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Physical activity and exercise during pregnancy

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DOI: 10.3109/21679169.2013.861509

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 European Journal of Physiotherapy, 2014; 16: 2–9

REVIEW ARTICLE

Physical activity and exercise during pregnancy

European Journal of Physiotherapy Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/01/14

MANZUR KADER1 & SAIRA NAIM-SHUCHANA2

1Sectionof Physiotherapy, Department of Neuroscience, Uppsala University, Uppsala, Sweden, 2Uppsala Kommun Vård &
Bildning, Uppsala, Sweden

Abstract
A physical inactive lifestyle is associated with increased prevalence of chronic diseases such as cardiovascular disease, type
2 diabetes, osteoporosis and cancer. The proportion of pregnant women with overweight or obesity is increasing rapidly
across the world and this excess weight, mainly obesity, is associated with increased risk of health problems during preg-
nancy and in connection with childbirth. Pregnancy poses significant physiological changes in the body and thus many
pregnant women are worried about being physically active or exercising during this period. This literature review aimed to
determine the advantages or disadvantages, current recommendations and restrictions on physical activity and exercise
during normal pregnancy. Searches were carried out on databases PubMed, CINHAL and the Cochrane Library. The
review indicates that all healthy pregnant women can be physically active to achieve health benefits. Physical activity and
For personal use only.

exercise during pregnancy does not increase any risk of adverse pregnancy or birth outcomes, not even for elite athlete
women. All healthy pregnant women can remain physically active. However, high-risk sports or hard working should be
avoided; greater caution and carefulness should be taken to avoid any unexpected complications and elite knowledge about
physical activity and exercise during normal pregnancy is necessary.

Key words: Exercise, physical activity, pregnancy

Introduction
Physical activity has been defined as “any bodily
movement produced by skeletal muscles that result
in energy expenditure”. Exercise is “a subset of phys-
ical activity that is planned, structured, repetitive,
and purposeful in the sense that improvement or
maintenance of physical fitness is the objective” (1).
Lack of physical activity is rising in many coun-
tries and a physically inactive lifestyle is associated
with increased prevalence of chronic diseases such as
cardiovascular disease, type 2 diabetes, osteoporosis
and cancer and their risk factors such as raised
blood pressure, raised blood sugar and overweight
(1,2). The World Health Organization (WHO) rec-
ommends that adults aged 18–64 years need to
do physical activity at least five times a week for at
least 30 min at moderate intensity (2).
Pregnancy poses significant physiological changes,
in terms of increased cardiorespiratory capacity, mus-
culoskeletal, hormonal and some other physiological
adaptations. There is an increase in blood volume,
heart rate and stroke volume, as well as cardiac out-
put, and a decrease in systemic vascular resistance.
Oxygen uptake increases up to 10–20% compared
with before pregnancy. There is a gradual decrease
in maternal body temperature with increasing gesta-
tional age; a decrease in temperature of 0.3°C (0.5°F)
occurs in the first trimester, with further decreases
of 0.1°C (0.2°F) per month through 37 weeks of
gestation (3). Hormonal changes (increased levels
of oestrogen and relaxin) during pregnancy cause
an increased mobility of the joints. Balance may be
affected by changes in posture with increased risk
of falling. Pregnant women typically develop lumbar
lordosis, which results in very high prevalence (45%)
of low back pain (4). More frequent emptying of
the urinary bladder and urgency are common
during pregnancy because of fetal pressure, which
increases the risk for the development of urinary
incontinence (5).

Correspondence: Manzur Kader, Division of Pediatrics, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska University
Hospital, Huddinge, B62, SE-141 86 Stockholm, Sweden. E-mail: manzur.kader@ki.se

(Received 29 September 2013 ; accepted 28 October 2013)

ISSN 2167-9169 print/ISSN 2167-9177 online © 2014 Informa Healthcare
DOI: 10.3109/21679169.2013.861509

