Hi, I'm Dr. Sarah Wong and I'm going to be talking to you today about exercise recommendations in pregnancy. We are going to review the recommendations for exercise in pregnancy, discuss the benefits of exercise as well as the risks, and review exercise prescription in this patient population. So to start, we'll talk a little bit about exercise recommendations in pregnancy. Pregnancy is looked at as an ideal time to focus on health routines. So for women who are already having healthy routines, we should encourage them to continue that and that includes exercise. For women who don't necessarily exercise or have those healthy routines in place, pregnancy is a good time to start those routines. The goal of exercise in pregnancy is to pursue moderate intensity exercise for at least 20 to 30 minutes per day on most days of the week. One of the first questions we get from patients all the time is, is it safe to exercise? Is there any chance that this is going to cause harm to myself or the baby? What we know is that physical inactivity and excessive weight gain are both independent risk factors for maternal obesity and pregnancy complications. We also know that regular exercise does not result in miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery. There have been studies, pretty extensive studies, on various types of exercise including walking, stationary cycling, aerobics both on land and in water, resistance exercise, and stretching exercise, and all of these exercises have been found to be safe during pregnancy. So what are some of the benefits of exercise in pregnancy? So we know that women who exercise have a higher incidence of cesarean birth or instrumented vaginal deliveries. We also know there's a lower incidence of excessive gestational weight gain, gestational diabetes, and gestational hypertensive disorders including preeclampsia. We also know that there's improved postpartum recovery time in women who exercise during pregnancy as well as a lower incidence of depressive disorders in the postpartum period. In pregnancy there's a greater self-reported overall, in women who have a greater self-reported overall physical fitness and cardiorespiratory fitness, these women typically have less body pain, lumbar and sciatic pain, and reduced pain disability overall. So I want to discuss next some of the kind of things to keep in mind when we're prescribing exercise to our patients, focusing specifically on some of the contraindications and things to avoid. There are some contraindications to exercise. I'm going to mention just a few, you can see a list here, but I want to mention a few that are more related to the pregnancy itself, an incompetent cervix, multiple gestational pregnancy at risk for premature labor, persistent second trimester or third trimester bleeding, placenta previa after 26 weeks, premature labor during the current pregnancy, or ruptured membranes, as well as preeclampsia or pregnancy-induced hypertension. So it's important to remember that in women who have some of these conditions that we are discussing what exercise regimens might be safe or what to avoid with their obstetrician. There's also a few exercises that we definitely want to avoid in pregnancy. So contact activities with a high risk of abdominal trauma, things like football obviously aren't a good idea for a pregnant woman, as well as activities with a high risk of falling. So downhill skiing might not be a good option. Scuba diving is also not recommended in pregnancy. It's also important to understand some of the warning signs that we need to inform our patients about on when to discontinue exercise in pregnancy and contact their obstetrician. These include vaginal bleeding, abdominal pain, contractions, amniotic fluid leakage, dyspnea before exertion, dizziness, headache, chest pain, muscle weakness that affects balance, or calf pain or swelling. So I want to talk just a little bit about some things to think about with exercise prescription because as we know in our regular patient population, exercise prescription is beneficial. Pregnant women are the same as our regular patient population. They are more likely to follow our recommendations if we give them more specific guidelines and a written prescription. So it's important to remember that the principles of exercise prescription for pregnant women really don't differ that much from the general population. The goal of exercise in pregnancy is moderate intensity exercise for at least 20 to 30 minutes per day on most days per week. So for women who were sedentary prior to pregnancy, it's important to give them guidelines as to how to start exercising. And this should be started slow and worked up to this 20 to 30 minutes per day goal. Whereas women who are already exercising are really able to maintain the exercises they were doing prior to pregnancy. So because we know that there can be a blunted heart rate response or normal heart rate response in pregnancy, it's now thought that monitoring exercise with intensity level is better than monitoring with heart rate response. So when we look at the board grading skill for rating of perceived exertion, we're really looking at trying to get in the range of a 13 to 14, which is somewhat hard. An easy way to tell our patients to kind of monitor this on their own is to do the talk test, which just means that they're able to hold a conversation while exercising. And if they're able to do this, it likely means that they're not overexerting themselves. Some precautions are things to keep in mind when prescribing exercise. Obviously, the patients need to remain well hydrated. Avoid long periods of lying flat on their back. So this may mean modifying some of the exercises that they were doing previously and to stop exercising if they have any of the warning signs that I mentioned previously. It's also important to make sure that your patients are exercising in a in a thermo controlled environment. So hot yoga is probably not the best exercise for a pregnant woman. So we want to encourage people to engage in both aerobic and strength conditioning exercises, and as I mentioned before, if they were sedentary prior to pregnancy, we really want to do a gradual progression of exercise, whereas women who exercised previously are able to engage in high intensity exercise programs if they were doing so prior to pregnancy. Been shown to have no adverse effects on the pregnancy, and those are encouraged to continue with modifications as needed as the pregnancy goes on into the third trimester. I do want to talk a little bit about barriers to exercise. I think when we're prescribing exercise in our pregnant population, it's really important to remember that not everyone has the access to exercise facilities and and the ability to exercise as much as maybe some of our other patients. So we know that there's a greater rate of obesity and excessive weight gain during pregnancy in black women. We also know that the odds of meeting physical activity recommendations is significantly higher in white women as compared to women of other racial racial and ethnic groups. So it's important to keep this in mind. This becomes an even larger issue in low income