Supervised exercise-based intervention to prevent excessive gestational weight gain: a randomized controlled trial

Healthcare Professionals' Beliefs and Views towards Exercise during Pregnancy: A Cross-Sectional Study in Greece

BACKGROUND

Healthcare professionals appear to play a key role in shaping pregnant women's views and attitudes towards lifestyle issues, such as exercise. The aim of this study is to investigate the views and beliefs of Greek midwives and obstetricians regarding exercise during pregnancy.

METHODS

This is a cross-sectional study conducted during the period of January 2022-March 2023. For this study, 237 Greek midwives and obstetricians employed in healthcare settings in Attica, Greece completed an anonymous and self-report questionnaire. Four different/independent models of multivariate analyses of variance were conducted.

RESULTS

The vast majority of these healthcare professionals (88.6%) believed that exercise during pregnancy is generally beneficial. According to the multivariate analyses, healthcare professionals with postgraduate/doctoral studies were more likely to believe that (a) exercise is generally beneficial (p = 0.03), (b) pregnant women should be informed about it (p = 0.028), (c) informing pregnant women is necessary/useful (p = 0.023), and (d) pregnant women showed interest in it (p = 0.034). Also, freelance midwives were more likely to believe that pregnant women should be informed about exercise (p = 0.006), and that they showed interest in it (p = 0.034). In addition, (a) freelance midwives (p = 0.050), and those who had experience in antenatal counselling (p = 0.037), as well as (b) obstetricians who were largely experienced in monitoring normal pregnancies (p = 0.001), were less likely to associate exercise during pregnancy with the occurrence of placental abruption.

CONCLUSION

Alongside healthcare professionals' educational level, their professional setting and professional experience emerge as key factors and need to be considered when designing innovative interventions to support exercise during pregnancy.

Rethinking causal assumptions about maternal BMI, gestational weight gain, and adverse pregnancy outcomes

BACKGROUND

The aim of this study was to evaluate commonly assumed causal relationships between body mass index (BMI), gestational weight gain (GWG), and adverse pregnancy outcomes, which have formed the basis of guidelines and interventions aimed at limiting GWG in women with overweight or obesity. We explored relationships between maternal BMI, total GWG (as a continuous variable and as 'excessive' GWG), and pregnancy outcomes (including infant birthweight measures and caesarean birth).

METHODS

Analysis of individual participant data (IPD) from the i-WIP (International Weight Management in Pregnancy) Collaboration, from randomised trials of diet and/or physical activity interventions during pregnancy reporting GWG and maternal and neonatal outcomes. Women randomised to the control arm of 20 eligible randomised trials (4370 of 8908 participants) from the i-WIP dataset of 36 randomised trials (total 12,240 women). The main research questions were to characterise the relationship between maternal BMI and (a) total GWG, (b) the risk of 'excessive' GWG (using the Institute of Medicine's guidelines), and (c) adverse pregnancy outcomes as mediated via GWG versus other pathways to determine the extent to which the observed effect of maternal BMI on pregnancy outcomes is mediated via GWG. We utilised generalised linear models and regression-based mediation analyses within an IPD meta-analysis framework.

RESULTS

Mean GWG decreased linearly as maternal BMI increased; however, the risk of 'excessive' GWG increased markedly at BMI category thresholds (i.e. between the normal and overweight BMI category threshold and between the overweight and obese BMI category threshold). Increasing maternal BMI was associated with increased risk of all pregnancy outcomes assessed; however, there was no evidence that this effect was mediated via effects on GWG.

CONCLUSIONS

There is evidence of a meaningful relationship between maternal BMI and GWG and between maternal BMI and adverse pregnancy outcomes. There is no evidence that the effect of maternal BMI on outcomes is via an effect on GWG. Our analyses also cast doubt on the existence of a relationship between 'excessive' GWG and adverse pregnancy outcomes. Our findings challenge the practice of actively managing GWG throughout pregnancy.

Mapping Lifestyle Interventions for Gestational Diabetes Prevention: A Scoping Review

PURPOSE OF REVIEW

The purpose of this study was to conduct a scoping review to map intervention, sample, and physiologic measurement characteristics of lifestyle interventions for gestational diabetes mellitus (GDM) prevention.

RECENT FINDINGS

A total of 19 studies met selection criteria from 405 articles screened (PubMed, Web of Science). No studies were US-based (47% multi-site), and all were delivered in clinical settings. The most targeted nutrition components were low carbohydrate intake (sugar rich foods/added sugars, low glycemic index), low fat intake (mainly low-fat meat, dairy, and saturated fat), and increased fruits and vegetables. Many studies promoted 150 min/week moderate-intensity physical activity. Only two studies provided supervised physical activity sessions. Dietitians and nurses were the most common implementers. Samples were characterized as adults with obesity (mean age 31 yr, BMI 31 kg/m2). Asian populations were predominantly studied. Four studies used theoretical frameworks (75% of which used Social Cognitive Theory). GDM diagnostic criteria set forth by the American Diabetes Association were the most widely used. Insulin sensitivity was commonly assessed via fasting indices. There was a lack of multi-disciplinary, multi-level, and theory-based lifestyle interventions for reducing GDM risk. Addressing these gaps and prioritizing high-risk populations in the US with measurement of traditional and novel biomarkers will advance the field.

Monitored home-based with or without face-to-face exercise for maternal mental health during the COVID-19 pandemic

INTRODUCTION

Despite the known beneficial effects of exercise, most pregnant women do not exercise regularly. Most studies on exercise have been conducted on supervised exercise and there is limited evidence regarding the adherence and effect of other exercise programs on pregnancy outcomes. Therefore, we aimed to investigate adherence to a face-to-face plus monitored home exercise program versus a monitored home-based exercise program on its own during pregnancy. In addition, effects of these two exercise programs on women's mental health during pregnancy and postpartum (primary outcomes) and on some other maternal and neonatal outcomes (secondary outcomes) will be assessed.

METHODS

In this superiority trial with three parallel arms, 150 women at 12-18 weeks of gestation will be randomised equally into three groups (face-to-face plus monitored home exercise, only monitored home-based exercise, and control). The exercise programs will be performed up to the 38th week of gestation during which participants will be assessed at specific intervals during the pregnancy, and post-partum and followed up until six months after childbirth. The exercise diary will be used to assess the adherence. The Edinburgh Depression Scale and the Positive and Negative Affect Schedule will be used to assess prenatal and postnatal depression and affect, respectively.

DISCUSSION

This study reflects the feasibility and acceptance of two exercise programs for pregnant women and their effects on important outcomes. If these programs are followed properly and effectively, pregnant women's health can be improved using these methods at a lower cost compared to the conventional supervised exercise program.

Simultaneous selection and incorporation of consistent external aggregate information

Interest has grown in synthesizing participant level data of a study with relevant external aggregate information. Several efficient and flexible procedures have been developed under the assumption that the internal study and the external sources concern the same population. This homogeneity condition, albeit commonly being imposed, is hard to check due to limitedly available external information in aggregate data forms. Bias may be introduced when the assumption is violated. In this article, we propose a penalized likelihood approach that avoids undesirable bias by simultaneously selecting and synthesizing consistent external aggregate information. The proposed approach provides a general framework which incorporate consistent external information from heterogeneous study populations as long as the conditional distribution of the dependent variable under investigation is same and differences in the independent variable distributions are properly accounted for via a semi-parametric density ratio model. The proposed approach also properly accounts for the sampling errors in the external information. A two-step estimator and an optimization algorithm are proposed for computation. We establish the selection and estimation consistency and the asymptotic normality of the two-step estimator. The proposed approach is illustrated with an analysis of gestational weight gain management studies.

Influence of Physical Activity during Pregnancy on Maternal Hypertensive Disorders: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Gestational hypertension is a notable concern with ramifications for maternal and fetal health. Preemptive measures, including physical activity (PA), are crucial. There is a pressing need for comprehensive investigations into the impact of various forms of PA on hypertensive disorders. A systematic review and meta-analysis (CRD42022372468) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Our review exclusively considered randomized clinical trials (RCTs) between 2010 and 2023, using the following databases: EBSCO, including Academic Search Premier, Education Resources Information Center, PubMed/MEDLINE, SPORTDiscus, and OpenDissertations; Clinicaltrials.gov; Web of Science; Scopus; the Cochrane Database of Systematic Reviews; and the Physiotherapy Evidence Database (PEDro). The primary outcome was hypertensive disorders occurring during pregnancy (14 studies). Diagnosed preeclampsia (15 studies) and blood pressure levels were also examined (17 studies). PA during pregnancy was significantly associated with a reduced risk of hypertensive disorders (RR = 0.44, 95% CI = 0.30, 0.66). The data also indicate a positive correlation between PA during pregnancy and both systolic (MD = -2.64, 95% CI = -4.79, -0.49) and diastolic (MD = -1.99, 95% CI = -3.68, -0.29) blood pressure levels. The relationship between PA and the incidence of diagnosed preeclampsia did not demonstrate a statistically significant association (RR = 0.81, 95% CI = 0.59, 1.11; p = 0.20). Random effects were used for all analyses. PA during pregnancy promises to improve maternal health by reducing the risk of gestational hypertension and positively affecting systolic and diastolic blood pressure.