The proportion of pregnant women with over-
weight or obesity is increasing rapidly across the
world. This is a very serious problem when over-
weight and obesity increases in mother, as this excess
weight, mainly obesity, is associated with elevated
risks of serious complications during both pregnancy
and in connection with childbirth. It is well docu-
mented that maternal obesity is strongly associated
many adverse obstetric and neonatal outcomes such
as diabetes, preterm birth, caesarean section, post-
European Journal of Physiotherapy Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/01/14
partum haemorrhage, macrosomia and low birth
weight in different ethnic groups (6).
In the past, most pregnant women were worried
about being physically active or exercising during
pregnancy in order to achieve a safe pregnancy con-
dition and a growing fetus. The American College of
Obstetricians and Gynecologists (ACOG) published
their first guidelines for leisure-time physical activity
for pregnant women in 1985. Not surprisingly, the
guidelines were derived from the limited evidence-
based research data available at that time and they
restricted stringently the type, intensity and duration
of exercise during pregnancy to minimize both
maternal and fetal risk (7). In 1994, the ACOG mod-
ified their recommendations to state that pregnant
For personal use only.
women, in the absence of contraindications, can
continue to exercise at moderate intensity for 30 min
or more per day, at least three times per week (8).
So, recently this perception about physical activity
and exercise during pregnancy has changed greatly.
As non-pregnant women, many pregnant women
may wish to continue exercising during pregnancy
to gain the important health benefits of regular phys-
ical activity. Evidence-based recommendations for
exercise during pregnancy are therefore important.
The aim of this review was to provide insight into
the advantages or disadvantages, current recommen-
dations and restrictions on physical activity and exer-
cise during normal pregnancy.
The specific objectives of this review were:
• to explore the advantages or disadvantages
with physical activity and exercise during nor-
mal pregnancy;
• to investigate how exercise influences on the
pregnant woman and fetus;
• to identify the restrictions and contraindica-
tions to physical activity and exercise during
pregnancy; and
• to determine the recommendations for com-
petitive athletics (elite sport) during pregnancy.
Method
The articles included in this review were retrieved
using the databases PubMed, CINHAL and the
Cochrane Library. The search terms used were
Physical exercise during pregnancy 3
“Exercise”, “Physical activity” and “Pregnancy” in
different combinations. The search was limited to
articles based on humans, written in English.
The inclusion criteria intended to find articles
based on studies dealing with physical activity and
exercise during normal pregnancy with healthy
women (not during pregnancy with pregnancy-
related medical conditions such as high blood pres-
sure or high blood sugar).
The exclusion criteria were the activity or exer-
cise during pregnancy being carried out in combina-
tion with another treatment, such as acupuncture.
In the beginning, titles and abstracts of the arti-
cles were reviewed and the articles that were assessed
as interesting and relevant for this review were
selected. Apart from this, some additional studies
that were cited in the selected articles were chosen
to ensure all relevant articles were selected for this
review. The search primarily targeted randomized
controlled trials and cohorts or prospective study
designs; however, one cross-sectional study was also
included, which matched well with the search crite-
ria. A total of 10 research articles of relevance were
chosen, which were considered up to date. Further-
more, some review articles were selected to write
more about advantages, recommendations and con-
traindications of exercise during pregnancy.
Results
All the articles that were the basis for this review
agree that all healthy pregnant women can be physi-
cally active to achieve great health benefits, and phys-
ical activity and exercise during normal pregnancy
should be encouraged. None of the articles noted
any disadvantages or adverse outcomes of physical
activity and exercise during normal pregnancy if
the exercise programme followed the recommended
guidelines. A summary of the major findings from the
research articles has been presented in Table I. A nar-
rative description of all the articles is given below.
Different types of physical activity
It has been demonstrated that the centre of gravity
in the human body moves forward during pregnancy
and this can cause poor postural control, which can
affect the physical performance. Some features of
physical activities that include rhythmic and dynamic
exertion with major muscle groups are recommended
such as brisk walks, swimming, water gymnastics,
hiking, jogging, climbing stairs/step-ups, aerobic
dance, cycling, rowing, skating and rope skipping are
especially tailored for pregnant women (9–11). Walk-
ing and swimming/water gymnastics are so gentle