households. So we know that when looking at low income households, especially in black women, 35 percent of those women report no exercise and over 50 percent report only non strenuous physical activity, meaning they didn't get their heart rate up and weren't weren't increasing their rate of breathing at all during exercise. There was a study that was performed where they looked at barriers to exercise. So in the study, they had focus groups and they talked about what barriers there are to exercise, specifically during pregnancy. So in this specific study, it included black women in low income households, most of whom had household incomes of less than ten thousand dollars per year. And we're all these women were largely also on Medicaid as far as health insurance goes. So they found a few barriers that I think are really important for us to keep in mind. So there's individual or interpersonal barriers. So some of these are physical limitations, extreme fatigue during pregnancy, emesis during pregnancy, as well as pain. So we need to make sure we're addressing these conditions, especially the pain in our patients, if we're asking them to exercise, because if if they're if they have pelvic girdle pain, that could limit what they're able to do and may make them feel like exercises isn't best for them. Time is also an issue. You know, I think we probably all feel this all the time that there's never enough hours in the day and our patients are no different between work and family commitments. Oftentimes it seems like the day is filled. So kind of, you know, talking through this with the patient and troubleshooting ways of finding time throughout the day to exercise and really stressing the fact that we're looking at, you know, actual exercise, not just child care duties and walking around at work. But we want to have focused exercise time. The patients also felt that there were information barriers, so specifically a lack of guidance from their health care workers. So, again, if we're able to to give the patient an exercise prescription with very detail, very good details about what we want them to do, that is helpful. There's also resource barriers, so financial constraints as well as lack of neighborhood facilities and resources. And finally, there there were barriers related to cultural influence. They also asked this group of patients which what what may be some ways to overcome some of these barriers and some of the things that were listed were having specific, specific targeted exercise programs for patients or finding exercises that they may be able to do at home or in a group setting, as well as increasing resources in their in their area. So the last thing I want to talk about are a couple of targeted exercises that can be helpful during pregnancy. The first of these is is core strengthening and in in pregnancy, as you know, as the as the the fetus grows and the abdominal muscles kind of separate and stretch, the core strength of of individuals is compromised. On top of that, there are women who avoid core strengthening because of concern that they could be injuring them, injuring their baby or hurting, hurting their baby. So it's important to encourage core strengthening and specifically targeting the deep core muscles, so transverse abdominis, as well as the pelvic floor muscles. Both of these sets of muscles are important for support, as well as during labor and delivery. So some targeted exercises that may be important to include in an exercise program or in a physical therapy prescription include things like posterior pelvic tilts, which can be done in supine position during first trimester and may be modified to be in standing during second and third trimester. Wall squats with transverse abdominis activation and pelvic floor muscle contraction, as well as transverse abdominal stabilization while sitting on a Swiss ball and marching. Glute strengthening is another important focus during pregnancy, so we know that glute weakness affects the mechanics of the pelvis during pregnancy and can lead to low back and pelvic girdle pain. So targeted strengthening of the glutes can lead to less pelvic girdle pain. So one targeted exercise that might be included is a side-lying glute mean strengthening. Other exercises to add or consider in the third trimester might be deep squats to help open up the pelvis in preparation for labor and delivery. And finally, training in open glottis pushing. So the typical type of pushing that women are instructed to do during labor and delivery is closed glottis or Valsalva pushing. And this is actually not the best form of pushing for the pelvic floor muscles and can lead to a higher likelihood of prolapse down the road, as well as incontinence and pelvic floor dysfunction. So training women in open glottis pushing or pushing against while exhaling through pursed lips is more beneficial. So this type of pushing does not cause the diaphragm to lower, but instead focuses on using the abdominal or core muscles to increase pressure and fetal descent. So that's what I have for you today regarding exercise in pregnancy. I would like to turn this over to my colleague, Dr. Hameed, who is going to discuss postpartum exercise considerations. So thank you so much. I'm Dr. Hameed. I'm going to be talking a little bit about postpartum exercise considerations. So to start, I have no relevant disclosures. Objectives, we're going to talk a little bit about some common musculoskeletal problems in postpartum women and using a case based approach today to do so. We're also going to talk a little bit about how to return postpartum women to an exercise program, as well as discuss the safety of exercise in the postpartum period as well. So I wanted to start off with, you know, how do you get back into exercise? When is it safe? And really, this question depends on a lot of different questions. So I think the first question we need to ask is how much did this woman exercise during pregnancy? What was the duration and intensity of her labor, as well as the style of delivery? Meaning, did she end up needing to have stitches during or after delivery? Were there need for forceps or vacuum delivery to be used? Was it a large baby? Was there a C-section? For example, after a C-section, we know that in rabbits, the abdominal fascia actually doesn't regain tensile strength or close to 100 percent tensile strength until one year after that surgery. So it really can take a while for those muscles to sort of come back together and improve that tensile strength. Additionally, you know, there's not a lot of research here to sort of tell us how much is too much. There are a few studies looking at women in India and Nepal who do heavy physical work and did so sort of within one month of having a child. And that did increase the risk of urinary incontinence, as well as prolapse in these populations. So something to keep in mind that certainly going too quickly might not be a good idea. What are some of the barriers to exercise? I think there are a lot of different barriers that women experience, especially after a baby. Not everybody looks like the women in the picture on the right hand corner. So starting off, there's psychological