Influence of Physical Activity during Pregnancy on Neonatal Complications: Systematic Review and Meta-Analysis

Newborn hospitalisations after delivery are indicators of poor neonatal health with potential risks of future diseases for children. Interventions to promote a healthy environment have been used during pregnancy, with physical activity as a principal element. A systematic review and meta-analyses were performed to evaluate the effect of physical activity during pregnancy on neonatal intensive care unit (NICU) admissions and Apgar 1 and 5 scores (Registration No.: CRD42022372493). Fifty studies (11,492 pregnant women) were included. There were significantly different rates of NICU admissions between groups (RR = 0.76, 95% CI = 0.62, 0.93; Z = 2.65, p = 0.008; I2 = 0%, and Pheterogeneity = 0.78), and significant differences in Apgar 1 (Z = 2.04; p = 0.04) (MD = 0.08, 95% CI = 0.00, 0.17, I2 = 65%, Pheterogeneity = 0.00001) and Apgar 5 (Z = 3.15; p = 0.002) (MD = 0.09, 95% CI = 0.04, 0.15, I2 = 80%, and Pheterogeneity = 0.00001), favouring intervention groups. Physical activity during pregnancy could help to reduce the risk of NICU admissions that are related to neonatal complications.

Supervised physical activity and the incidence of gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Gestational diabetes mellitus (GDM) characterized by dysfunction in maintaining glucose homeostasis is recognized as the most common metabolic complication associated with pregnancy leading to adverse clinical outcomes for maternal and fetal health. Although previous analysis of the findings from randomized controlled trials (RCTs) support that regular physical activity reduces the incidence of GDM during pregnancy, less is known about the optimal timing of intervention with respect to trimester stage.

OBJECTIVES

To examine the interaction between both the timing and volume of supervised physical activity interventions on reducing the incidence of GDM during pregnancy.

STUDY DESIGN

Electronic databases including CINAHL, Embase, Medline and the Cochrane library were searched for records up to 29 September 2022. Eligibility criteria were RCTs including standard antenatal care + supervised physical activity intervention without dietary modification vs. those receiving standard antenatal care alone in women with no previous diagnosis of GDM, type 1 or type 2 diabetes mellitus.

RESULTS

Of the 3411 records identified, 20 RCTs comprising 6732 participants were included. It was found that supervised physical activity interventions decreased GDM risk when started within the first trimester (RR: 0.57, 95% CI: 0.41-0.79; p = .001) and by accumulating >600 MET·min·wk^-1 of exercise (RR: 0.77, 95% CI: 0.60-0.98; p = .03) compared with standard antenatal care alone. Women with a BMI ≤25 kg/m² experienced the greatest risk reduction in GDM following supervised exercise training (RR: 0.51, 95% CI: 0.34-0.75; p = .001).

CONCLUSION

Supervised physical activity reduces the incidence of GDM during pregnancy. It is recommended that pregnant individuals achieve a minimum of 600 MET·min·wk^-1 of physical activity during the first trimester in order to reduce their odds of developing GDM. Attaining a healthy pre-pregnancy BMI is also an important determinant for the prevention of GDM with exercise.

Effectiveness of Lifestyle Interventions during Pregnancy on Preventing Gestational Diabetes Mellitus in High-Risk Women: A Systematic Review and Meta-Analyses of Published RCTs

BACKGROUND

Until now, it is uncertain whether lifestyle interventions during pregnancy can prevent gestational diabetes mellites (GDM) in high-risk pregnant women.

OBJECTIVE

This study aims at investigating the effectiveness of dietary interventions and/or exercise interventions during pregnancy for preventing GDM in high-risk pregnant women.

MATERIALS AND METHODS

Eligible randomized controlled trials (RCTs) were selected after a search in CENTRAL, Scopus, and PubMed. Synthesis was performed for the outcome of GDM in women with any identified GDM risk factor. Separate meta-analyses (MA) were performed to assess the efficacy of either nutrition or physical activity (PA) interventions or both combined compared with standard prenatal care for preventing GDM. Subgroup and sensitivity analyses, as well as meta-regressions against OR, were performed to assess potentional heterogeneity. Overall quality, the quality of RCTs, and publication bias were also evaluated.

RESULTS

A total of 13,524 participants comprising high-risk pregnant women in 41 eligible RCTs were analyzed for GDM. Women receiving only a nutrition intervention during pregnancy were less likely to experience GDM compared with women following standard prenatal care. Among 3109 high-risk pregnant women undergoing only dietary intervention for preventing GDM, 553 (17.8%) developed GDM; however, the result of the MA was marginally not significant (OR 0.73, 95%CI 0.51, 1.03; p-value 0.07), (Q 21.29, p-value 0.01; I2 58% (95%CI 10, 78%)). Subgroup analyses demonstrated an effect for studies that were conducted in Great Britain (OR 0.65, 95%CI 0.49, 0.81; p-value 0.003), and in Spain (OR 0.50, 95%CI 0.27, 0.94; p-value 0.03), for studies with forms of the Mediterranean diet as the intervention's component (OR 0.61; 95%CI 0.46, 0.81; p-value 0.0005), and for studies including a motivation arm in the intervention (OR 0.71, 95%CI 0.58, 0.87; p-value 0.0008). Among 2742 high-risk pregnant women being analyzed for GDM outcome after receiving only an exercise intervention, 461 (16.8%) were diagnosed with GDM. Women after receiving PA intervention were less likely to develop GDM (OR 0.64, 95%CI 0.51, 0.80; p-value < 0.0001), (Q 11.27, p-value 0.51; I2 0% (95%CI 0, 99%)). Finally, 1308 (17%) cases of GDM were diagnosed among 7673 high-risk pregnant women undergoing both diet and PA intervention. Women in the group of mixed lifestyle intervention had a significant reduction in incidence of GDM (OR 0.70, 95%CI 0.55, 0.90; p-value 0.005), (Q 50.32, p-value < 0.0001, I2 66%, (95% CI 44, 79%)).

CONCLUSIONS

The results of this study support the efficacy of lifestyle interventions during pregnancy for preventing GDM in high-risk women if an exercise component is included in the intervention arm, either alone, or combined with diet. A combined lifestyle intervention including physical exercise and a Mediterranean diet accompanied by motivation support may be considered the most effective way to prevent GDM among high-risk women during pregnancy. Future research is needed to strengthen these findings.

Impact of Exercise Intervention Combined with Optimal Mediterranean Diet Adherence during Pregnancy on Postpartum Body Composition: A Quasi-Experimental Study-The GESTAFIT Project

This study aimed to investigate whether the effects of an exercise program during pregnancy on postpartum body composition are moderated by following a healthy dietary pattern (i.e., Mediterranean diet (MD)). Eighty-three pregnant women (control n = 40, exercise n = 43) were included in the present quasi-experimental study. The exercise intervention consisted of a 60 min, 3 day/week throughout pregnancy from gestational week 17, supervised concurrent (aerobic + resistance) exercise program. A food frequency questionnaire and the MD Score (min-max: 0-50) were employed to assess dietary habits and the MD adherence during pregnancy, respectively. Postpartum body composition was measured with dual-energy X-ray absorptiometry, 6 weeks postpartum. The body mass index and the gynecoid fat mass at postpartum were lower in the exercise compared to the control group (p = 0.018 and p = 0.047, respectively). There was an interaction showing that the MD adherence during pregnancy positively moderated the effects of the exercise intervention on postpartum lean mass (p = 0.024), fat mass percentage (p = 0.092), android fat mass (p = 0.076), and android-to-gynecoid fat mass (p = 0.019). The Johnson-Neyman technique revealed that the effects of exercise were enhanced at a MD score of ~31 for lean mass, ~25 for fat mass, ~23 for android fat mass and ~29 for android-to-gynecoid fat mass. Our results suggest that a concurrent-exercise training plus an optimal MD adherence during pregnancy might be a useful strategy to promote a healthier body composition at the postpartum period.

Development and feasibility of a theory-guided and evidence-based physical activity intervention in pregnant women with high risk for gestational diabetes mellitus: a pilot clinical trial

BACKGROUND

Physical activity has been utilized as an effective strategy to prevent gestational diabetes mellitus (GDM). However, most pregnant women with high risk for GDM did not achieve the recommended physical activity level. Furthermore, relevant physical activity protocols have varied without theory-guided and evidence-based tailored to pregnant women with high risk for GDM. This study aimed to develop and pilot test a theory-guided and evidence-based physical activity intervention protocol for pregnant women with high risk for GDM.

METHODS

The study design was guided by the Medical Research Council Framework for Developing and Evaluating Complex Intervention (the MRC framework). The preliminary protocol for physical activity intervention was developed based on self-efficacy theory, research evidence identified from systematic reviews and clinic trials, stakeholder engagement, context, and economic considerations. The preliminary intervention protocol was validated through a content validity study by an expert panel of 10 experts. A single-blinded randomized controlled trial (RCT) was designed to test the feasibility and acceptability of the intervention.

RESULTS

The validity of the preliminary intervention protocol was excellent as consensus was achieved. The final 13 sessions of self-efficacy enhancing physical activity intervention protocol were developed, including knowledge education, exercise clinic visits and video, and group discussions with face-to-face and online blended sessions. In the feasibility study, 34 pregnant women with high risk for GDM were randomized for the intervention (n = 17) or the control group (n = 17). The recruitment and retention rates were 82.9% and 58.9%, respectively. Women in the intervention group had a lower incidence of GDM (26.7% vs. 36.5%) than the control group (P >0.05). All participants were satisfied with the intervention and agreed that the intervention was helpful.

CONCLUSIONS

The developed self-efficacy-enhancing physical activity intervention is a feasible and acceptable intervention for enhancing physical activity among pregnant women with high risk for GDM and is ready to be tested in a more extensive RCT study.

TRIAL REGISTRATION

The study was registered on 4 February 2022 (ChiCTR2200056355) by the Chinese Clini Trial Registry (CHiCTR).

Effectiveness of a structured exercise intervention in gestational weight gain in pregnant women with overweight and obesity: A systematic review with meta-analysis

OBJECTIVES

To assess the effectiveness of exercise interventions during pregnancy in managing gestational weight gain (GWG), excessive GWG, gestational diabetes (GD), hypertensive disorders, 2-h post-oral glucose tolerance test (OGTT), and birth weight in pregnant women with overweight/obesity (OW/OB).