Table I. Physical activity and exercise during pregnancy.
Reference, country, year
Gjestland et al. (16), Ahus,
Norway, 2013
Price et al. (17), Austin,
Texas, USA, 2012
Silveira & Segre (18), São
Sebastião, Brazil, 2012
Salvesen & Mørkved (19),
Trondheim, Norway, 2004
Pelaez et al. (20), Madrid,
Spain, 2013
Juhl et al. (21), Denmark,
2008
de Oliveria Melo et al. (22),
Campina Grande, Brazil,
2012
Tomić et al. (23), Zagreb,
Croatia, 2013
Madsen et al. (24),
Denmark, 2007
Larsson & Lindqvist (26),
Lund, Malmö and
Stockholm, Sweden, 2005
Note: OR, odds ratio; CI, cumulative incidence; VO2max, maximal oxygen consumption; HR, hazard ratio; MHR, maximum heart rate.
European Journal of Physiotherapy Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/01/14
Study design, participants and objectives
Birth Cohort study, 3482 pregnant women. To
investigate the association between exercise in
mid-pregnancy and low-back pain (LBP), pelvic
girdle pain and depression at 32 weeks of
pregnancy
Prospective randomized controlled trial, 41 women
to exercise group. To assess the benefits and
possible risks of aerobic exercise during
pregnancy
Prospective randomized controlled trial, 37 women
to exercise group, To assess the influence of
exercise on the type of delivery
Randomized controlled trial, 148 women in
exercise group. To examine the effect of pelvic
floor muscle training on labour
Randomized controlled trial, 73 women in exercise
group. To investigate the effect of pelvic floor
muscle exercise on the prevention of urinary
incontinence
The Danish National Birth Cohort with 87,232
singleton pregnancies. To examine the
relationship between physical exercise and the
risk of preterm birth
Randomized controlled trial, 125 women in two
exercise groups. To estimate the effect of exercise
on physical fitness, feto-placental blood flow, and
fetal growth
Randomized controlled trial, 166 women in
intervention group To assess the effect of
physical activity on abnormal fetal growth
Prospective study with retrospective data
collection, 92,671 women. To examine the
association between physical exercise and the
risk of miscarriage
Cross-sectional study, 37 women. To study
temperature and oxygen saturation responses
to low-impact exercise
For personal use only.
Intervention and length of exercise programme
Different type of self-reported exercises, e.g. brisk
walking, skiing, commuting to work by bike and
sports/exercise. In pregnancy weeks 17–21.
Intensity, frequency, duration of exercise varied
Moderate aerobic exercise on treadmills, elliptical
trainers, stationary bicycles or equivalent weight
training, 45–60 min, 4 days/week. Starting at
12–14 weeks, through 36 weeks of gestation
Stretching 5–10 min, strengthening exercise 30–40
min, with 10–30 reps, 2 days/week. Starting from
the 8th week of pregnancy until the end of