stresses, the lack of sleep, the demands of a new infant can be quite stressing for a new mother. The physical barriers. So recovering from a sort of prolonged labor and delivery or maybe a C-section as well. Social support systems, you know, especially right now with the pandemic, women are isolated even more. So that can sometimes interfere. And generally, you know, in terms of the feeling of discouragement that can sometimes happen if you were previously exercising and active, the fact that it can take some time to get back into exercise in and of itself can be discouraging to women and may make them not want to participate as much. There was one study that looked at new mothers, so mothers that had delivered within a year and found that 65 percent of them were sort of defined as inactive after childbirth. And even those that had been previously active, 43 percent were either inactive or irregularly active after giving birth. They describe personal issues, lack of support from their spouses, parenting responsibilities as reasons for why they didn't participate, and things that we need to be talking about with our patients just to make sure that if they are experiencing those barriers, trying to encourage them and find ways to overcome them. There are some guidelines available, but really sort of not concrete and a little vague. So the American College of Obstetrics and Gynecology has sort of, you know, one paragraph in their exercise guidelines for pregnancy about postpartum women and how they can return. So they state that, you know, once the patient is sort of physically and medically safe, they can start. That ranges anywhere from a few days postpartum to up to six weeks after delivery. And they don't really tell you what to look for here other than just, you know, that they're medically safe. They do encourage a gradual return and they do state, you know, that moderate weight loss while nursing is safe for the baby and for the mother. And they do, you know, sort of quote studies that have found that there's a decreased risk of postpartum depression, which is obviously very important in this patient population, but they don't really give a lot of headway. So hopefully we can kind of dive into that a little bit more. So I wanted to sort of speak a little bit about some specific musculoskeletal related obstacles that might be interfering and how we can try to help women that have these issues get back into exercise safely. So we'll sort of go over these three conditions, including low back and pelvic girdle pain, diastasis recti abdominis, as well as pelvic floor disorders and pain. So for low back and pelvic girdle pain, generally, you know, during pregnancy, as Dr. Hwang had mentioned, there's a prevalence of about 45% or so of women that suffer from this, and postpartum, actually one in four women can have persistent low back or pelvic girdle pain six months after delivery. That is also seen in elite athletes, maybe not as high, but 12.6% found that they had pelvic girdle pain six weeks postpartum, and about 10% reported persistent low back pain six weeks postpartum. This is happening to women across the board. I wanted to start with a case. This is a G1, P1 female. She was a runner, and she came in one week after spontaneous vaginal delivery. She had severe groin pain. She was actually in such tremendous pain that she was really using a wheelchair actually at home. She was taking pain medications without relief, and really her OB history was fairly unremarkable. She was able to run into her third trimester. She did, however, have an induced and prolonged delivery, had some second degree tearing, and did have an epidural as well. Otherwise, medical history was unremarkable. Her physical examination, she had a severely intalgic gait. She was really having trouble even getting onto the examination table. She had tremendous tenderness to palpation at the pubic symphysis, and she was unable to do this test here, which is the active straight leg raise test, or the adductor test either. This was her x-ray, so this revealed a 27-millimeter pubic symphysial separation, which you can see in the middle there, and certainly was the source of her pain. Let's talk a little bit about pubic symphysial pain. Widening of the pubic symphysis is actually quite normal. This generally happens within around the 10th to 12th week of the pregnancy, so pretty early. We think it's driven by hormonal changes, including a relaxin and other hormonal milieu that's occurring. Generally, the normal distance of the pubic symphysis is about 10 millimeters, and widening can happen between 3 and 7 millimeters during the pregnancy. The incidence of pubic symphysial pain, just the pain itself, is anywhere from 20 to 28%. However, separation generally happens during delivery, especially with an epidural, and the thought is that the lack of pain feedback allows women to overpush, and then that's when the separation can occur, and this can happen in one in every 500 to 600 births. Risk factors for this, so definitely a larger baby can be a reason, undergoing induction and placement of epidural, like I mentioned. A breach presentation or prior history of pelvic trauma can also be risk factors. And generally, treatment can be conservative, especially if it's less than a 25-millimeter separation, and then the literature is sort of a little bit sparse in between 25 and 40 millimeters, meaning that there are some cases that have gone to surgery and some that have been treated conservatively successfully. Generally, though, if there's more than a 40-millimeter separation, there's pelvic ring instability at that point, and so surgery is generally recommended. On the right is a picture of the largest separation I'd seen, which was 62 millimeters, and this patient did have to go operative intervention. When you have a separation, there is an increased risk of osteoarthritis pubis, as well as a possible recurrence risk of about 50% in future pregnancies, so definitely something to keep in mind with these women. So this is sort of a picture of sort of the first-line treatment, which is a lot of the times using a binder to really help stabilize. I thought this was a nice picture of showing really how effective the binder can be. So on the top, you can see that the pubic symphysis is nicely reduced with the pelvic binder at the level of about the ASIS. However, if it's too high, which you can see in the picture below, you can sort of see that that separation is maintained, so really making sure that if we're going to go with a binder for treating these women, that we make sure that we're applying it correctly and that the woman knows how to do so. So for this patient, we ended up doing the binder. We also sent her to a women's health physical therapy. She worked with a specific therapist that worked with postpartum women. She started working on pelvic girdle and pelvic floor strengthening and stabilization exercises, and actually was able to get back into running about nine months postpartum, but still didn't feel 100%, and at that point, she was still breastfeeding. And so I wanted to bring that up as sort of just another thought is that when a woman is postpartum