METHODS

The search strategy was conducted in five electronic databases, restricting to articles published within the past 10 years. Randomized controlled trials comparing exercise intervention with usual prenatal care in pregnant women with OW/OB were considered. Two reviewers extracted data and assessed the risk of bias using version 2 of the Cochrane risk-of-bias tool for randomized trials and the quality of studies using Grading of Recommendations Assessment, Development and Evaluation classification. Continuous data were calculated as mean differences (MDs) and dichotomous data as risk ratios (RRs).

RESULTS

Seven trials comprising 1648 pregnant women were included. Exercise interventions were associated with lower GWG (MD, -1.19 kg [95% confidence interval, CI, -1.79 to -0.60]) and lower incidence of GD (RR, 0.56 [95% CI, 0.40-0.78]). When analyzing excessive GWG, 2-h post-OGTT, birth weight, and hypertensive disorders, there was no statistically significant difference between the exercise and usual care groups. The strength of evidence was considered moderate.

CONCLUSION

Exercise interventions during pregnancy in women with OW/OB were shown to influence GWG and the incidence of GD.

Influence of Physical Activity during Pregnancy on Birth Weight: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Birth weight is a marker that is often referred to determine newborn health, potential growth trajectories and risk of future disease. Accordingly, interventions to promote appropriate and healthy birth weight have been extensively studied and implemented in pregnancy. In particular, physical activity in pregnancy is recommended to promote appropriate fetal development and newborn birth weight. This systematic review and meta-analyses aimed to summarize the effect of physical activity during pregnancy specifically from randomized controlled trials on the following outcomes: birth weight, macrosomia, low birth weight, being large for the gestational age, and being small for the gestational age (Registration No.: CRD42022370729). 63 studies (16,524 pregnant women) were included. There was a significant negative relationship between physical activity during pregnancy and macrosomia (z = 2.16; p = 0.03; RR = 0.79, 95% CI = 0.63, 0.98, I2 = 29%, Pheterogeneity = 0.09). No other significant relationships were found. Promoting physical activity during pregnancy may be an opportune time to reduce the risk of future chronic disease, such as obesity, through the prevention of macrosomia and the promotion of appropriate birth weights.

Influence of Physical Activity during Pregnancy on Type and Duration of Delivery, and Epidural Use: Systematic Review and Meta-Analysis

Cesarean delivery may increase the need for anesthesia administration, thereby causing potential risks to both maternal and fetal health. This article aimed to investigate the effect of physical activity during pregnancy on the type of delivery, the duration of labor, and the use of epidurals (registration No.: CRD42022370646). Furthermore, 57 RCTs (n = 15301) were included showing that physical activity could decrease the risk of cesarean section (z = 3.22, p = 0.001; RR = 0.87, 95% CI = 0.79, 0.95, I2 = 37%, Pheterogeneity = 0.004), and 32 RCTs (n = 9468) showed significant decreases in instrumental delivery through performing physical activity (z = 3.48, p < 0.001; RR = 0.84, 95% CI = 0.76, 0.93, I2 = 0%, Pheterogeneity = 0.63). A significant decrease in the 15 RCTs' (n = 4797) duration of first stage labor was found in physically active pregnant women (z = 2.09, p = 0.04; MD = -62.26, 95% CI = -120.66, -3.85, I2 = 93%, Pheterogeneity < 0.001) compared to those not active. Prenatal physical activity could decrease the risk of cesarean section and instrumental delivery and the duration of first stage labor.

Is Exercise during Pregnancy a Risk for Gestational Age and Preterm Delivery? Systematic Review and Meta-Analysis

Traditionally, one of the primary concerns regarding exercise during pregnancy has been the potential of reducing gestational age and increasing the likelihood of preterm delivery. The aim of this study was to perform a systematic review about the effects of physical activity (PA) during pregnancy on gestational age and preterm delivery. A systematic review and two meta-analyses were performed (Registration No. CRD42022370770). Data sources from online databases were searched up to November 2022. The review exclusively included studies involving pregnant populations and interventions consisting of PA implemented during pregnancy. The primary outcomes analysed were gestational age, measured in weeks, and the occurrence of preterm deliveries. A total of 57 studies were analysed through two independent meta-analyses for the first one, no association was found between moderate exercise during pregnancy and gestational age (Z = 0.45, p = 0.65, ES = 0.08, 95% CI = -0.06-0.04, I2 = 42%, P heterogeneity = 0.001), showing the exercise group had a higher gestational age. In addition, no differences were found between groups in terms of number of preterm deliveries (RR = 0.96, (95% CI = 0.77-1.21, Z = 0.33, p = 0.74; ES = 0.07; I2 = 31%, P heterogeneity = 0.05)). The findings of this study indicate that there is no association between exercise during pregnancy and reduced gestational age or increased risk of preterm delivery in healthy pregnancies.

The Effects of Exercise during Pregnancy on Gestational Diabetes Mellitus, Preeclampsia, and Spontaneous Abortion among Healthy Women-A Systematic Review and Meta-Analysis

The aim was to compare the effects of different exercise modalities (aerobic, resistance, aerobic and resistance combined, or mind-body exercise) on gestational diabetes mellitus (GDM), preeclampsia, spontaneous abortion, withdrawal from the study, and adverse events in healthy pregnant women. A systematic search was conducted in February 2022 using MEDLINE, EMBASE, Cochrane library, and SPORT Discus to identify eligible randomized trials. The meta-analysis of 18 studies that examined exercise compared to no exercise showed a reduced risk of GDM (RR: 0.66 (95% CI: 0.50 to 0.86)). No subgroup differences were found regarding modality, intensity, or supervision. Exercise did not reduce the risk of preeclampsia (nine studies, RR: 0.65 (95% CI: 0.42 to 1.03)); however, in subgroup analyses, mind-body exercise and low-intensity exercise seemed to be effective in reduction of preeclampsia. There was no effect of exercise on withdrawal or adverse events found. No studies reported on spontaneous abortion, therefore, exercise during pregnancy is beneficial and safe. In the prevention of GDM, any modality and intensity seem equally effective. Subgroup analyses support an association between mind-body exercise and physical activity with low intensity and reduced risk of preeclampsia, but more high-quality randomized studies are needed. PROSPERO: CRD42022307053.

Key Components of Antenatal Lifestyle Interventions to Optimize Gestational Weight Gain: Secondary Analysis of a Systematic Review

Importance

Randomized clinical trials have found that antenatal lifestyle interventions optimize gestational weight gain (GWG) and pregnancy outcomes. However, key components of successful interventions for implementation have not been systematically identified.

Objective

To evaluate intervention components using the Template for Intervention Description and Replication (TIDieR) framework to inform implementation of antenatal lifestyle interventions in routine antenatal care.

Data Sources

Included studies were drawn from a recently published systematic review on the efficacy of antenatal lifestyle interventions for optimizing GWG. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, MEDLINE, and Embase were searched from January 1990 to May 2020.

Study Selection

Randomized clinical trials examining efficacy of antenatal lifestyle interventions in optimizing GWG were included.

Data Extraction and Synthesis

Random effects meta-analyses were used to evaluate the association of intervention characteristics with efficacy of antenatal lifestyle interventions in optimizing GWG. The results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data extraction was performed by 2 independent reviewers.

Main Outcomes and Measures

The main outcome was mean GWG. Measures included characteristics of antenatal lifestyle interventions comprising domains related to theoretical framework, material, procedure, facilitator (allied health staff, medical staff, or researcher), delivery format (individual or group), mode, location, gestational age at commencement (<20 wk or ≥20 wk), number of sessions (low [1-5 sessions], moderate [6-20 sessions], and high [≥21 sessions]), duration (low [1-12 wk], moderate [13-20 wk], and high [≥21 wk]), tailoring, attrition, and adherence. For all mean differences (MDs), the reference group was the control group (ie, usual care).

Results

Overall, 99 studies with 34 546 pregnant individuals were included with differential effective intervention components found according to intervention type. Broadly, interventions delivered by an allied health professional were associated with a greater decrease in GWG compared with those delivered by other facilitators (MD, -1.36 kg; 95% CI, -1.71 to -1.02 kg; P < .001). Compared with corresponding subgroups, dietary interventions with an individual delivery format (MD, -3.91 kg; 95% CI -5.82 to -2.01 kg; P = .002) and moderate number of sessions (MD, -4.35 kg; 95% CI -5.80 to -2.89 kg; P < .001) were associated with the greatest decrease in GWG. Physical activity and mixed behavioral interventions had attenuated associations with GWG. These interventions may benefit from an earlier commencement and a longer duration for more effective optimization of GWG.

Conclusions and Relevance

These findings suggest that pragmatic research may be needed to test and evaluate effective intervention components to inform implementation of interventions in routine antenatal care for broad public health benefit.

Effects of prenatal exercise on gestational weight gain, obstetric and neonatal outcomes: FitMum randomized controlled trial

BACKGROUND

To investigate the effects of two different exercise interventions during pregnancy on gestational weight gain (GWG) and obstetric and neonatal outcomes compared to standard care. Additionally, we aimed to improve standardization of GWG measurements by developing a model to estimate GWG for a standardized pregnancy period of 40 weeks and 0 days accounting for individual differences in gestational age (GA) at delivery.

