Exercise in obese pregnant women: positive impacts and current perceptions

Figures & data

Table 1 Risks associated with overweight and obesity during pregnancy

Maternal risks
Pregnancy	– Gestational diabetes^Citation16
	– Hypertensive disorders^Citation16
	– Difficulty with ultrasound scanning and amniocentesis^Citation7
Labor and birth	– Preterm birth (iatrogenic)^Citation16
	– Induction of labor^Citation15,Citation16
	– Cesarean section^Citation15,Citation16
	– Anesthetic complication^Citation7
	– Risk of thromboembolism^Citation7
Postpartum	– Infection^Citation7
	– Prolonged hospital stay^Citation7
Infant risks	– Perinatal death^Citation16
	– Congenital anomalies^Citation16
	– Shoulder dystocia and birth trauma^Citation7
	– Macrosomia^Citation16
	– Low Apgar score^Citation7
	– Hypoglycemia^Citation15
	– Hyperbilirubinemia^Citation7
	– NICU admission^Citation16

Abbreviation: NICU, neonatal intensive care unit.

Table 2 Studies describing exercise and maternal and neonatal health outcomes

Study and location(s)	Design	n	Outcomes	Findings
Barakat et al^Citation71 Spain and Sweden	Randomized controlled trial	83	Maternal glucose tolerance and prevalence of gestational diabetes	Exercise during pregnancy was associated with better maternal glucose tolerance (P < 0.01), but not with the incidence of gestational diabetes.
Carmichael et al^Citation72 US	Case control	831	Neural tube defects	In women who did not use folate supplements, leisure-time physical activity was associated with a 30%–50% lower risk of neural tube defects compared with women who were inactive during pregnancy.
Clapp et al^Citation38 US	Randomized controlled trial	46	Antenatal placental growth rate and neonatal and placental morphometric measurements	Exercise was associated with increased infant birth weight (P = 0.05), length (P = 0.05), and lean body mass (P = 0.05).
				Exercise was also associated with increased placental growth rate (P = 0.04) and indexes of placental function (P < 0.05).
de Barros et al^Citation73 Brazil	Randomized controlled trial	64	Insulin requirement and glycemic control	Resistance exercise was associated with a reduced number of women who required insulin (P = 0.005).
Dempsey et al^Citation25 US	Case control	541	Gestational diabetes	Physical activity during the first 20 weeks of pregnancy was associated with a 50% reduction in risk of gestational diabetes (OR 0.40, 95% CI 0.23–20.68).
Dempsey et al^Citation26 US	Retrospective cohort	909	Gestational diabetes	Recreational physical activity before pregnancy was associated with a risk reduction of 56% for gestational diabetes. Physical activity during pregnancy only did not reduce risk of diabetes, although physical activity both before and during pregnancy reduced risk of diabetes compared with inactive women (RR 0.31).
Evenson et al^Citation36 US	Prospective cohort	1699	Prematurity	Vigorous leisure activity during the first trimester (OR 0.80, 95% CI 0.48–1.35) and second trimester (0.52, 0.24–1.11) had protective effect against preterm birth.
Fortner et al^Citation74 US	Prospective cohort	1043	Hypertensive disorder	Higher level of sports/exercise in early pregnancy was associated with decreased risk of hypertensive disorders (Ptrend = 0.04).
Haakstad and Bo^Citation75 Norway	Randomized controlled trial	105	Birth weight, incidence of low birth weight and macrosomia, and Apgar score	Supervised aerobic exercise was not associated with difference of birth weight or incidence of low birth weight and macrosomia, but higher Apgar score at 1 minute (P = 0.02).
Hatch et al^Citation37 US	Retrospective cohort	557	Prematurity	Vigorous leisure-time physical activities were associated with a reduced risk (RR = 0.11) of preterm birth.
Hui et al^Citation76 Canada	Randomized controlled trial	190	Excessive gestational weight gain	Higher physical activity during pregnancy was associated with reduced excessive gestational weight gain (P = 0.01).
Ko et al^Citation77 US	Randomized controlled trial	1196	Incidence of gallbladder sludge or stones	Vigorous physical activity did not decrease the incidence of gallbladder sludge or stones during pregnancy at 18 weeks (RR = 0.89) and 36 weeks (RR = 1.31).
Latka et al^Citation78 US	Case control	346	Miscarriage	Leisure-time physical activity during pregnancy was a protective factor against miscarriage (OR = 0.6, 95% CI 0.3–0.9).
Lynch et al^Citation33 Australia	Prospective cohort	23	Cardiovascular function	Exercise was associated with improved aerobic fitness, as measured by physical work capacity (P = 0.003), and also decreased maternal heart rate (P = 0.041) and mean fetal heart rates (P = 0.001).
Martin and Brunner Huber^Citation29 US	Retrospective cohort	3348	Hypertensive complications	Higher level of physical activity during pregnancy was associated with a lower risk of hypertensive complications (physical activity for 1–4 days per week: OR = 0.63, 95% CI 0.45–0.90; physical activity for 5+ days per week: OR = 0.46, 95% CI 0.20–1.02).
Mattran et al^Citation79 US	Retrospective cohort	300	Offspring size at 18–24 months	Leisure-time physical activity was associated with lower toddler weight (P = 0.06) and weight-for-height (P = 0.06).
May et al^Citation80 US	Case control	61	Fetal cardiac autonomic control	At 36 weeks of gestational age, fetal heart rate was significantly lower in the exercise group (P < 0.001). Heart-rate variability was also higher in the exercise group.
Melzer et al^Citation31 Switzerland	Retrospective cohort	71	Mode of birth, resting metabolic rate, total energy expenditure, activity-related energy expenditure, maximal oxygen uptake, sleeping heart rate, and movement (accelerometer)	Active women were fitter, with lower sleeping heart rate when compared with inactive women. Active women had shorter duration of second stage of labor (P = 0.05). Inactive women were at higher risk of operative birth (OR = 3.7, 95% CI 0.87–16.08).
Nascimento et al^Citation81 Brazil	Randomized controlled trial	82	Gestational weight gain, blood pressure, perinatal outcome, and quality of life	There was no difference in gestational weight gain, blood pressure, perinatal outcome, or quality of life in pregnant women who had supervised exercise intervention or routine care.
Oken et al^Citation27 US	Retrospective cohort	1805	Gestational diabetes or abnormal glucose tolerance during pregnancy	Vigorous physical activity before pregnancy was associated with a reduced risk of 44% for gestational diabetes (OR = 0.56, 95% CI 0.33–0.95) and 24% for abnormal glucose tolerance (0.76, 0.57–1.0).
Polman et al^Citation34 UK	Case control	66	Mood states before and after exercise sessions	Aqua class and gym class, but not parentcraft class, resulted in enhanced mood in women in 2nd and 3rd trimester when compared with the controls (P < 0.01).
Poudevigne and O’Connor^Citation35 US	Prospective cohort	24	Energy expenditure and psychological well-being	Increased fatigue and vigor scores in pregnant women from 12 to 16 weeks and from 32 to 36 weeks gestational age.
				Above average level of physical activity during the 2nd and 3rd trimesters was associated with mood stability.
Stutzman et al^Citation32 Canada	Quasirandomized controlled trial	22	Blood pressure, heart rate variability, and baroreflex sensitivity	Exercise lowered resting systolic blood pressure and diastolic blood pressure (P < 0.05).
Sorensen et al^Citation30 US	Case control	584	Preeclampsia	Regular activity during early pregnancy was associated with a 35% reduced risk of preeclampsia (OR = 0.65, 95% CI 0.43–0.99). This risk was further reduced in women performing vigorous physical activity (0.46, 0.27–0.79).