and still breastfeeding, some of those hormonal changes are still occurring, and so there may still be some inherent laxity in the pelvic girdle, and that might not improve until really she's done breastfeeding, which happened in our case. So about 15 months postpartum, she stopped breastfeeding, and her symptoms did gradually or continue to improve, and she was able to continue running. So the next case I wanted to talk about was going over diastasis recti abdominis. So this is sort of the abdominal sort of core sort of separation that Dr. Huang had described that happens during pregnancy, and so we know as the uterus grows, the abdominal muscles, including the rectus muscles, can stretch, and this postpartum rates are sort of all over the place. It's been reported anywhere from 30% to 68% of women in the postpartum period, and generally, if there's going to be spontaneous recovery, it should happen by eight weeks or so. There was a good study by Moda in 2015 that really relied on ultrasound, and they found that 100% of women during pregnancy in the third trimester met the cutoffs for diastasis recti. That sort of persisted in about 50% of women at four to six weeks postpartum, and actually in this cohort, about 39% persisted at six months postpartum. And really no studies on elite athletes in this case, however, this can certainly influence low back and pelvic girdle pain as well as pelvic floor pain in these women. So this is another case. So this is a 28-year-old soccer player that I had seen with a grade one anterolosesis at L5-S1, and she came in eight weeks postpartum with axial low back pain. Her pain was generally mechanical, nothing ridiculous, and her goal was to kind of get back into running and soccer, but hadn't been able to do so due to the back pain. She'd been doing some yoga, however. In terms of her pregnancy, she did really well. She was induced around 40 weeks. She did have to undergo a C-section, though, due to non-reassuring fetal heart tracing, and then during a yoga class, noticed that there was sort of some bulging of her abdominal region. So this was sort of part of her physical exam. So she did have tenting of the abdominal muscles, meaning that there was bulging sort of in the midline when she did a partial sit-up. On examination, she had about a three-finger breadth diastasis of the rectus muscle. She had some tenderness at L5-S1 in the spine's processes and had some low back pain with transitioning between flexion and extension. Otherwise, her neurologic exam was fairly normal. And so, just to sort of go over some of the cutoffs that we use, so as we sort of think about the rectus muscles sort of pictured there at the top on the right, what you can see is that there are sort of the different bundles of the muscle groups, and then they're sort of connected by the linea alba, and so the distance between the rectus muscles is something called the interrecti distance, and the cutoffs are a little controversial in the literature. Depending on where you look, you'll find there are sometimes a little bit different cutoffs but generally accepted cutoffs are about anything greater than 22 millimeters above the umbilicus would be considered a diastasis recti, and then anything greater than 16 millimeters below the umbilicus would be considered positive for this. Just so that you know, around the umbilicus, there is some separation that's inherent to linea alba and very common, so that's why we measure above and below. So generally, these develop in the third trimester. Risk factors potentially could be C-section, although it's controversial as well. Certainly women with multiparous or multiple gestations are at higher risk. That same ultrasound study found that age, BMI, weight gains, hypermobility score, the weight of the baby, abdominal circumference of 35 weeks, or prior history of exercise in pregnancy were not really associated with developing this. Ultrasound can also be really helpful here, and it can help us quantify that inter-recti distance. It can also be used as biofeedback tools, meaning that in an exercise session, you can encourage the woman with different exercises to see if those muscles will approximate. You can also, obviously, measure change in response to her rehabilitation, actually objectively, which is nice. This is a picture here outlining the two stars, or the approximation of the linea alba. You can see it in the picture below, labeled B. There's a stretching of the two rectus muscles and that linea alba, so it shows you what it can look like on ultrasound. For this patient, we ended up sending her to a women's health physical therapist. She underwent scar massage for her C-section. She did undergo core strengthening and functional training exercises and did quite well at five months postpartum, was able to get back into running and playing soccer. I also wanted to talk a little bit about postpartum pelvic floor disorders. It is estimated that about 50% of women will lose pelvic floor support after delivery. Urinary incontinence is one of those signs that we see a lot of, and so anywhere between 15% and 30% of women will have symptoms of urinary incontinence after the first year of delivery. Up to 20% can also suffer anal incontinence, especially if they had an obstetrical sphincter injury, so something to look out for as well. Less likely, I think, for women to sometimes talk about that. And then in terms of the elite athletes, there is some actually pretty good research out there to suggest that actually elite athletes have the same prevalence of stress urinary incontinence as are normal women in the general population at six weeks postpartum, it's about 30%. So definitely something that happens to a lot of women, and the stress of the pelvic floor, especially with things like running, can be part of why that is. So this was our last case today. So 29-year-old G1P1 female. She had had sort of a longstanding history. She came to see me 18 months postpartum. She'd had this sort of persistent left buttock pain. She'd seen multiple providers. It was really non-radiating and just sort of in that buttock region. Her OBE history was pretty unremarkable. She was active until the third trimester. She did have first-degree tearing with delivery. She did have an epidural. However, prior to seeing me, she had undergone physical therapy for several months. She had tried acupuncture. She tried multiple injections, including a trochanterversa injection, an SI joint injection, an epidural injection, and really none provided much relief. In terms of her physical examination, so she did have pelvic obliquity and sort of a functional leg-like discrepancy. She had some tenderness at the left sacral sulcus, as well as a long dorsal ligament. She had some restriction and extension of the lumbosacral spine. However, otherwise, really didn't have much else in terms of SI joint maneuvers and sort of dural tension signs. Her single-leg squat did, however, reveal really decreased lumbopelvic stability and sort of medial collapse of the knee as she did that. On further questioning, she also was having some urinary incontinence and some pain with intercourse. And so based on that, I ended up doing a