METHODS

In a randomized controlled trial we compared the effects of structured supervised exercise training (EXE) three times per week throughout pregnancy versus motivational counselling on physical activity (MOT) seven times during pregnancy with standard care (CON) on GWG and obstetric and neonatal outcomes. Uniquely, to estimate GWG for a standardized pregnancy period, we developed a novel model to predict GWG based on longitudinally observed body weights during pregnancy and at admission for delivery. Observed weights were fitted to a mixed effects model that was used to predict maternal body weight and estimate GWG at different gestational ages. Obstetric and neonatal outcomes, among them gestational diabetes mellitus (GDM) and birth weight, were obtained after delivery. GWG and the investigated obstetric and neonatal outcomes are secondary outcomes of the randomized controlled trial, which might be underpowered to detect intervention effects on these outcomes.

RESULTS

From 2018-2020, 219 healthy, inactive pregnant women with median pre-pregnancy BMI of 24.1 (21.8-28.7) kg/m² were included at median GA 12.9 (9.4-13.9) weeks and randomized to EXE (n = 87), MOT (n = 87) or CON (n = 45). In total 178 (81%) completed the study. GWG at GA 40 weeks and 0 days did not differ between groups (CON: 14.9 kg [95% CI, 13.6;16.1]; EXE: 15.7 kg [14.7;16.7]; MOT: 15.0 kg [13.6;16.4], p = 0.538), neither did obstetric nor neonatal outcomes. For example, there were no differences between groups in the proportions of participants developing GDM (CON: 6%, EXE: 7%, MOT: 7%, p = 1.000) or in birth weight (CON: 3630 (3024-3899), EXE: 3768 (3410-4069), MOT: 3665 (3266-3880), p = 0.083).

CONCLUSIONS

Neither structured supervised exercise training nor motivational counselling on physical activity during pregnancy affected GWG or obstetric and neonatal outcomes compared to standard care.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03679130; 20/09/2018.

Exercise during pregnancy for preventing gestational diabetes mellitus and hypertensive disorders: An umbrella review of randomised controlled trials and an updated meta-analysis

OBJECTIVE

This study aimed to provide, through an umbrella review, an overview of the effect of single exercise interventions during pregnancy on gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP). Also, to update the current evidence through an updated meta-analysis.

DESIGN

Umbrella review.

SETTING

PubMed, EMBASE, Web of Science, Cochrane database of systematic reviews, Epistemonikos, SPORTDiscus, Clinicaltrials.gov, and PROSPERO register were searched from the database inception until August 2021.

POPULATION

Peer-reviewed systematic reviews and meta-analyses of randomised controlled trials (RCTs) and RCTs samples.

METHODS

Random-effects model was used to calculate relative risk with 95% confidence interval in the updated meta-analysis. The reference category was the groups that received usual prenatal care. AMSTAR 2 and the Cochrane Collaboration tool were used to assess the quality and GRADE approach was used to assess the overall certainly of evidence.

MAIN OUTCOME MEASURES

GDM and HDP relative risk.

RESULTS

Twenty-three systematic reviews and meta-analyses; and 63 RCTs were included. Single exercise interventions reduced the incidence of GDM and HDP in most systematic reviews and meta-analyses. Moreover, exercise interventions during pregnancy decrease the incidence of developing GDM and GH, particularly when they are supervised, have a low to moderate intensity level, and are initiated during the first trimester of pregnancy.

CONCLUSION

Based on the findings, obstetric and physical exercise professionals could recommend exercise interventions during pregnancy as an effective strategy to improve maternal outcomes.

Maternal Mortality in the United States: Trends and Opportunities for Prevention

Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and socioeconomic factors. Similar to other developed nations, the United States has seen a shift in the underlying causes of pregnancy-related death, with a relative increase in mortality resulting from diseases of the cardiovascular system and preexisting medical conditions. Improved continuity of care aimed at identifying reproductive-age women with preexisting conditions that may heighten the risk of maternal death, preconception management of risk factors for major adverse pregnancy outcomes, and primary care visits within the first year after delivery may offer opportunities to address gaps in medical care contributing to the unacceptable rates of maternal mortality in the United States.

Effectiveness of different behavioral interventions on gestational weight gain, post-partum weight retention and anthropometric measures in pregnancy: A randomized controlled trial

Background: The antenatal and postnatal periods are critical stages in a woman's reproductive life. Many physical changes occur during pregnancy, such as water retention and excessive weight gain. The aim of the present study is to find out the effectiveness of various behavioral interventions during pregnancy to prevent excessive gestational weight gain (GWG) and postpartum weight retention (PPWR). Methods: In this parallel-group randomized controlled trial, 150 pregnant women with singleton pregnancy, aged 20-30 years, body mass index (BMI)≥18.5 kg/m2 and gestational age of less than 16 weeks were randomly allocated into five groups (N=30 in each group): Group A: Control; Group B: Supervised exercise; Group C: Pedometer; Group D: Text message; and Group E: Pedometer plus text message group. Group B received four supervised exercise sessions per month up to delivery; Groups C and E were urged to increase their levels of physical activity, focusing on pedometer-measured step counts of at least 5000-7500 steps per day on seven consecutive days each month. Group E along with group D also received standard SMS messages about physical activity, diet, motivation, and educational-specific topics. Results: The between-group comparisons revealed a statistically significant reduction in PPWR but insignificant difference in GWG. The greatest reduction in PPWR was found in the supervised exercise group (MD=3.25 kg, 95% CI: [1.75, 4.75], P=0.0001 with effect size (η² )=0.155). Conclusion: The study found that the supervised exercise can be seen as an effective way of improving the physical activity level and reducing excessive PPWR in pregnant women.

Implementation of Antenatal Lifestyle Interventions Into Routine Care: Secondary Analysis of a Systematic Review

IMPORTANCE

Lifestyle interventions in pregnancy optimize gestational weight gain and improve pregnancy outcomes, with implementation recommended by the US Preventive Services Task Force. Yet, implementation research taking these efficacy trials into pragmatic translation remains limited.

OBJECTIVE

To evaluate success factors for implementing pregnancy lifestyle interventions into antenatal care settings in a meta-analysis, using the penetration, implementation, participation, and effectiveness (PIPE) impact metric.

DATA SOURCES

Data from a previous systematic review that searched across 9 databases, including MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database, were obtained, in 2 stages, up to May 6, 2020.

STUDY SELECTION

Randomized clinical trials reporting gestational weight gain in singleton pregnancies.

DATA EXTRACTION AND SYNTHESIS

The association of penetration, implementation, and participation with effectiveness of antenatal lifestyle interventions in optimizing gestational weight gain was estimated using random-effects meta-analyses. The Cochrane risk of bias tool, version 1.0, was used to assess risk of bias.

MAIN OUTCOMES AND MEASURES

Penetration (reach), implementation (fidelity), participation, and effectiveness of randomized clinical trials of lifestyle interventions in pregnancy.

RESULTS

Ninety-nine studies with 34 546 participants were included. Only 14 studies reported penetration of target populations. Overall, 38 studies (38.4%) had moderate fidelity, 25 (25.2%) had high fidelity, and 36 (36.4%) had unclear fidelity. Participation was reported in 84 studies (84.8%). Lifestyle interventions were associated with reducing gestational weight gain by 1.15 kg (95% CI, -1.40 to -0.91 kg).

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that, despite the large body of evidence on efficacy of lifestyle interventions during pregnancy in optimizing gestational weight gain, little guidance is available to inform implementation of this evidence into practice. There is a need to better elucidate implementation outcomes in trial design alongside pragmatic implementation research to improve the health of women who are pregnant and the next generation.

The Influence of Exercise, Lifestyle Behavior Components, and Physical Fitness on Maternal Weight Gain, Postpartum Weight Retention, and Excessive Gestational Weight Gain

This study examines (a) the influence of exercise, lifestyle behavior components (sedentary time, physical activity, and sleep and dietary patterns), and physical fitness on maternal weight gain, postpartum weight retention, and excessive gestational weight gain and (b) whether exercise protects against the adverse effects of impaired metabolism and nonoptimal body composition related to excessive gestational weight gain. Subjects were assigned to either a supervised concurrent (aerobic + resistance) exercise program followed 3 days/week (n = 47) or a control group (n = 54). Sedentary time, physical activity, sleep and dietary patterns (assessed by accelerometry and questionnaires), muscle strength (handgrip test), and cardiorespiratory fitness (Bruce test) were determined at gestational Weeks 16 and 33 (early-middle and late pregnancy, respectively), and at 6 weeks postpartum. Weight gain and weight retention were calculated using recorded weights at prepregnancy, early-middle, and late pregnancy, and at 6 weeks postpartum. Birth complications, maternal postpartum body composition, cardiometabolic, and inflammatory markers in maternal and umbilical cord arterial and venous blood, and in colostrum, and mature milk were also recorded. The exercise intervention reduced late weight gain (B = -2.7, SE = 0.83, p = .003) and weight retention (B = -2.85, SE = 1.3, p = .03), independent of any lifestyle behavior component or physical fitness, but did not prevent excessive weight gain. Increasing cardiorespiratory fitness, muscle strength, and sleep duration were associated with a smaller mean weight gain and lower excessive weight gain values (p < .05). Among the participants who experienced excessive weight gain, those who were exercisers had a lower body mass index and systemic tumor necrosis factor-alpha concentration, lower umbilical cord venous tumor necrosis factor-alpha and arterial interferon gamma levels, higher cord arterial interleukin-10 levels, and improved placental function compared with controls (p < .05). In summary, exercise may help optimize gestational weight gain and weight retention, and may attenuate the impaired phenotype related to excessive weight gain. Increasing cardiorespiratory fitness, muscle strength, and sleep duration might help to prevent excessive weight gain during pregnancy.