Abbreviations: OR, odds ratio; CI, confidence interval; RR, relative risk; US, United States.

Table 3 Studies describing physical activity pattern during pregnancy

Study and location	Design	n	Outcomes	Findings
Women of all weight categories
Borodulin et al^Citation47 US	Prospective cohort	471	Physical activity	Physical activity declined during pregnancy.
Duncombe et al^Citation48 Australia	Cross-sectional	158	Time in physical activity	There was a significant reduction in both the prevalence of exercise and time spent exercising during pregnancy.
Fell et al^Citation49 Canada	Retrospective cohort	1737	Physical activity	There was a decline in physical activity in early pregnancy. Obesity was associated with discontinuation of sport.
Mottola and Campbell^Citation50 Canada	Prospective cohort	529	Physical activity	During pregnancy, all activities declined, with the exception of walking, which increased in the 3rd trimester.
Schmidt et al^Citation51 US	Cross-sectional	233	Total energy expenditure	No significant difference identified in the median total energy expenditure over 1st, 2nd, or 3rd trimester of pregnancy.
Watson and McDonald^Citation52 New Zealand	Prospective cohort	197 women	Physical activity	Activity declined throughout pregnancy (P = 0.002).
Overweight and obese women
McParlin et al^Citation53 UK	Retrospective cohort	55 overweight and obese	Time in physical activity	There was a significant reduction of physical activity from 1st to 2nd trimester (P = 0.018).
Renault et al^Citation54 Denmark	Cross-sectional	163 obese and 175 overweight	Physical activity	Obese women had fewer step counts when compared with women of normal weight (P < 0.05). In obese women, there was an increase in activity from early to midpregnancy, followed by a decline in the 3rd trimester.

Abbreviations: UK, United Kingdom; US, United States.

Table 4 Studies describing enablers and barriers of active lifestyle during pregnancy

Study, location	Design	n	Findings
Clarke and Gross^Citation46 UK	Interviews and questionnaires	57	Enablers: receiving advice and education.
			Barriers: concerns about safety, physical limitations, low motivation, and limited facilities or spaces.
Duncombe et al^Citation48 Australia	Questionnaire	158	Enablers: feeling of fitness, tone, and strength; relieving stress; enjoyment; having a regular routine.
			Barriers: tiredness, lack of time, dislike of exercise, and concern about safety.
Evenson et al^Citation62 US	Short telephone interview	1535	Barriers: pregnancy complications and other health problems, personal reasons, social and cognitive reasons, and environmental factors.
Pereira et al^Citation63 US	Questionnaire	1442	Barriers: work commitment, pregnancy complications, and feelings of depression.
Symons Downs and Hausenblas^Citation64 US	Questionnaire	74	Enablers: feeling that exercise improves mood, increases stamina, staying fit, feeling that weight is under control, and influence from family.
			Barriers: physical limitations and restrictions, tiredness, lack of time, gaining weight, caring for other children, worry about safety, weather, and low motivation.
Thornton et al^Citation65 US	Interviews	10 pregnant and postpartum and 8 family members	Enablers: partner’s advice and support, cultural norms, health professional’s advice, friends’ support and companionship, and access to child care.

Abbreviations: UK, United Kingdom; US, United States.

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