pelvic floor exam as well. Important positives there, she did have some tenderness, sort of an increased resting state of both the left deep levator ani and obturator internus, and sort of weak pelvic floor contraction difficulty with coordination of the pelvic floor as well. And so just a sort of reminder is that pelvic floor dysfunction can really look like a lot of different things. So it can present as pain, similar to the patient I just described. It can also present with incontinence, either stress urinary merge or mixed incontinence. It can also present as prolapse, anal incontinence, pain with intercourse. Even constipation or urinary retention can be signs of pelvic floor dysfunction, as well as symptoms of pudendal neuropathy. And just remember the pelvic floor muscles have a lot of different functions. They contribute to not only the stress continence mechanism, but they help unload or sort of control that intra-abdominal pressure as being the floor of the floor. And sort of an intact pelvic floor can really help with the stiffness and stability of the pelvic ring as well. So for this patient, and sort of postpartum rehab in general, what are things that you can help women with? There is a sort of specialized women's health division of the APTA, where women's health therapists really sort of delving into the pelvic floor exist. And so you can look for those therapists specifically to help work on posture and gait, but also coordination of the core and the pelvic floor musculature, looking at body mechanics and manual techniques, actually internal sort of myofascial release can be very helpful. Use of biofeedback can be helpful as well, breathing techniques. And really, at the end of the day, it's going to be an individualized approach here with sort of specific stabilizing exercises, but also sort of making sure that the pelvic floor muscles can relax and the muscles themselves are coordinated to help with the functions of the pelvic floor. So for our patient, I ended up sending her to women's health physical therapy. She ended up undergoing sort of those similar techniques that we talked about and was able to really get back into an exercise program. So I know I mentioned that there was sort of not a ton of literature out there, even from the ACOG, in terms of sort of specific guidelines to return to exercise. So I did want to sort of give a little bit of more guidance there. So generally, in terms of those medical complications, we really want to make sure that there's no sort of fatigue, potential anemia that might be affecting the woman, any sort of vaginal bleeding. We want to make sure it's really stopped before encouraging women to get back into exercise. And certainly, if they're having any pain, they should sort of stop. Really slow and gradual progression is really important here. They can start with 15 to 30 minutes of moderate activity, three days a week, and then increase from there. Muscle toning exercises, especially focusing on the low back, the abdominals or core muscles, pelvic floor, and upper body can be very helpful as well. And just remember, I always try to encourage women that it's OK if it takes several months to even up to a year or even two years to get back into prior sort of pre-pregnancy fitness levels. So I think encouraging women and making sure that that may take some time is important. You also want to make sure that in terms of fatigue and sort of if they're tired because they're not sleeping well, that they should make sure that they're taking breaks and not overdoing it. And really incorporating the child can actually be really helpful and fun for them and fun for the baby. So an idea to kind of make sure that women can find time because of those barriers that we talked about. This was a nice program. Actually, I don't think that the pictures will show up, unfortunately, but basically sort of a strength training guide that was available in the literature to sort of help women sort of get back into an exercise program. So for sort of a general program, it's sort of starting with pelvic floor exercises, adding in sort of a modified front plank, some wall leans, clamshells, and bridges can sort of be a nice sort of starting step. This program encouraged at week two to add in some of those side-lying glute-meat strengthening exercises. At week three, adding in some prone hip extension and then sort of taking away that modification from the front plank if the woman is ready. At week four, you can sort of start having women do a little bit of a side bridge or a side plank. And then week five, sort of encouraging some squats, forward step-ups onto a step or a block if you have it. Front plank with adding in some leg extension as well as side bridges and quadruped arm raise can be helpful. You can sort of add in some quadruped leg extension at week six and then by week seven, encouraging some lunges, lateral step downs, and then sort of progressing to a bird dog exercise. And that can sometimes be sort of a nice program that I've given to women before that just really want to ramp up a little bit of exercise, they're not having so much pain or discomfort, they don't necessarily need a physical therapist, this can be a nice program to help give women. Before letting women get back into running, there is also some tests that you can do, some screens that you can do to make sure that the pelvic floor is not going to be sort of overworked. And so you want to make sure that women are not having pain, heaviness, dragging, or incontinence when they're walking for 30 minutes, when they do a single leg balance for 10 seconds, when they do 10 repetitions of a single leg squat, which I think is an excellent exercise to look to see sort of biomechanically what's happening, making sure that they're not having any pain or incontinence with jogging on the spot for one minute, doing 10 forward bounds and 10 hop in place on each leg can be a nice way to sort of screen in the office. You don't have to necessarily do all of these just to make sure that women are really truly ready to get back into a running program and not going to overstress the pelvic floor. Lastly, I just wanted to kind of quickly talk about nursing mothers. So if you are nursing, what's the rules for exercise? It's fine to be exercising, but you probably do either want to nurse or pump prior to exercise to avoid that sort of engorgement. The other thing you want to keep in mind is that lactic acid can actually build up from high intensity exercise for up to about 30 minutes after exercise. So you don't want to give that to the baby. So waiting that little bit of time and not being really needing to feed right after you're done exercising can help. You want to make sure that you're monitoring fluid intake, eating nutritious meals, wearing a secure bra can be helpful, but generally there's not really any risk to the baby in terms of reducing the nutritiousness of the milk or nutritional value or the quality of the milk. Just make sure that the infant is growing as you'd expect. The last note I wanted to just sort of mention is really what's happening with their calcium sort of homeostasis during pregnancy and then sort of with the