The prevention of gestational diabetes mellitus (The role of lifestyle): a meta-analysis

Gestational diabetes mellitus (GDM) is the most common complication of pregnancy. The disease is on the rise worldwide with deleterious consequences on the fetus, mother, and children. The study aimed to review the role of lifestyle in the prevention of GDM. We searched PubMed, SCOPUS, Web of Science, Cochrane Library, EBSCO, and Google Scholar from the first published article up to December 2021; articles were eligible if they were controlled trials, prospective cohorts, and case-control. Out of 5559 articles retrieved, 66 full texts were screened, and 19 studies were included in the meta-analysis. (6 studies assessed the effects of diet, and 13 were on exercise). The dietary intervention showed significant positive effect on GDM, odd ratio = 0.69, 95% CI, 0.56-84, P-value for overall effect = 0.002. The DASH diet was better than Mediterranean Diet (odd ratio, 0.71, 95% CI, 68-74, P-value < 0.001). Regarding exercise, no significant prevention was evident on GDM, odd ratio, 0.77, 95% CI, 0.55-1.06, P-value = 0.11. However, a significant prevention of gestational diabetes was found when the exercise was mild-moderate (odd ratio = 0.65, 95% CI, 0.53-80, P < 0.0001) and started in the first trimester (odd ratio, 0.57, 95% CI, 0.43-0.75, P < 0.0001. No significant effect was found when the exercise was vigorous (odd ratio = 1.09, 95% CI, 0.50-2.38, P = 0.83) and started during the second trimester of pregnancy (odd ratio, 1.08, 95% CI, 0.65-1.80, P = 0.77. Diet and early mild-moderate exercise were effective in GDM prevention. Exercise during the second trimester and moderate-vigorous were not. Further studies assessing the type, duration, and frequency of physical activity are needed.

Exercise throughout Pregnancy Prevents Excessive Maternal Weight Gain during the COVID-19 Pandemic: A Randomized Clinical Trial

The purpose of this study was to examine the effects of a virtual exercise program throughout pregnancy during the COVID-19 pandemic on maternal weight gain. A randomized clinical trial (NCT NCT04563065) was performed. In total, 300 pregnant individuals were assessed for eligibility, and a total of 157 were randomized, of which 79 were in the control group (CG), and 78 were in the intervention group (IG). Those in the intervention group participated in a virtual supervised exercise program throughout pregnancy, 3 days per week. Fewer pregnant participants exceeded the weight gain recommendations in the IG group than in the CG (n = 4/5.9% vs. n = 31/43.1%, p = 0.001). Weight gain during pregnancy was lower in the IG than in the CG (9.96 ± 3.27 kg vs. 12.48 ± 4.87 kg, p = 0.001). Analysis of subgroups based on pre-pregnancy body mass index, showed significant differences in excessive maternal weight gain between study groups in normal-weight (IG, n = 0/0% vs. CG, n = 10/25%, p = 0.001) and those with overweight (IG, n = 2/18% vs. CG, n = 12/60%, p = 0.025). A virtual supervised exercise program throughout pregnancy could be a clinical tool to manage maternal weight gain during the COVID-19 pandemic by controlling excessive gain.

Active Pregnancy: A Physical Exercise Program Promoting Fitness and Health during Pregnancy-Development and Validation of a Complex Intervention

Physical activity during pregnancy is a public health issue. In the view of reproducibility and the successful implementation of exercise interventions, reporting the quality of such study design must be ensured. The objective of this study was to develop and validate a physical exercise program promoting fitness and health during pregnancy. A qualitative methodological study was carried out. For the description of the exercise program, the Consensus on Exercise Reporting Template (CERT) was used. For the validation of the program, the revised guideline of the Criteria for Reporting the Development and Evaluation of Complex Interventions in Health Care (CReDECI2) was followed and went through three stages of development, piloting, and evaluation. The customizable exercise program was designed and validated by exercise and health specialists based on evidence-based, international recommendations and supported by different educational tools to be implemented by qualified exercise professionals in health and fitness settings. A 12-week testing intervention addressing a group of 29 pregnant women was carried out. The program's feasibility was subsequently evaluated by all the pregnant women. The CReDECI2 process guides practitioners and researchers in developing and evaluating complex educational interventions. The presented intervention may assist exercise specialists, health professionals, and researchers in planning, promoting, and implementing a prenatal exercise program.

Can Group Exercise Programs Improve Health Outcomes in Pregnant Women? An Updated Systematic Review

Current scientific evidence supports the recommendation to initiate or continue physical exercise in healthy pregnant women. Group exercise programs have positive effects on improving health, well-being, and social support. In 2015, a systematic review was provided to evaluate the evidence on the effectiveness of group exercise programs in improving pregnant women's and newborns' health outcomes and to assess the content of the programs. This review aims to update this knowledge between 2015 and 2020. The exercise program designs were analyzed with the Consensus of Exercise Reporting Template (CERT) model, the compliance with the current guidelines, and effectiveness in the maternal health and fitness parameters. Three databases were used to conduct literature searches. Thirty-one randomized control trials were selected for analysis. All studies followed a supervised group exercise program including aerobic, resistance, pelvic floor training, stretching, and relaxation sections. Group interventions during pregnancy improved health and fitness outcomes for the women and newborns, although some gaps were identified in the interventions. Multidisciplinary teams of exercise and health professionals should advise pregnant women that group exercise improves a wide range of health outcomes for them and their newborns.

Efficacy of behavioral interventions in managing gestational weight gain (GWG): A component network meta-analysis

OBJECTIVE

To identify the most effective behavioral components within lifestyle interventions to optimize gestational weight gain (GWG) to inform guidelines, policy and translation into healthcare.

METHODS

Behavioral components were identified from study level data of randomized antenatal lifestyle interventions using a behavioral taxonomy framework and analyzed using component network meta-analysis (NMA). The NMA ranked behavioral combinations hierarchically by efficacy of optimizing GWG. Direct and estimated indirect comparisons between study arms (i.e., control and intervention) and between different component combinations were estimated to evaluate component combinations associated with greater efficacy.

RESULTS

Overall, 32 studies with 11,066 participants were included. Each intervention contained between 3 and 7 behavioral components with 26 different behavioral combinations identified. The majority (n = 24) of combinations were associated with optimizing GWG, with standard mean differences (SMD) ranging from -1.01 kg (95% CI -1.64 to -0.37) and -0.07 kg (-0.38 to 0.24), compared with controls. The behavioral cluster identified as most effective, included components of goals, feedback and monitoring, natural consequences, comparison of outcomes, and shaping knowledge (SMD -1.01 kg [95% CI -1.64 to -0.37]).

CONCLUSION

Findings support the application of goal setting, feedback and monitoring, natural consequences, comparison of outcomes, and shaping knowledge as essential, core components within lifestyle interventions to optimize gestational weight gain.

Exercise Interventions for Weight Management During Pregnancy and up to 1 year Postpartum Among Normal Weight Women and Women with Overweight and Obesity: An Updated Systematic Review

Background

Given the increased occurrence of pre‐gravid obesity in recent years, and the implications of maternal obesity for maternal and offspring health, it is evident that there is a continued need to investigate antenatal and postnatal weight management strategies and to provide evidence‐based advice for exercise‐based interventions. Given the small number of studies (n = 5) included in an original systematic review by our group in 2015, it was important to add to the dataset by assessing data published since 2015, in order to provide a more in‐depth view of current knowledge.

Objective

To provide an updated systematic review on studies employing exercise interventions for weight management in pregnant and postpartum women.

Methods

A systematic review of randomised controlled trials evaluating the effects of an exercise intervention on gestational weight gain and postpartum weight management in normal weight women, and women with overweight and obesity was conducted. PubMed, Scopus, Central Register of Controlled Trials and Web of Science were searched for studies published between September 2013 and June 2021. No restrictions were set on type, intensity, duration, or frequency of exercise intervention. Only studies that targeted body weight or mass as a primary outcome were included.

Results

Thirteen studies were included in this review: 11 during and two following pregnancy. Exercise significantly reduced gestational weight gain in five of the pregnancy studies and induced significant weight loss in one of the postpartum studies. Across studies, there were large disparities in exercise modality, frequency, and duration, although moderate intensity exercise was consistently employed.

Conclusions

Some studies showed positive effects of exercise on weight management during and following pregnancy. While there is still no consensus on effective exercise intervention approaches, it is crucial that physical activity, of any safe form, is recommended to encourage healthy weight management during this time.

Effects of Supervised Exercise on the Development of Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-Analysis

Hypertensive disorders of pregnancy (HDP) are the most common medical complication in pregnancy, affecting approximately 10–15% of pregnancies worldwide. HDP are a major cause of maternal and perinatal morbidity and mortality, and each year, worldwide, around 70,000 mothers and 500,000 babies die because of HDP. Up-to-date high-quality systematic reviews quantifying the role of exercise and the risks of developing HDP are currently lacking. Physical exercise is considered to be safe and beneficial to pregnant women. Supervised exercise has been shown to be safe and to be more beneficial than unsupervised exercise in the general population, as well as during pregnancy in women with obesity and diabetes. Therefore, we undertook a systematic review and meta-analysis to investigate the effects of women performing supervised exercise during pregnancy compared to a control group (standard antenatal care or unsupervised exercise) on the development of HDP. We searched Medline, Embase, CINHAL, and the Cochrane Library, which were searched from inception to December 2021. We included only randomized controlled trials (RCTs) investigating the development of HDP compared to a control group (standard antenatal care or unsupervised exercise) in pregnant women performing supervised exercise. Two independent reviewers selected eligible trials for meta-analysis. Data collection and analyses were performed by two independent reviewers. The PROSPERO registration number is CRD42020176814. Of 6332 articles retrieved, 16 RCTs met the eligibility criteria, comparing a total of 5939 pregnant women (2904 pregnant women in the intervention group and 3035 controls). The risk for pregnant women to develop HDP was significantly reduced in the intervention compared to the control groups, with an estimated pooled cumulative incidence of developing HDP of 3% in the intervention groups (95% CI: 3 to 4) and of 5% in the control groups (95% CI: 5 to 6), and a pooled odds ratio (OR) comparing intervention to control of 0.54 (95% CI:0.40 to 0.72, p < 0.001). A combination of aerobic and anaerobic exercise, or yoga alone, had a greater beneficial effect compared to performing aerobic exercise only (mixed-OR = 0.50, 95% CI:0.33 to 0.75, p = 0.001; yoga-OR = 0.28, 95% CI:0.13 to 0.58, p = 0.001); aerobic exercise only-OR = 0.87, 95% CI:0.55 to 1.37, p = 0.539). Pregnancy is an opportunity for healthcare providers to promote positive health activities, thus optimizing the health of pregnant women with potential short- and long-term benefits for both mother and child. This systematic review and meta-analysis support a beneficial effect of either structured exercise (combination of aerobic, strength, and flexibility workouts) or yoga for preventing the onset of HDP. Yoga, considered a low-impact physical activity, could be more acceptable and safer for women in pregnancy in reducing the risk of developing HDP.

