Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: Systematic review and meta-analysis of randomized clinical trials.

INTRODUCTION: The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical contraindications are recommended to start or continue regular aerobic and strength training for at least 150 min per week to prevent pregnancy-related diseases and conditions. Urinary incontinence in pregnancy, episiotomy and third- or fourth-degree perineal tear during labor can greatly impact womens' health, quality of life and ability to be physically active. The aim of this study was to examine the efficacy of pelvic floor muscle training (PFMT) during pregnancy in the prevention of urinary incontinence, episiotomy, and third- or fourth-degree perineal tear. MATERIAL AND METHODS: A systematic review and meta-analysis (CRD42022370600) was performed. Only randomized clinical trials published between 2010 and 2023 were included. The following databases were examined: EBSCO (including Academic Search Premier, Education Resources Information Center, MEDLINE, SPORTDiscus and OpenDissertations databases), Clinicaltrials.gov, Web of Science, Scopus, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database (PEDro). Three meta-analyses to investigate the effect of PFMT exclusively or implemented as a section within a physical activity program during pregnancy on urinary incontinence, episiotomy, and third- or fourth-degree perineal tear were conducted. RESULTS: Thirty studies were analyzed (N = 6691). An effective preventive action of PFMT was found for urinary incontinence (z = 3.46; p < 0.0005; relative risk [RR] = 0.72, 95% confidence interval [CI]: 0.59, 0.87, I2 = 59%) and third- or fourth-degree perineal tear (z = 2.89; p = 0.004; RR = 0.50, 95% CI: 0.31, 0.80, I2 = 48%) but not for episiotomy (z = 0.80; p = 0.42; RR = 0.95, 95% CI: 0.85, 1.07, I2 = 75%). CONCLUSIONS: PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes.

A scoping review exploring stigma associated with postpartum urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Postpartum urinary incontinence (UI) is prevalent, yet health-seeking behaviours for prevention and treatment are markedly low. Health-related stigma refers to conditions that may be socially devalued and considered deviating from "expected norms" and is a barrier to equitable health care. It may be plausible that stigma is associated with postpartum UI and leads to avoiding health-seeking behaviours, which this scoping review sought to examine and summarize. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews was followed. The following keywords were used to develop a search strategy: Postpartum, Urinary Incontinence and Stigma. The search was carried out on PubMed, PsycInfo, Scopus, CINAHL, Web of Science and ProQuest Dissertation and Theses Global. All study designs (clinical trials, observational studies, qualitative studies) were eligible for inclusion. Data were extracted and mapped to identify causal factors of postpartum UI stigma and implications for outcomes and behaviours. RESULTS: Twelve studies were included. Most studies utilized questionnaires assessing constructs related to quality of life that also captured potential stigma, or interviews. Sources of postpartum UI stigma included community values surrounding UI and self-stigma, whereby participants directed stereotypes associated with urinary leakage towards themselves. Implications of postpartum UI stigma included negative mental emotions such as shame and embarrassment, which led to avoiding situations where they needed to disclose symptoms, including in health care environments. CONCLUSIONS: Future research requires a purposeful assessment of postpartum UI stigma to learn from lived experience how to mitigate stigma and improve quality of care.

The 'new normal' includes online prenatal exercise: exploring pregnant women's experiences during the pandemic and the role of virtual group fitness on maternal mental health.