lactation period. So generally during pregnancy, a lot of our calcium intake is actually increased, increased absorption from the gut as we eat our calcium level while pregnant, and that obviously goes to the bones and it also goes to the baby. However, in lactation, that increased absorption from the gut actually goes away. And so a lot more of the calcium that actually is expressed through the breast milk will actually come from the bones. And so there are studies that suggest that during lactation, 4% to 7% of women will experience bone loss in the lumbar spine and the femoral neck. So we want to really keep that in mind in terms of the women that are breastfeeding, especially that are runners. There are case reports of stress fractures and other things, so really making sure that there's a slow and gradual progression and ramp up I think is very important, especially if they're breastfeeding. So in summary, exercise is safe. Really should start slow, increase aerobic exercise and loads gradually, making sure that they're conditioning the lumbopelvic musculature in particular. Screening can really help us know if a woman is safe to get back into running. And rehabbing with sort of women's health therapists for specific musculoskeletal, peripartum disorders can really be key to get the new mom back into an exercise program. Thank you very much. Hello. I'm Kate Tema, and I'm going to talk to you today about some anatomical and physiological changes of pregnancy as well as delve into some preconception exercise considerations. I have no disclosures. So when we think about pregnancy there are many different changes that occur and we're just going to give a brief overview of some physiological, anatomical, and postural changes that occur during pregnancy. From a physiological and hormonal standpoint there are many hormones that are increased to maintain pregnancy. Of note human chorionic gonadotropin tells the corpus luteum to make estrogen and progesterone. Progesterone is critical for maintaining pregnancy. The uterine lining and breast changes. Estrogen leads to the maturation of the uterine lining, growth of blood vessels, increased size of the uterus and breasts, and has a relaxing effect on ligaments and joints. These hormones are secreted by the corpus luteum until the placenta takes over at about 10 weeks. And studies have shown that estrogen and progesterone levels are more elevated in the third trimester in patients who experience joint pain during pregnancy. Another important hormone is relaxin. It's a polypeptide hormone that's secreted by the corpus luteum and the placenta. It elevates during that first trimester and it peeps at about week 12 towards the end of the first trimester. Then it declines 50% by about 17 to 24 weeks at which point it plateaus until delivery where we see an abrupt decline. There's no pre-delivery surge as there is are in many other hormonal effects in pregnancy and after delivery is non-detectable. Relaxin is thought to remodel pelvic connective tissue. It actually decreases the total collagen content of that tissue and the pubic symphysis undergoes a transformation with the added effect of estrogen from a highland cartilage to more of a fibrocartilage at the intrapubic ligament. It also is known to inhibit uterine contractility during pregnancy and it has a very controversial relationship to ligament dyslaxia. There have been many studies over the years that have looked at relaxin levels and its association to pain in pregnancy and there have been conflicting results with some showing a association and others showing a weak or no association. From a physiological standpoint there are also many cardiovascular changes in pregnancy. Increased cardiac output is more so than increased heart rate. Blood pressure decreases during early pregnancy and plasma volume will increase by 40 to 50 percent during pregnancy. When we look at the changes at three to six months postpartum, these changes should have gone back to the normal pre-partum state. In terms of joints, there's increased joint laxity throughout the body during pregnancy, especially with attention to the pelvis. The pubic symphysis is known to widen at about 10 to 12 weeks gestation and that may increase to up to 5 to 8 millimeters prior to delivery. At delivery or child birth, an increase of up to 10 millimeters total or 1 centimeter is considered to be normal but higher levels than that are associated with ligamentous disruption of the pubic symphysis and in some cases also at the sacroiliac joints. The good news is that when we look at imaging studies later on postpartum, most of these changes will resolve and if you were to do an x-ray you know 4 to 12 weeks after delivery, you would expect the width of the pubic symphysis to return to normal in most patients. The sacroiliac joints which are normally very tight firm joints have increased motion during pregnancy and lumbar lordosis has controversial effects during pregnancy in terms of whether there's increased lordosis in patients. Joint laxity, knees are more in a hyperextended position in many women during pregnancy and there's increased foot pronation and loss of the arch during pregnancy that has been shown in studies. Most of that is related to increased width and increased size of postpartum with most of the effects being seen in the first pregnancy but in general about a half the size per pregnancy would be considered usual. Anatomical changes at the muscular level, the rhomboids undergo increased stress with the enlargement of the breasts. Pectoralis muscles in the opposite side have a shortening effect due to enlarged breasts. The rectus abdominis muscle lengthens and separates. Up to two-thirds of women will expect that will experience a diastasis recti during pregnancy and this leads to decreased function and decreased biomechanical effects of the rectus abdominis. On the flip side, the paraspinal muscles shorten with increased load and the pelvic floor is supporting this gravid uterus throughout pregnancy. It becomes overstretched, stressed, and often fatigued. At the core level, the core is so important to everything that we do in life because it transfers energy from the upper to the lower extremities. It helps to maintain an upright posture. It stabilizes that thorax and pelvis dynamically throughout all the activities we do in life. It assists with lifting, pushing, exertion, birthing, and continence and is very critical with these actions and it supports forces or exertion on the skeleton that the alone could not withstand. In pregnancy, all bets are off. So this nice tight core that you know that we aspire to is being pushed by this gravid uterus during pregnancy. Hormonal changes have effects and so the diaphragm is now sitting at a mechanical disadvantage. You know, higher up the abdominal musculature is being stretched. The lumbar musculature is at a disadvantage and the pelvic floor is carrying around the gravid uterus. So what do we, what do we know about the effects of this? Well, the pelvic floor is so important, you know, to so much of what we do in life and we know that in voluntary exercise there's a co-contraction of the pelvic floor muscles and other core