Physical activity before pregnancy and the risk of hypertensive disorders of pregnancy

BACKGROUND

It is unclear whether pre-pregnancy physical activity influences the risk of hypertensive disorders of pregnancy and whether any impact is similar for preeclampsia or gestational hypertension.

OBJECTIVE

To evaluate the relation between pre-pregnancy physical activity with hypertensive disorders of pregnancy and its alignment with current recommendations for physical activity for the general population.

METHODS

We studied 28,147 singleton pregnancies from 18,283 women participating in the Nurses' Health Study-II without chronic hypertension, cardiovascular disease, or cancer, between 1989 and 2010. Women self-reported physical activity before pregnancy and pregnancy complications, including preeclampsia and gestational hypertension. Logistic regression models using generalized estimating equations to account for within-woman correlations across pregnancies were used to estimate the relative risk (95%CI) of preeclampsia and gestational hypertension across quartiles of pre-pregnancy physical activity, adjusting for age at pregnancy, parity, smoking, multivitamin use, infertility history, marital status, race, year of pregnancy, and history of preeclampsia.

RESULTS

We identified 842 (3.0%) pregnancies with preeclampsia and 905 (3.2%) pregnancies with gestational hypertension. Physical activity before pregnancy was related to a lower risk of hypertensive disorders of pregnancy (RR=0.75 [95%CI: 0.65, 0.87] for women in the highest quartile compared to the lowest quartile). This relation was driven by a 39% lower risk of gestational hypertension (RR=0.61; 95%CI:0.50,0.76) comparing women in the highest quartile of physical activity (≥ 30.6 MET-h/wk) vs. women in the lowest quartile (<6.0 MET-h/wk). Women whose moderate physical activity levels exceeded those recommended in the Physical Activity Guidelines for Americans (>5 h/wk) had a 50% lower (RR=0.50; 95%CI:0.36,0.69) risk of gestational hypertension than women who did not meet this recommendation (<2.5h/wk). For vigorous physical activity, the risk of gestational hypertension was lower among women who met (1.25-2.5 h/wk; RR=0.77; 95%CI: 0.64, 0.93) or exceeded (>2.5h/wk; RR=0.76; 95%CI: 0.62,0.92) the recommendations than women whose activity levels were below those recommended. Physical activity was not related to the risk of preeclampsia (RR=0.93; 95%CI:0.76,1.14).

CONCLUSIONS

Physical activity before pregnancy may lower the risk of developing gestational hypertension but not preeclampsia.

Physical Exercise vs. Metformin to Improve Delivery- and Newborn-Related Outcomes Among Pregnant Women With Overweight: A Network Meta-Analysis

Background: Overweight/obesity is associated with the risk of delivery- and newborn-related complications in pregnancy. Interventions such as exercise or metformin could reduce the risk of these complications. Objective: To estimate and compare the effects of different types of exercise interventions (i.e., aerobic, resistance, combined exercise) and metformin on delivery- and newborn-related outcomes among pregnant women with overweight/obesity. Methods: MEDLINE, Scopus, Web of Science, Cochrane Library databases and the gray literature were searched from inception to September 2021. This systematic review was registered in PROSPERO (CDR: 42019121715). Randomized controlled trials (RCTs) of metformin or an exercise intervention aimed at preventing cesarean section, preterm birth, macrosomia, or birth weight among pregnant women with overweight/obesity were included. Random effects meta-analyses and frequentist network meta-analyses (NMA) were conducted for each outcome. Results: Fifteen RCTs were included. In the NMA, metformin reduced the risk of cesarean section (RR = 0.66, 95% CI: 0.46, 0.95), combined exercise reduced the risk of macrosomia (RR = 0.37, 95% CI: 0.14, 0.95), and aerobic exercise reduced birth weight (mean difference = -96.66 g, 95% CI: -192.45, -0.88). In the subgroup among pregnant women with obesity, metformin reduced the risk of cesarean section (RR = 0.66, 95% CI: 0.45, 0.97). Conclusions: Combined exercise could reduce the risk of macrosomia in pregnant women with overweight, whereas metformin could reduce the risk of cesarean section in pregnant women with obesity. However, previous evidence suggests a larger effect of physical exercise in other outcomes for this population group. Therefore, the medicalization of healthy pregnant women with obesity is not justified by the current evidence. Systematic Review Registration: PROSPERO: CRD42019121715; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019121715.

Coping with Stress in Complicated Pregnancy and Gestational Weight Gain

Maternal obesity is one of the leading health problems in the world. Excessive gestational weight gain (GWG) can lead to many complications during pregnancy, especially when it is accompanied by diabetes. Moreover, the risk of excessive GWG in pregnant women is significant, irrespective of prenatal counseling. Studies on this subject concerning coping with stress are lacking in the literature. The present work is aimed at evaluating the styles of coping with stress and their relation to GWG in pregnant women with gestational diabetes (GDM) for whom sudden adaptation to dietary management during this period can be challenging. It was indicated that women with GDM reported high stress related to potential maternal-fetal complications and worries about compliance with dietary management. The overall weight gain of participants in pregnancy was determined in connection to their prepregnancy body mass index (BMI) and classified based on the Institute of Medicine guidelines. A standardized psychological scale was used to assess coping styles. The results showed that almost half of the participants did not meet the Institute of Medicine recommendations for weight gain during pregnancy. There were significant correlations between the styles of coping with stress and the GWG. Additionally, low correlations were indicated between emotional, avoidant, task-oriented coping styles and the age of pregnant women with GDM. Regression analysis showed that the stress-coping style that focused on emotions was the most predictive of overall weight gain. There is a need for a better understanding of psychological barriers in achieving the recommended GWG and potential limitations in providers' interventions, particularly for GDM.

Exercise versus Metformin to Improve Pregnancy Outcomes among Overweight Pregnant Women: A Systematic Review and Network Meta-Analysis

Being overweight is associated with pregnancy-related disorders such as gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), and excessive maternal weight gain (MWG). Exercise and metformin reduce the risk of these disorders. This network meta-analysis (NMA) aims to compare the effect of metformin and different types of exercise (aerobic, resistance and combined) on the risk of GDM, HDP, and MWG among overweight/obese pregnant women. Medline, EMBASE, Web of Science and Cochrane Library were searched from inception to June 2021. Meta-analyses and NMAs were performed. Sixteen randomized controlled trials were included. In the NMA, aerobic exercise showed an effect on GDM (RR = 0.51, 95% CI = 0.26, 0.97), and metformin a reduction in MWG (MWG = -2.93 kg, 95% CI = -4.98, -0.87). No intervention showed any effect on the reduction of HDP. Our study suggests that aerobic exercise may have the greatest effect in reducing the risk of GDM, and perhaps, the MWG. Strategies should be developed to increase adherence to this type of intervention among overweight women without contraindications. Although metformin could reduce MWG, medicalization of pregnancy in healthy women is not justified with the present results. More research is needed on the effect of the intensity and frequency of exercise sessions and the length of interventions.

Level of exercise and physical activity among pregnant women in Saudi Arabia: A systematic review

The current study aimed to clarify the health benefits of physical activity on the mother and fetus in the Saudi women population. Besides, it is intended to provide recommendation based on the literature and results of studies from Saudi Arabia for exercise in pregnancy to improve the general health of women in Saudi Arabia. Prenatal physical exercise enhances physical and mental health of pregnant women. It can also reduce the risk of multiple pregnancy-related complications such as; lower back pain, fluid retention and risk of gestational diabetes. All these factors can affect fetal development and life later. Multiple studies showed that prenatal exercise could reduce the risk of fetal macrosomia with no effect on other perinatal or postnatal complications. The study followed the systematic literature review approach where it included multiple medical search Databases using PICOS eligibility criteria up to January 2019. The review was based on the following keywords: pregnancy, gestational, or prenatal) and (physical exercise, exercise, or physical activity. There are only two studies that dealt with physical exercises among Saudi women. The results indicated a relation between prenatal physical exercise on improving or decreasing risks on the mother and child during pregnancy.

Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category.

OBJECTIVE

To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation.

DATA SOURCES

Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021.

STUDY SELECTION

Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating with dual review.

MAIN OUTCOMES AND MEASURES

Gestational weight-related outcomes; maternal and infant morbidity and mortality; harms.

RESULTS

Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], -1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, -2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, -1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, -1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, -1.02 kg [95% CI, -1.30 to -0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, -7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, -0.63 kg [95% CI, -1.44 to -0.01]). Data on harms were limited.

CONCLUSIONS AND RELEVANCE

Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons. In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%). Reported rates of overweight and obesity are higher among Black, Alaska Native/American Indian, and Hispanic women and lower among White and Asian women. Excess weight at the beginning of pregnancy and excess gestational weight gain have been associated with adverse maternal and infant health outcomes such as a large for gestational age infant, cesarean delivery, or preterm birth.