pregnancy
Structured pelvic floor exercise programme. Eight to
12 intensive contractions of the pelvic floor
muscle, 3 times/week. Between 20 and 36 weeks
of pregnancy
Structured pelvic floor exercise programme, 55–60
min in duration, 3 times/week. Between 14–36
weeks of pregnancy
Different type of self-reported exercises: swimming,
low-impact activities, e.g. walking/hiking and
bicycling. Intensity, frequency, duration of
exercise, and length of exercise varied
Moderate intensity walking, 15 min or more, 3
times/week. Starting at 13 and 20 weeks until the
28 weeks of gestation
Objectively measured exercises: warm-up (5 min),
aerobic exercise (30 min), stretching (10 min),
and cooldown (5 min). 3 times/week. Starting
from 6–8 weeks until the end of pregnancy
Self-reported exercises, e.g. jogging, walking/hiking,
workout/fitness, bicycling/horseback riding,
swimming. Intensity, frequency, duration of
exercise varied
Both conditioning and weight-bearing activities,
stretching and relaxation. Jumps, running, and
exercises from a supine position were excluded.
Around gestational age of 25.4 weeks
4
Major outcomes
M. Kader & S. Naim-Shuchana
The women who exercised ⱖ 3 times/week reported
less pelvic girdle pain (OR 0.76, 95% CI
0.61–0.96), who exercised 1–2 times/week
reported less LBP (OR 0.80, 95% CI 0.66–0.97)
and depression (OR 0.66, 95% CI 0.48–0.91)
Exercised women improved aerobic fitness
(p ⬍ 0.05), muscular strength (p ⬍ 0.01), fewer
caesarean deliveries (p ⬍ 0.01), and recovered
faster postpartum (p ⬍ 0.05)
The women who were engaged in regular exercise
had 29.7% higher rate of vaginal deliveries
(p ⫽ 0.031)
Trained women had a lower rate of prolonged
second-stage labour (OR 0.24, 95% CI 0.16–
0.33), than the women who did not train (OR
0.38, 95% CI 0.28–0.47)
Trained women had 34.5% less urinary incontinence
than the non-trained women (p ⬍ 0.001)
Trained women had almost 40% reduced risk of
preterm birth (OR 0.82, 95% CI 0.76–0.88). The
association was not affected by the type of exercise
Improved VO2max. No difference in large for
gestational age or small for gestational age and no
difference in birth weights between the
intervention and control group
Trained women had 6.5% lower frequency of
macrosomia in newborns (p ⫽ 0.048) and 6.5%
less gestational diabetes (p ⫽ 0.008). No significant
differences in intrauterine growth restriction
between the intervention and control group
Increased risk of miscarriage (HR 3.7, 95% CI
2.9–4.7), who exercised ⬎ 7 h/week. High-impact
exercise, e.g. jogging, ball games was associated
with increased risk of miscarriage, but no
association after 18 weeks of gestation
None of the women were even close to approaching
a dangerous body temperature at an intensity level
of 69% of their MHR, (36.5 vs 36.7 or 36.5° C,
p ⫽ 0.1, p ⫽ 0.5)