BACKGROUND: Prenatal anxiety and depressive symptoms have significantly increased since the onset of the coronavirus (COVID-19) pandemic In addition, home confinement regulations have caused a drastic increase in time spent sedentary. Online group fitness classes may be an effective strategy that can increase maternal physical activity levels and improve mental health outcomes by providing an opportunity for social connectedness. The present study explores the experiences of pregnant women who participated in an online group exercise program during the pandemic and identifies relationships with maternal mental health and well-being. In addition, we present person-informed recommendations on how to improve the delivery of future online prenatal exercise programs. METHODS: Semi-structured interviews were conducted with pregnant women (8-39 weeks of pregnancy) who participated in an online group exercise program, from March to October 2020 in Spain. A phenomenological approach was taken, and open-ended questions were asked to understand women's experiences throughout the pandemic and the role the online exercise classes may have had on their physical activity levels, mental health, and other health behaviours such as diet. A thematic analysis was performed to evaluate data. In addition, women completed the State-Trait Anxiety Inventory and these data supplemented qualitative findings. RESULTS: Twenty-four women were interviewed, and the anxiety scores were on average 32.23 ± 9.31, ranging from low to moderate levels. Thematic analysis revealed that women felt safe exercising from home, an increased availability of time to schedule a structured exercise class, and consequently an improvement in their adherence to the program and other behaviours (i.e., healthier diet). Women emphasized feeling connected to other pregnant women when they exercised online together, and overall, this had a positive effect on their mental well-being. Women suggested that future online exercise programs should include flexible options, detailed instructions and facilitation by a qualified exercise professional. CONCLUSION: Pregnant women are receptive to online group exercise classes and expressed that they are an accessible option to accommodating physical activity during the pandemic. In addition, the online group environment provides an important sense of connectivity among pregnant women exercising together and this may mitigate the detrimental effect of COVID-19 on maternal mental health.

Population characteristics associated with adherence to prenatal group-based exercise programs.

Community-based supervised group exercise may be an effective option to increase activity levels throughout pregnancy. Previous studies that have explored predictors of low adherence to exercise during pregnancy have not examined group-based settings. We analysed an international cohort of 347 pregnant women who participated in group-based prenatal exercise interventions (from <20 weeks to 34-36 weeks pregnant). Probable adherence predictors informed by previous literature that were assessed included: pre-pregnancy physical activity level and body mass index (BMI) classification, age, number of previous pregnancies, and education level. Adherence was measured by attendance. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated to explore the relationship between the selected predictors and high adherence (≥70%). Post-secondary education level versus only secondary (aOR 5.28; CI 1.67; 16.72) or primary level (aOR 13.82; CI 4.30; 44.45) presented greater likelihood to have high adherence to the exercise intervention than low adherence. Future research and public health initiatives should consider implementing strategies to overcome education-related barriers to improve accessibility to prenatal exercise.

Obesity can offset the cardiometabolic benefits of gestational exercise.

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

Physical activity and prenatal depression: going beyond statistical significance by assessing the impact of reliable and clinical significant change.

BACKGROUND: Previous literature supports exercise as a preventative agent for prenatal depression; however, treatment effects for women at risk for prenatal depression remain unexplored. The purpose of the study was to examine whether exercise can lower depressive symptoms among women who began pregnancy at risk for depression using both a statistical significance and reliable and clinically significant change criteria. METHODS: This study is a secondary analysis of two randomized controlled trials that followed the same exercise protocol. Pregnant women were allocated to an exercise intervention group (IG) or control group (CG). All participants completed the Center for Epidemiological Depression (CES-D) scale at gestational week 9-16 and 36-38. Women with a baseline score ⩾16 were included. A clinically reliable cut-off was calculated as a 7-point change in scores from pre- to post-intervention. RESULTS: Thirty-six women in the IG and 25 women in the CG scored ⩾16 on the CES-D at baseline. At week 36-38 the IG had a statistically significant lower CES-D score (14.4 ± 8.6) than the CG (19.4 ± 11.1; p < 0.05). Twenty-two women in the IG (61%) had a clinically reliable decrease in their post-intervention score compared to eight women in the CG (32%; p < 0.05). Among the women who met the reliable change criteria, 18 (81%) in the IG and 7 (88%) in the CG had a score <16 post-intervention, with no difference between groups (p > 0.05). CONCLUSIONS: A structured exercise program might be a useful treatment option for women at risk for prenatal depression.

Physical exercise programme during pregnancy decreases perinatal depression risk: a randomised controlled trial.