OBJECTIVE

The USPSTF commissioned a systematic review to evaluate the benefits and harms of behavioral counseling interventions to prevent adverse health outcomes associated with obesity during pregnancy and to evaluate intermediate outcomes, including excess gestational weight gain. This is a new recommendation.

POPULATION

Pregnant adolescents and adults in primary care settings.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons.

RECOMMENDATION

The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. (B recommendation).

Structured supervised exercise training or motivational counselling during pregnancy on physical activity level and health of mother and offspring: FitMum study protocol

INTRODUCTION

A physically active lifestyle during pregnancy improves maternal and offspring health but can be difficult to follow. In Denmark, less than 40% of pregnant women meet physical activity (PA) recommendations. The FitMum study aims to explore strategies to increase PA during pregnancy among women with low PA and assess the health effects of PA. This paper presents the FitMum protocol, which evaluates the effects of structured supervised exercise training or motivational counselling supported by health technology during pregnancy on PA level and health of mother and offspring.

METHODS AND ANALYSIS

A single-site three-arm randomised controlled trial that aims to recruit 220 healthy, pregnant women with gestational age (GA) no later than week 15 and whose PA level does not exceed one hour/week. Participants are randomised to one of three groups: structured supervised exercise training consisting of three weekly exercise sessions, motivational counselling supported by health technology or a control group receiving standard care. The interventions take place from randomisation until delivery. The primary outcome is min/week of moderate-to-vigorous intensity PA (MVPA) as determined by a commercial activity tracker, collected from randomisation until GA of 28 weeks and 0-6 days, and the secondary outcome is gestational weight gain (GWG). Additional outcomes are complementary measures of PA; clinical and psychological health parameters in participant, partner and offspring; analyses of blood, placenta and breastmilk samples; process evaluation of interventions; and personal understandings of PA.

ETHICS AND DISSEMINATION

The study is approved by the Danish National Committee on Health Research Ethics (# H-18011067) and the Danish Data Protection Agency (# P-2019-512). Findings will be disseminated via peer-reviewed publications, at conferences, and to health professionals via science theatre performances.

TRIAL REGISTRATION NUMBER

NCT03679130.

PROTOCOL VERSION

This paper was written per the study protocol version 8 dated 28 August 2019.

Effectiveness of a Smartphone App to Promote Healthy Weight Gain, Diet, and Physical Activity During Pregnancy (HealthyMoms): Randomized Controlled Trial

Background

Excessive gestational weight gain (GWG) during pregnancy is a major public health concern associated with negative health outcomes for both mother and child. Scalable interventions are needed, and digital interventions have the potential to reach many women and promote healthy GWG. Most previous studies of digital interventions have been small pilot studies or have not included women from all BMI categories. We therefore examined the effectiveness of a smartphone app in a large sample (n=305) covering all BMI categories.

Objective

To investigate the effectiveness of a 6-month intervention (the HealthyMoms app) on GWG, body fatness, dietary habits, moderate-to-vigorous physical activity (MVPA), glycemia, and insulin resistance in comparison to standard maternity care.

Methods

A 2-arm parallel randomized controlled trial was conducted. Women in early pregnancy at maternity clinics in Östergötland, Sweden, were recruited. Eligible women who provided written informed consent completed baseline measures, before being randomized in a 1:1 ratio to either an intervention (n=152) or control group (n=153). The control group received standard maternity care while the intervention group received the HealthyMoms smartphone app for 6 months (which includes multiple features, eg, information; push notifications; self-monitoring; and feedback features for GWG, diet, and physical activity) in addition to standard care. Outcome measures were assessed at Linköping University Hospital at baseline (mean 13.9 [SD 0.7] gestational weeks) and follow-up (mean 36.4 [SD 0.4] gestational weeks). The primary outcome was GWG and secondary outcomes were body fatness (Bod Pod), dietary habits (Swedish Healthy Eating Index) using the web-based 3-day dietary record Riksmaten FLEX, MVPA using the ActiGraph wGT3x-BT accelerometer, glycemia, and insulin resistance.

Results

Overall, we found no statistically significant effect on GWG (P=.62); however, the data indicate that the effect of the intervention differed by pre-pregnancy BMI, as women with overweight and obesity before pregnancy gained less weight in the intervention group as compared with the control group in the imputed analyses (–1.33 kg; 95% CI –2.92 to 0.26; P=.10) and completers-only analyses (–1.67 kg; 95% CI –3.26 to –0.09; P=.031]). Bayesian analyses showed that there was a 99% probability of any intervention effect on GWG among women with overweight and obesity, and an 81% probability that this effect was over 1 kg. The intervention group had higher scores for the Swedish Healthy Eating Index at follow-up than the control group (0.27; 95% CI 0.05-0.50; P=.017). We observed no statistically significant differences in body fatness, MVPA, glycemia, and insulin resistance between the intervention and control group at follow up (P≥.21).

Conclusions

Although we found no overall effect on GWG, our results demonstrate the potential of a smartphone app (HealthyMoms) to promote healthy dietary behaviors as well as to decrease weight gain during pregnancy in women with overweight and obesity.

Trial Registration

ClinicalTrials.gov NCT03298555; https://clinicaltrials.gov/ct2/show/NCT03298555

International Registered Report Identifier (IRRID)

RR2-10.2196/13011

Pregnancy swimming prevents early brain mitochondrial dysfunction and causes sex-related long-term neuroprotection following neonatal hypoxia-ischemia in rats

Neonatal hypoxia-ischemia (HI) is a major cause of cognitive impairments in infants. Antenatal strategies improving the intrauterine environment can have high impact decreasing pregnancy-derived intercurrences. Physical exercise alters the mother-fetus unity and has been shown to prevent the energetic challenge imposed by HI. This study aimed to reveal neuroprotective mechanisms afforded by pregnancy swimming on early metabolic failure and late cognitive damage, considering animals' sex as a variable. Pregnant Wistar rats were submitted to daily swimming exercise (20' in a tank filled with 32 °C water) during pregnancy. Neonatal HI was performed in male and female pups at postnatal day 7. Electron chain transport, mitochondrial mass and function and ROS formation were assessed in the right brain hemisphere 24 h after HI. From PND45, reference and working spatial memory were tested in the Morris water maze. MicroPET-FDG images were acquired 24 h after injury (PND8) and at PND60, following behavioral analysis. HI induced early energetic failure, decreased enzymatic activity in electron transport chain, increased production of ROS in cortex and hippocampus as well as caused brain glucose metabolism dysfunction and late cognitive impairments. Maternal swimming was able to prevent mitochondrial dysfunction and to improve spatial memory. The intergenerational effects of swimming were sex-specific, since male rats were benefited most. In conclusion, maternal swimming was able to affect the mitochondrial response to HI in the offspring's brains, preserving its function and preventing cognitive damage in a sex-dependent manner, adding relevant information on maternal exercise neuroprotection and highlighting the importance of mitochondria as a therapeutic target for HI neuropathology.

Obesity can offset the cardiometabolic benefits of gestational exercise

Pregnancy exercise can prevent excessive gestational weight gain (EGWG), gestational diabetes mellitus (GDM) and hypertension (GH), but inter-individual variability has not been explored. We aimed to analyze the prevalence--and potential sociodemographic and medical predictors of--non-responsiveness to gestational exercise, and the association of non-responsiveness with adverse pregnancy outcomes. Among 688 women who completed a supervised light-to-moderate intensity exercise program (three ~1-h sessions/week including aerobic, resistance, and pelvic floor muscle training) until near-term, those who showed EGWG, GDM or GH were considered 'non-responders'. A low prevalence of non-responders was observed for GDM (3.6%) and GH (3.4%), but not for EGWG (24.2%). Pre-pregnancy obesity was the strongest predictor of non-responsiveness for GH (odds ratio 8.40 [95% confidence interval 3.10-22.78] and EGWG (5.37 [2.78-10.39]), whereas having a highest education level attenuated the risk of being non-responder for GDM (0.10 [0.02-0.49]). Non-responsiveness for EGWG was associated with a higher risk of prolonged labor length, instrumental/cesarean delivery, and macrosomia, and of lower Apgar scores. No association with negative delivery outcomes was found for GDM/GH. In summary, women with pre-pregnancy obesity might require from additional interventions beyond light-to-moderate intensity gestational exercise (e.g., diet and/or higher exercise loads) to ensure cardiometabolic benefits.

Guideline No. 391-Pregnancy and Maternal Obesity Part 1: Pre-conception and Prenatal Care

OBJECTIVE

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on pre-conception and pregnancy care. Part II will focus on team planning for delivery and Postpartum Care.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

TARGET POPULATION

Women with obesity who are pregnant or planning pregnancies.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committee peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings, at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affected pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

GUIDELINE UPDATE

SOGC guidelines will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

SPONSORS

This guideline was developed with resources funded by the SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017.

OBJECTIVES

To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).

DATA COLLECTION AND ANALYSIS

We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it.