that most of the women can continue with them until
the birth. Tai chi and some forms of yoga are other
good options when they facilitate relaxation and
increase body awareness (12).
Heavy weight training and contact sports with
high risk of falling over or a blow to the stomach, for
example, football, horse riding, martial arts and ski-
ing should be avoided (11). Scuba diving should not
be performed during pregnancy, as it is easy to form
gas bubbles in the fetal blood (13). Physical exercise
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at high altitude (⬎ 2500 m) has been shown to cause
a diversion of blood from the placenta to the woman’s
muscles. Theoretically, this can cause lack of oxygen
to the fetus and hence at least 4–5 days adjustment
is need to return to the normal metabolism (14).
Intensity, frequency and duration of exercise
The recommendation of exercise for a healthy adult
is at least five times a week for at least 30 min at
moderate intensity. Moderate exercise is defined as
exercise of 3–4 METS (metabolic equivalent task) or
any activity that is equivalent in difficulty to brisk
walking. One MET is the energy used by the body
while sitting (15).
For personal use only.
The most commonly prescribed combinations of
sets and repetitions that have been recommended for
pregnant women are 12–15 repetitions in the two to
three sets (11,12). The purpose of physical activity
during pregnancy should be to maintain physical
status rather than to improve it and to lose weight.
Exercise contributes to keep the body weight within
reasonable limits, which is positive for both woman
and the fetus (11).
Positive effects of physical activity and exercise
during pregnancy
General fitness and well-being. Physical activity and
exercise during pregnancy provides a range of health
benefits. A birth cohort study with 3482 pregnant
women in Norway, where the women were engaged
in different types of self-reported exercises, e.g. brisk
walking, skiing, commuting to work by bike and
sports/exercise between the pregnancy weeks 17 and
21. The study showed that physical activity during
pregnancy had a clinically significant reduction in
pelvic girdle pain, low back pain and depression (16).
The studies by Price et al. (17) and by Silveira &
Segre (18) from prospective randomized controlled
trials assessed the influence of medium intensity
aerobic exercise on general fitness, muscular strength
and on the type of delivery. In the study by Price
et al. (17), 43 women were in intervention or exercise
group for moderate aerobic exercises with both
upper extremity and lower extremity exercises on
Physical exercise during pregnancy 5
treadmills, elliptical trainers, stationary bicycles or an
equal time interval of weight training. In the study
by Silveira & Segre (18), 37 women were in an group
for stretching and strengthening exercises in different
ways. The studies demonstrated that well-trained
women managed the birth better, had a higher rate
of vaginal deliveries or a lower rate of caesarean sec-
tions (17,18) and had more aerobic fitness, muscular
strength, reduced time for the birth and reduced risk
of childbirth complications (17). Moreover, trained
women recovered faster postpartum and had better
profile of pregnancy-related medical conditions such
as high blood pressure and blood sugar than the
women who did not train (17).
Pelvic floor muscle and urinary incontinence. Pelvic floor
muscle training during pregnancy results in improved
muscular control and strong muscular flexibility. In
the study by Salvesen & Mørkved (19), 148 women
were randomized to an intervention group for a struc-
tured exercise programme for the pelvic floor muscles
with 8–12 intensive contractions three times a week.
This study demonstrated that well-trained women
had a lower rate of prolonged second-stage labour
than the women who did not participate in the pelvic
floor muscle training. The pelvic floor exercises also
prevented urinary incontinence during pregnancy
and after childbirth. In the study by Pelaez et al. (20),
73 women were randomized to a similar structured
pelvic exercise programme three times per week,
with 55–60 min in duration. The study showed that
95.2% of the women in exercise group had no leakage
vs 60.7% of women in the control group at the end
of intervention (week 36 of pregnancy) (p ⬍ 0.001).
They recommended that all pregnant women prac-
tice their pelvic floor muscle exercises daily.
Premature birth. There is no connection between phys-
ical exercise and the risk of premature birth or any
other increased risk of adverse pregnancy or child-
birth outcomes. A study from the Danish National
Birth Cohort with 87,232 singleton pregnancies
examined that physical activity and exercise might be
able to prevent a premature birth. The study women
participated in different types of exercises, most com-
monly swimming, low-impact activities (aerobics/