musculature including the transversus abdominis to maintain that lumbopelvic stability. In women, there is a broader shallower pelvis and they rely more on SI joint stability from the pelvic floor due to the increased mobility of the pelvis. This is unlike the SI joints in men which fit together much more like a puzzle piece and so they don't rely on that muscular stability in the way that women do. That effect becomes important because in pregnancy when the pelvic floor is at a disadvantage and when there are hormonal changes that are increasing the laxity of these joints, maintaining that SI joint stability becomes even more challenging and important. The pelvic floor in a sitting or more upright sitting postures do recreate greater pelvic floor resting muscle activity and over 50% of women who report some form of lumbopelvic pain have also been diagnosed with pelvic floor dysfunction. During childbearing, the pelvic floor actually undergoes extreme strain. The pubic occidius muscles increase to three times their size during labor which is really important because if you look at how an extremity muscle such as a bicep stretches, if it were to be stretched one and a half times its normal length, it would actually rupture during that activity. So in many ways the pelvic floor muscles are very resilient but you also see why they're at such risk for injury during pregnancy and childbirth. Assisted delivery increases that risk of pelvic floor trauma and vaginal delivery is the number one risk factor for stress urinary incontinence and the number of children someone has is that is the number one risk factor for having later prolapsed surgery. Some postural changes there are many during pregnancy. Many are related to the urine and breast enlargement. There's a weight gain of up to 20 to 40 pounds sometimes even more so in many women and then the ligaments it's in joint laxity that we discussed. There are spinal changes with women adapting a more head forward posture and exaggerated thoracic kyphosis and that controversial thought about lumbar hyperlordosis during pregnancy and the anterior pelvic tilt. Center of gravity naturally shifts during pregnancy due to all of these changes and so many women will adapt a wider base of support when they ambulate. Looking at the schematic on the left is you know what we hope to avoid in in pregnancy and things in terms of like muscular strengthening and postural correction can help us to maintain a better posture during pregnancy which can also prevent some of the musculoskeletal conditions and pain that we have so commonly in pregnancy. One of the biggest concerns from musculoskeletal standpoint in pregnancy is low back and pelvic girdle pain and what are some of those exercise implications. So we know that women up to 50 to 80 percent will report some sort of non-specific low back pain in pregnancies and the studies are varied because they all use different definitions of low back and pelvic pain in pregnancy but if you use the 2008 criteria for pelvic girdle pain that shows an incidence of about 25 to 50 percent of patients and this is including pain you know in the SI joints or pubic symphysis and if you include the lumbar region then the results are much higher than that. So why does it matter in terms of exercise? Well we know that women who had low back pain prior to a pregnancy are at a much higher risk for getting back pain in pregnancy or pelvic girdle pain and those that had pelvic girdle or low back pain in a prior pregnancy have a 50% increased risk of having it in a subsequent pregnancy. So that lack of exercise is known to be a one very important risk factor in terms of the development of pelvic girdle and low back pain which is why things that we think about in terms of prevention adding exercise to the regimen can be very helpful. So let's talk about exercise a little bit more and how we use it kind of as a medicine in terms of preconception benefits. First it's important to define it because there are many different definitions in the literature but if you look at the US Department of Health and Human Services definitions physical activity is defined as any skeletal muscle induced body movement that increases energy expenditure more so than the individuals resting energy expenditure or resting expenditure excuse me. Exercise is considered to be more of a structured or planned activity for physical fitness and health but in the literature these are often used interchangeably between physical activity exercise and leisure time physical activity when you're describing activities that are used for the benefit of health and fitness. If you look at the federal physical activity guidelines they're pretty clear and they're pretty easy you know to understand. They basically recommend two and a half hours which is a hundred and fifty minutes a week of moderate intensity aerobic activity. So this is anything that's going to get your heart pumping faster than usual and they also recommend that you consider breaking that up into 20 to 30 minute intervals on most days of the week. In addition to that aerobic activity they feel that it's very important to get muscle strengthening activity on at least two days out of your week and if you're somebody who prefers more of a vigorous activity or vigorous intensity activity like brisk running you could aim for 75 minutes a week as long as it's a vigorous activity. Why is physical activity so important? We all know that there are many many benefits but it's really important in terms of chronic disease. Approximately 50% of US adults live with a chronic disease and 25% live with two or more chronic diseases. The important part about that is that seven out of ten of those most common chronic diseases are actually affected by regular physical activity. However only half of US adults meet just the aerobic activity requirements and fewer than that meet the aerobic end strength training requirements combined. The cost to public health and to the nation are huge. There are over 100 million health care dollars spent each year and one out of ten premature deaths can be linked to physical inactivity. What are some of the effects on conception and the benefits of preconception exercise? Well if you think about it's really an ideal time to make positive lifestyle changes or to continue those active lifestyles as you're thinking about pursuing a pregnancy. The American College of Obstetrics and Gynecology recommends that regular physical activity occur for women prior to during as well as after pregnancy and they recommend that in the absence of any medical contraindications they follow the physical activity guidelines put out by the federal government which we just discussed. The peripartum period they feel is an ideal time for behavior modification because of the increased motivation for women to maintain these healthy lifestyles for both themselves as well as their future children and that they have more frequent access to medical care and monitoring during this period. Unfortunately physical activity while it doesn't meet the guidelines for many women in pre-pregnancy and it definitely doesn't meet them in pregnancy it actually decreases during pregnancy