AUTHORS' CONCLUSIONS

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Gestational Exercise and Maternal and Child Health: Effects until Delivery and at Post-Natal Follow-up

We studied the influence of pregnancy exercise on maternal/offspring cardiometabolic health until delivery and at follow-up. We pooled data from two randomized controlled trials from our group that were performed following the same methodology (one unpublished). We also collected follow-up data de novo from the participants of both trials and their offspring. In total, 1348 women with uncomplicated, singleton gestations were assigned to an intervention (n = 688, performing a supervised, moderate-intensity exercise program (three sessions/week)) or control group (n = 660). Maternal outcomes were excessive gestational weight gain (EGWG), gestational hypertension/diabetes and, at follow-up, return to pre-pregnancy weight within six months, hypertension, overweight/obesity, and other cardiometabolic conditions. Offspring outcomes were macrosomia and low-birthweight and, at follow-up, overweight/obesity, low-weight, and cardiometabolic conditions. Adherence to the intervention, which proved safe, was > 95%. Pregnancy exercise reduced the risk of EGWG, gestational hypertension, and diabetes (adjusted odds ratio (OR) and 95% confidence interval: 0.60 (0.46–0.79), 0.39 (0.23–0.67), and 0.48 (0.28–0.84)), and it was associated with a greater likelihood of returning to pre-pregnancy weight (2.37 (1.26–4.54)) and a lower risk of maternal cardiometabolic conditions (0.27 (0.08–0.95)) at the end of follow-up (median 6.1 years (interquartile range 1.8)). Pregnancy exercise also reduced the risk of macrosomia (0.36 (0.20–0.63)) and of childhood overweight/obesity during the first year (0.20 (0.06–0.63)). Our findings suggest that pregnancy exercise might protect maternal/offspring health.

A Longitudinal Study of Physical Activity to Improve Sleep Quality During Pregnancy

PURPOSE

To explore the association between maternal physical activity (PA) and sleep quality during pregnancy, and the necessary PA level at different gestational stages to attain improved sleep quality.

METHODS

A total of 2443 participants were recruited from the Shanghai Maternal-Child Pairs Cohort (Shanghai MCPC) study, who had completed questionnaires including the Pittsburgh Sleep Quality Index (PSQI) and the International Physical Activity Questionnaire (IPAQ) at gestational weeks (GW) of 12-16 and 32-36. PSQI scores and their seven components at the two GW were compared, as were PSQI scores at 12-16 and 32-36 GW and the increment in PSQI relative to PA. Regression analysis was conducted to assess the effect of PA and its change on the total PSQI score at different GW.

RESULTS

The mean PSQI scores increased significantly during pregnancy, from 6.30 ± 3.01 at 12-16 GW to 7.23 ± 3.47 at 32-36 GW. Compared with women in low PA level, moderate levels of PA at both 12-16 GW and 32-36 GW were significantly reduced PSQI scores of 0.42 (95% CI:-0.68,-0.16) and 0.32 (95% CI:-0.63,-0.01), respectively. At 32-36 GW, high PA level also significantly decreased PSQI score, with a greater decline than moderate PA level. (AOR=-0.87,95% CI:-1.57,-0.18). PA increment from 12-16 to 32-36 weeks of pregnancy created a significant decline of 0.54 in PSQI scores.

CONCLUSION

The study revealed sleep quality was worse at the third trimester and moderate PA level had the potential for improvement of sleep quality both in the first and the third trimester. High PA level was also beneficial to improve sleep quality of pregnant women in the third trimester.

SLK Triple Therapy Improves Maternal and Fetal Status and Promotes Postpartum Pelvic Floor Function in Chinese Primiparous Women

Background

During pregnancy, appropriate physical activity plays critical roles in maternal and fetal health. This study investigated the effects of Sophrology childbirth-Kegel-Lamaze respiratory training (SLK triple therapy) on maternal and newborn health, pelvic floor function, and quality of life.

Material/Methods

Single-pregnant primiparous women involved in this study were divided into the control group (n=120) and the SLK triple therapy group (n=120). SLK triple therapy was taught to and practiced by the women in the SLK triple therapy group. Data on delivery mode (natural delivery or cesarean section), postpartum complications (postpartum urinary incontinence, postpartum hemorrhage), and birth process were recorded. Apgar scores and body weight of newborns were evaluated. Pelvic floor function, postpartum emotion, and sexual functions were assessed.

Results

Women in the SLK triple therapy group had significantly better natural delivery rate compared to the control group (p<0.05). SLK triple therapy significantly decreased the postpartum urinary incontinence rate and reduced the postpartum hemorrhage rate compared to the control group (p<0.05). Birth process and postpartum hemorrhage volume in the SLK triple therapy group were also significantly lower compared to the control group (p<0.05). Apgar scores were significantly lower and body weights were significantly higher in the SLK triple therapy group compared to the control group (p<0.05). SLK triple therapy significantly improved pelvic floor function compared to the control group (p<0.05). SLK triple therapy significantly decreased SDS scores and enhanced FSFI scores compared to the control group (p<0.05).

Conclusions

SLK triple therapy improved maternal and fetal health by improving pregnancy outcomes, promoting postpartum pelvic floor function, reducing the incidence of depression, and enhancing sexual function. Therefore, SLK triple therapy has great utility in treating primiparous women.

Protective Effect of Exercise in Pregnant Women Including Those Who Exceed Weight Gain Recommendations: A Randomized Controlled Trial

OBJECTIVE

To investigate the effect of supervised moderate to vigorous exercise on gestational weight gain, its related risks (gestational diabetes [GD]), macrosomia, and type of delivery), and the preventive effects on women who exceed the weight gain recommendations.

PATIENTS AND METHODS

We conducted a single-center, 2-armed, randomized controlled trial between October 1, 2009, and June 30, 2011, in which 678 women were assessed and 345 were randomized by a central computer system to an intervention group (N=115) or a standard care group (N=230). The intervention exercise program consisted of 70 to 78 sessions (24 weeks, 3 times per week, 60-65 minutes per session, moderate to vigorous intensity). The standard care group received usual care. Excessive gestational weight (EGW) gain was calculated on the basis of the 2009 Institute of Medicine (IOM) recommendations.

RESULTS

Of the 345 women randomized for treatment, 44 were lost to follow-up, leaving 301 women for analysis (intervention, 100; standard care, 201). Fewer women in the intervention group exceeded IOM recommendations (22 [22.0%] vs 69 [34.3%]; P=.03), including overweight and obese women (15 of 35 [42.9%] vs 40 of 50 [80.0%]; P=.001). Analysis of women exceeding weight recommendations revealed that the 3 main related risks were directly related to EGW gain in the standard care group (GD, P=.003; macrosomia, P<.001; type of delivery, P<.001) but not in the intervention group (GD, P>.99; macrosomia, 0%; type of delivery, P=.46).

CONCLUSION

Supervised moderate to vigorous exercise performed throughout gestation was effective in the prevention of EGW gain even for women with a pregestational body mass index greater than 25 kg/m². It also prevented its related risks (GD, macrosomia, and type of delivery) including for women exceeding the IOM recommendations, so we suggest that being active outweighs the effect of possible weight gain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01477372.

Feasibility of conducting an early pregnancy diet and lifestyle e-health intervention: the Pregnancy Lifestyle Activity Nutrition (PLAN) project

BACKGROUND

Childhood obesity is a global issue. Excessive weight gain in early pregnancy is independently associated with obesity in the next generation. Given the uptake of e-health, our primary aim was to pilot the feasibility of an e-health intervention, starting in the first trimester, to promote healthy lifestyle and prevent excess weight gain in early pregnancy. Methods: Women were recruited between 8 and 11 weeks gestation and randomised to the intervention or routine antenatal care. The intervention involved an e-health program providing diet, physical activity and well-being advice over 12 weeks.

RESULTS

Women (n = 57, 43.9% overweight/obese) were recruited at 9.38 ± 1.12 (control) and 9.06 ± 1.29 (intervention) weeks' gestation, mainly from obstetric private practices (81.2%). Retention was 73.7% for the 12-week intervention, 64.9% at birth and 55.8% at 3 months after birth.No difference in gestational weight gain or birth size was detected. Overall treatment effect showed a mean increase in score ranking the perceived confidence of dietary change (1.2 ± 0.46, p = 0.009) and score ranking readiness to exercise (1.21 ± 0.51, p = 0.016) over the intervention. At 3 months, infants weighed less in the intervention group (5405 versus 6193 g, p = 0.008) and had a lower ponderal index (25.5 ± 3.0 versus 28.8 ± 4.0 kg/m3) compared with the control group.

CONCLUSION AND DISCUSSION

A lifestyle intervention starting in the first-trimester pregnancy utilising e-health mode of delivery is feasible. Future studies need strategies to target recruitment of participants of lower socio-economic status and ensure maximal blinding. Larger trials (using technology and focused on early pregnancy) are needed to confirm if decreased infant adiposity is maintained.

Impact of exercise on maternal gestational weight gain: An updated meta-analysis of randomized controlled trials

BACKGROUND

Clinical evidence indicates that women will benefit from regular physical activity during pregnancy. This study aimed to summarize and update the evidence on the effect of exercise on maternal gestational weight gain (GWG).

METHODS

We conducted a systematic literature search of Pubmed, Embase, and Cochrane Library from inception until July, 2018 for randomized controlled trials (RCTs) that investigate the effect of physical exercises on the maternal GWG compared with that of no physical exercises or conventional medical care. We extracted data from eligible trials for study characteristics, interventions, patients' baseline characteristics and outcomes for the study populations of interest. We conducted meta-analyses using random effects models.

RESULTS

From 844 citations, 23 RCTs including 4462 pregnant women met the inclusion criteria. Meta-analysis indicated that compared with that in women having conventional medical care, GWG was significantly decreased in pregnant women with physical exercise [weighted mean difference (WMD) -1.02, 95% CI -1.35 to -0.70; P < .01; I = 48.4%]. Women appeared to benefit more for gestational weight control for exercise frequency of 3 times per week (WMD -1.22, 95% CI -1.55 to -0.90; I = 40.3%) and exercise duration of 30 to 45 minutes each time (WMD -1.32, 95% CI -1.79 to -0.85; I = 1.5%).

CONCLUSION

This meta-analysis provides indications that exercise intervention can reduce maternal GWG for pregnant women, especially for those with exercise frequency of 3 times per week and duration of 30 to 45 minutes each time.