gymnastics, dancing, walking/hiking, yoga) and bicy-
cling. Intensity, frequency, duration and length of
exercise varied according to the women’s physical
condition and preference. It was suggested that it did
not matter in what type of physical activity and exer-
cise the pregnant woman was engaged in (21).
Fetal blood flow and fetal growth. Studies from ran-
domized controlled trials by de Oliveria Melo et al.
(22) in Brazil and by Tomić et al. (23) in Croatia
 6 M. Kader & S. Naim-Shuchana
investigated the effects of physical exercise during
pregnancy on fetal blood flow and fetal growth. The
study by de Oliveria Melo et al. (22) included187
women who were randomized to one of three groups:
with exercise initiated at 13 weeks of gestation, at
20 weeks of gestation and a control group with
no supervised exercise. The women in the exercise
groups were instructed to do moderate intensity
supervised walking three times per week until the
28 weeks of gestation. The basic findings were a
European Journal of Physiotherapy Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/01/14
significant improvement of mean maximal oxygen
consumptions with no differences in the frequency
of large for gestational age or small for gestational
age, and no difference in mean birth weights. They
suggested that walking as a form of physical activity
has an important role in the development of the
physical fitness level of pregnant women without
affecting feto-placental blood flow or fetal growth.
The study by Tomić et al. (23) consisted of 166
women in the randomized group who received vari-
ous types of objectively measured aerobic exercises
with a frequency of three times per week throughout
the whole pregnancy period, starting from the 6th–
8th week of pregnancy. A lower frequency of mac-
rosomia in newborns (6.0% vs 12.5%, p ⫽ 0.048)
For personal use only.
and gestational diabetes (1.8% vs 8.3%, p ⫽ 0.008)
was observed in the study group than the control
group, but no significant differences were observed
in terms of intrauterine growth restriction and in
other perinatal outcomes among the two groups.
Miscarriage. A study from the Danish National Birth
Cohort with 92,671 singleton pregnancies demon-
strated that exercise during early pregnancy (11–14
weeks) was associated with the risk of miscarriage
while the risk was less during later gestation (15–22
weeks), and no significant association was found after
18 weeks of gestation. When compared with non-
trained women, high-impact exercise, e.g. weight bear-
ing, jumping (for 75–269 min/week), was associated
with a higher risk of miscarriage, but swimming for the
same duration was associated with a decreased risk of
miscarriage (24). It was recommended that even if any
woman was used to exercising before pregnancy, she
should not increase exercise level before the 14th week.
After week 14, the risk of miscarriage and hyperthermia
drops and most women start to feel more energetic.
Restrictions and contraindications
Medical conditions where physical exercise should be
avoided
ABSOLUTE CONTRAINDICATIONS TO EXERCISE IN
PREGNANCY (11)
• Haemodynamically significant heart disease
• Restrictive lung disease
• Incompetent cervix/cerclage
• Multiple gestation at risk for premature
labour
• Persistent second or third trimester bleeding
• Placenta praevia after 26 weeks gestation
• Premature labour during the current pregnancy
• Ruptured membranes
• Pregnancy induced hypertension
RELATIVE CONTRAINDICATIONS TO AEROBIC EXERCISE
DURING PREGNANCY (11, 12)
(Contact with the midwife or doctor is recommended
for any exercise pass)
• Severe anaemia
• Unevaluated maternal cardiac arrhythmia
• Chronic bronchitis
• Poorly controlled type I diabetes
• Extreme morbid obesity
• Extreme underweight (body mass index,
BMI ⬍ 12)
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in current
pregnancy
• Poorly controlled hypertension/preeclampsia
• Orthopaedic limitations
• Poorly controlled seizure disorder
• Poorly controlled thyroid disease
• Heavy smoker
WARNING SIGNS TO TERMINATE EXERCISE WHILE
PREGNANT (11)
• Vaginal bleeding
• Dyspnoea before exertion
• Dizziness
• Headache
• Chest pain
• Muscle weakness
• Calf pain or swelling (need to rule out
thrombophlebitis)
• Preterm labour
• Decreased fetal movement
• Amniotic fluid leakage
Competitive athletics (elite sport) and pregnancy
Competitive athletes tend to retain their strenuous
training schedule throughout pregnancy and res-
ume their high-intensity training schedule after the
birth earlier than women who did not participate
in sports at a competitive level. Competitive ath-
letes fall into two general categories: (i) the effects
of pregnancy on competitive ability; (ii) the effects
of strenuous exercise and competition on preg-
nancy, particularly the fetus. These women would
certainly require obstetric supervision other than
the routine prenatal care and should have continuous

