerance in most pregnancies; however, short-term abnormalities in fetal heart rate and subsequent pregnancy complications have been observed, as well. A survey of Colorado obstetrical care providers yielded consensus that preterm labor and bleeding complications of pregnancy are the most commonly encountered pregnancy complications among high-altitude pregnant visitors. Dehydration, engaging in strenuous exercise before acclimatization, and participation in activities with high risk of trauma are behaviors that may increase the risk of pregnancy complications. Medical and obstetrical conditions which impair oxygen transfer at any step between the environment and fetal tissue may compromise fetal oxygenation. Knowledge of the medical, obstetrical, and behavioral risk factors during pregnancy at high altitude can help the pregnant visitor to high altitude avoid such complications.

Exercise during pregnancy: safe and beneficial for most

Regular, moderate exercise does not significantly affect length of gestation or birth weight, and it may ease pregnancy and labor. Active pregnant women should maintain adequate hydration and nutrition, avoid hyperthermia, and take precautions if obstetric or medical complications are present. Supine exercise, contact sports, high-altitude exertion, and scuba diving should be avoided, and some women, including those who lift weights or do high-impact exercise, may need to modify their routines. Most women can begin or continue to exercise during pregnancy.

Physical activity at altitude in pregnancy

Advice to pregnant women wishing to exercise at altitude is based only on isolated observations and a handful of systematic studies, none of which have explored the limits of combined exercise and altitude exposure in human pregnancy (ie, at maximal exercise and maximal altitude). Guidelines must therefore be based on a variety of sources, including the physiology of permanent residence at high altitude, in particular the degree of (and hence requirement for) adaptations specific to pregnancy over and above simple altitude acclimatization, and data from the few systematic studies in human pregnancy under conditions of short-term altitude exposure with or without exercise. Because the effects of altitude and exercise may be synergistic rather than additive, and because individual altitude tolerance and exercise capacity cannot be reliably determined at sea level, advice should err on the side of caution by not allowing for the substantial safety margins by which pregnancies are probably protected. An altitude of 2,500 m (8,250 ft) should not be exceeded in the first 4 to 5 days of short-term exposure. If exercise is performed directly after exposure, this should take place at correspondingly lower altitude, especially in the first few days. Compounding risks, eg, maternal smoking, anemia or fetal growth retardation, must be carefully excluded.

Physical activity and the risk of preterm labor: an epidemiological review and synthesis of recent literature

Considerable recent research effort of physical activity and pregnancy has included evaluation of preterm labor, preterm delivery, and gestational age at delivery. This review specifically evaluates recent studies that included such assessments of gestational parameters. Methodological difficulties (eg, small sample size, selective clinical populations) have prevented clear generalizable findings regarding the impact of physical activity on preterm labor and delivery. The outcomes evaluated are often times not similar from study to study and, with the associated differences in research design, prevent valid meta-analyses of this topic. Because there is some evidence that gestation and birthweight may decrease among physically active women, larger-scale, randomized clinical trials designed specifically to evaluate whether this association is simply a minor change in gestation and birthweight, or if this difference is manifested clinically in higher rates of preterm labor and delivery and low birthweight, are warranted. Without larger, population-based randomized studies, clinicians will remain unclear about the potential risks and/or benefits related to gestational duration of maternal exercise in their populations.

Applications of methods and techniques in the study of aerobic fitness during pregnancy

This article is a critical review of the general principles of exercise physiology and their relevance in pregnancy. An overview of the published studies and their conclusions are provided.

Cardiovascular responses to aerobic exercise during pregnancy and postpartum

The many physiological and hormonal changes occurring during pregnancy have the potential to affect a woman's cardiovascular responses to aerobic exercise. For example, it seems that increased mass and dilation of the left ventricle allow maintenance of wall stress, ensuring adequate pumping function throughout gestation. Also, a woman's cardiac output response to exercise is typically increased during pregnancy, owing to alterations in both heart rate and stroke volume. However, mean arterial pressure response is not usually affected by pregnancy because the increased blood flow to the uteroplacental unit, skin, and kidneys results in a concomitant decrease in systemic vascular resistance. It should be noted that there is no clear agreement on the mechanisms behind hemodynamic responses to exercise throughout gestation. Indeed, a pregnant woman's cardiac output during physical activity may be affected by (1) gestational age, (2) body position, (3) exercise intensity and modality, and (4) fitness level.