and only a third of women reported that they met the federal guidelines during pregnancy. However preconception physical activity is strongly predictive of continued physical activity in pregnancy so if we can get to them early and we can get them into a great routine they're more likely to maintain that during pregnancy which will have many health benefits for themselves as well as for their child. Exercise in terms of conception we know that physical activity on a regular basis has many positive effects on general health. It improves weight control, it decreases stress level, it improves sleep hygiene, it improves cardiovascular fitness and it has mental health benefits and many of these things are tied into infertility and the stressors from these concerns may actually affect fertility. When we're thinking about conception there has been a study showing that moderate physical activity improved IVF conception as well as live births in women who are obese. So not only were they more likely to conceive during IVF but of those that conceived they were more likely to have live births than those who are inactive. There are more conflicting results with extensive vigorous activity physical activity in terms of possible negative effects on fertility at the extreme cases and one thing to keep in mind is the female athlete triad which is a syndrome of three and related conditions with nutritional status or energy availability being the core component which has direct effects on menstrual function as well as bone health and if you're not getting enough nutrition to support both the intensity of the sport that you're doing as well as your body's physiological functions it will go into an emergency shutdown mode and during that time it will affect your reproductive axis and can lead to functional hypothalamic menstrual dysfunction or at an extreme situation amenorrhea. This may not become noticeable on a clinical standpoint until someone is trying to get pregnant and because they may have an undulation and it's not until they're desiring pregnancy that they may realize that they have low energy availability and functional hypothalamic menstrual dysfunction as a result. Of the leading cause of inovulatory infertility however is polycystic ovarian syndrome. This is a multifactorial metabolic disorder includes many aspects including insulin resistance and a risk for type 2 diabetes as well as cardiovascular disease. Insulin resistance in PCOS has direct effects on reproductive function. It's exacerbated by obesity which is a common side effect of PCOS and exercise improves insulin resistance in PCOS as well as BMI and it improves ovulation frequency. There has been a randomized controlled child looking at the effect of exercise and lifestyle modifications including weight loss on the effects of fertility in PCOS and they found that in overweight or obese women who had these lifestyle modifications they actually demonstrated improved fertility and live births versus those who underwent immediate infertility treatment. So like these lifestyle modifications were actually more effective than proceeding directly with infertility treatment which is very encouraging. Gestational diabetes is another very important medical condition that is seen often in pregnancy. It affects up to 15 to 20 percent of pregnancies and it's more commonly seen in women who are sedentary or overweight. The concern is that up to 70 percent of these women will have a risk for future type 2 diabetes and in infants born to women who have gestational diabetes there's an increased risk of many medical side effects including macrosomia, hypoglycemia, later onset of a later obesity and type 2 diabetes in life. The effects of physical activity show some positive considerations and any preconception or early pregnancy physical activity was shown to reduce the odds of gestational diabetes in one study and then greater than 90 minutes a week of preconception physical activity had a 40% reduced odds of gestational diabetes. These physical activity guidelines should be performed in conjunction with nutritional modifications for better effect. So what about exercise in the preconception period? What things you need to keep in mind? Well physical activity choices should mimic physical activity in pregnancy because many women will not actually know that they're pregnant early on in pregnancy and so you want to do things that would be considered safe for someone who might already be pregnant. The sports that are considered safe by the ACOG guidelines and also sustainable in pregnancy are things that you want to think about. Swimming, walking, running if you're already doing that, stationary bike, yoga, Pilates, lightweight lifting and water aerobics are all considered safe and sustainable throughout pregnancy. So these are things that in preconception you might want to consider getting into the habit of. Aerobic exercise is important to prep for those cardiovascular changes and the fitness and endurance demands of pregnancy. Strength training and core stabilization will help to decrease the risk for musculoskeletal pain in pregnancy and then thinking about pelvic floor prehabilitation. So really improving the strength, the stability and the function of your pelvic floor prior to the stressors of pregnancy can help you to not only get through the pregnancy with less symptoms but also to improve your pelvic floor function more quickly after delivery. And then things to think about in case you happen to be pregnant and not know it or to avoid sports with high risk of falls, abdominal trauma, scuba diving and high-altitude especially in the non-acclimated individuals. When you think about your exercise choices you always want to make sure that they're going to be adaptable as you become pregnant and as you go through pregnancy to meet those anatomical and physiological changes that will occur. And so initiating new routines during pregnancy may increase the risk of injury because you are not accustomed to them. So really thinking about getting to those in the pre-conception period you can prevent injury later on. Sedentary women are always encouraged to become physically active during pregnancy especially with medical guidance but it would be better to start those exercise programs several months prior to conception attempts so that they are more acclimated to those at the time. And vigorous activity is often considered safe in pregnancy if it was performed regularly prior to pregnancy. Making sure that if you are doing vigorous activity especially that you're maintaining hydration, optimal caloric intake to prevent things like the femalic triad and preventing hyperthermia. And then finally pre-conception physical fitness determines the level of safe physical activity in pregnancy. So the more that you can do before you're pregnant the better off you'll be in terms of physical activity during pregnancy. Thank you so much for your attention.

exercise recommendations

pregnancy

moderate intensity exercise

exercise benefits

cesarean birth

gestational weight gain

gestational diabetes

gestational hypertensive disorders

contraindications to exercise

warning signs during exercise