contact with both their obstetricians and physio-
therapists. It is important regularly to check both
weight gain and exercise (intensity, type and dura-
tion) (11,25).
As the pregnancy progresses, it becomes harder
for the woman to stay on the same performance level
as before pregnancy. Gaining weight in combination
with increased laxity in the joints and ligaments, and
changing the centre of gravity will cause unavoidable
limitations in most sports. The ability to start and
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stop, and to perform skilfully executed movements
becomes difficult. The relatively high intensity, fre-
quency and long duration of exercise session may
place an elite athlete pregnant women at an increased
risk of complications related to the regulation of
body temperature (11,12).
However, pregnant women have a better tem-
perature regulation than non-pregnant women. From
the study of temperature and oxygen saturation
responses to low-impact exercise in 37 healthy preg-
nant women in Sweden, it has been demonstrated
that women who exercised at a submaximal level of
⬍ 70% did not increase their body temperature; none
of the pregnant women were even close to approach-
ing a dangerous body temperature (26). Because of
For personal use only.
the type (high intensity, prolonged and frequent) of
training done by elite athletes, it is likely that weight
gain will be less for both mother and fetus than for
sedentary women. Extra attention should be put on
an adequate fluid intake before, during and after the
workout and an additional caloric intake of 300 kcal
daily after the 13th week of pregnancy is recom-
mended to meet metabolic needs (11,27).
Discussion
Pregnancy brings a great physical challenge and bur-
den for a woman. Being physically active during
pregnancy is beneficial, both physically and mentally.
It is important to have knowledge of how much or
little physical activity is appropriate for both the
woman and fetus. Physical activity and exercise dur-
ing pregnancy should always be done with caution,
regardless of the woman’s physical status. All preg-
nant women who want to start or continue with their
exercise should first consult their physiotherapist,
doctor or midwife. A thorough maternal assessment
of the woman, with particular consideration to dietary
intake, pre-pregnancy BMI and exercise history, is
recommended before beginning to exercise during
normal pregnancy.
Pregnancy is one of the most common reasons
why women stop exercising and gain weight. It is
noticeable from some studies that many women
stopped exercising or reduced exercise frequency. In
the study by Silveira & Segre (18), approximately
Physical exercise during pregnancy 7
30% of the selected pregnant women withdrew from
participating, and in the Birth Cohort study (16),
only 14.6% of the respondents followed the current
recommendation for exercise during pregnancy. In
the Danish National Birth Cohort (21), almost two-
thirds (63%) of the women did not engage in any
kind of exercise around the time of the first interview,
which dropped to 70% during the second interview;
in the Swedish study (26), 51% of the pregnant
women reduced the frequency of exercise during
pregnancy.
Engagement in an exercise programme was not
the same for all women. Pregnant women with the
highest level of education had greater engagement
with the exercise programmes in the studies by
Gjestland et al. (16) and Silveira & Segre (18).
The association of physical activity with increased
risk of miscarriage in the study by Madsen et al. (24)
indicates that, even if a woman was used to exercising
before pregnancy, she should not increase exercise
level before the 14th week and should avoid high-
risk exercise or hard working. None of the other stud-
ies found any disadvantages or adverse outcomes;
remarkably, the study by Tomić et al. (23) did not
report any miscarriage among the participants,
although the participants started exercising from
6–8 weeks. This may be because high-risk sports or
hard working were avoided and greater care was
taken in all the studies.
It is documented that, from about 4th month,
the venous return is prevented by the growing
uterus in supine position, so called vena cava com-
pression, and increases the risk of a reduced cardiac
output and blood pressure (28). In this case, phys-
ical exercise in the supine position should be avoided
from the 16th week of pregnancy. Although physical
exercise in the standing position for a longer time
can cause the same effect with blood pressure and
can reduce heart capacity, exercises while lying on
the side, sitting or standing short term should be
adapted (3).
A strength of this review is including many cohort
studies that clearly provide an appropriate progres-
sive sequence between exposure and outcome, and
permit the direct calculation of relative risks and inci-
dence rates in both the exposed (exercised) and
unexposed (non-exercised) groups (29). Another
strength of the review is including some randomized
controlled trials that have the ability to measure the
exercise programme objectively during the preg-
nancy, and to monitor closely the non-exercising
control group.
Some limitations from the studies should be
noted; many studies (16,21,24) used data on self-
reporting of exercise, which might have been influ-
enced by recall bias and over- or underestimation
 8 M. Kader & S. Naim-Shuchana
of estimation of physical activity (30). There is an
inconsistency in intensity, frequency, duration and
length of exercise period during pregnancy among
the studies and information about validation of the
questionnaires is missing in many studies. Some
studies followed their exercise programmes in com-
pliance with the guidelines set by the ACOG
(17,18,22,23). Some studies had a relatively small
sample size without any statistical sample size cal-
culation or without fulfilling the power-related
European Journal of Physiotherapy Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/01/14
demands of the study to ensure a moderate effect
size (20,26).
However, this review provides evidence-based
recommendations about the fact that all pregnant
women without medical risk can be physically active
to achieve great health benefits. This differs markedly
from previous recommendations when physical exer-
cise was thought to increase the risk of adverse preg-
nancy and birth outcomes (7). Even elite athlete
women can continue to train at a high level during
pregnancy, which is interesting. However, knowledge
about the elite sport in pregnancy is still very limited,
and hence more and larger studies are needed in the
area where much scientific proof is lacking. Through
a generous attitude to physical activity and exercise
For personal use only.
during pregnancy, women’s future health can be
promoted.
Conclusion
All healthy pregnant women can remain physically
active at a moderate intensity level for at least 30 min
a day. Physical activity and exercise during pregnancy
does not increase any risk of adverse pregnancy or
birth outcomes. However, high-risk sports or hard
working should be avoided; greater caution and care
should be taken to avoid any unexpected complica-
tions and elite knowledge about physical activity and
exercise during normal pregnancy is necessary.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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