INTRODUCTION: The incidence of depression is high during the perinatal period. This mood disorder can have a significant impact on the mother, the child and the family. OBJECTIVE: To examine the effect of an exercise programme during pregnancy on the risk of perinatal depression. METHODS: Healthy women who were <16 weeks pregnant were randomly assigned to two different groups. Women in the intervention group participated in a 60 min exercise programme throughout pregnancy, 3 days per week, which was conducted from October 2014 to December 2016. The Center for Epidemiological Studies-Depression Scale was used to measure the risk of depression at the beginning of the study (12-16 weeks), at gestational week 38 and at 6 weeks postpartum. RESULTS: One hundred and twenty-four pregnant women were allocated to either the intervention (IG=70) or the control (CG=54) group. No differences were found in the percentage of depressed women at baseline (20% vs 18.5%) (χ2=0.043; p=0.836). A smaller percentage of depressed women were identified in the IG compared with the CG at 38 gestational weeks (18.6% vs 35.6%) (χ2=4.190; p=0.041) and at 6 weeks postpartum (14.5% vs 29.8%) (χ2=3.985; p=0.046) using the per-protocol analysis. No significant differences were found using the intention-to-treat analyses, except in the multiple imputation analysis at week 38 (18.6% vs 34.4%) (χ2=4.085; p=0.049). CONCLUSION: An exercise programme performed during pregnancy may reduce the prevalence of depression in late pregnancy and postpartum. TRIAL REGISTRATION NUMBER: NCT02420288; Results.

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

OBJECTIVE: To perform a systematic review and meta-analysis examining the influence of acute and chronic prenatal exercise on fetal heart rate (FHR) and umbilical and uterine blood flow metrics. DESIGN: Systematic review with random-effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcomes (FHR, beats per minute (bpm); uterine and umbilical blood flow metrics (systolic:diastolic (S/D) ratio; Pulsatility Index (PI); Resistance Index (RI); blood flow, mL/min; and blood velocity, cm/s)). RESULTS: 'Very low' to 'moderate' quality evidence from 91 unique studies (n=4641 women) were included. Overall, FHR increased during (mean difference (MD)=6.35bpm; 95% CI 2.30 to 10.41, I2=95%, p=0.002) and following acute exercise (MD=4.05; 95% CI 2.98 to 5.12, I2=83%, p<0.00001). The incidence of fetal bradycardia was low at rest and unchanged with acute exercise. There were no significant changes in umbilical or uterine S/D, PI, RI, blood flow or blood velocity during or following acute exercise sessions. Chronic exercise decreased resting FHR and the umbilical artery S/D, PI and RI at rest. CONCLUSION: Acute and chronic prenatal exercise do not adversely impact FHR or uteroplacental blood flow metrics.

Is supine exercise associated with adverse maternal and fetal outcomes? A systematic review.

OBJECTIVE: Theoretical concerns regarding the supine position at rest due to the gravid uterus obstructing aorta and vena caval flow may impinge uterine blood flow (UBF) to the fetus and maternal venous return. DESIGN: Systematic review. DATA SOURCES: Online databases up to 11 December 2017. STUDY CRITERIA: Eligible population (pregnant without contraindication to exercise), intervention (frequency, intensity, duration, volume or type of supine exercise), comparator (no exercise or exercise in left lateral rest position, upright posture or other supine exercise), outcomes (potentially adverse effects on maternal blood pressure, cardiac output, heart rate, oxygen saturation, fetal movements, UBF, fetal heart rate (FHR) patterns; adverse events such as bradycardia, low birth weight, intrauterine growth restriction, perinatal mortality and other adverse events as documented by study authors), and study design (except case studies and reviews) published in English, Spanish, French or Portuguese. RESULTS: Seven studies (n=1759) were included. 'Very low' to 'low' quality evidence from three randomised controlled trials indicated no association between supervised exercise interventions that included supine exercise and low birth weight compared with no exercise. There was 'very low' to 'low' quality evidence from four observational studies that showed no adverse events in the mother; however, there were abnormal FHR patterns (as defined by study authors) in 20 of 65 (31%) fetuses during an acute bout of supine exercise. UBF decreased (13%) when women moved from left lateral rest to acute dynamic supine exercise. CONCLUSION: There was insufficient evidence to ascertain whether maternal exercise in the supine position is safe or should be avoided during pregnancy.

Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this review was to investigate the relationship between prenatal exercise, and low back (LBP), pelvic girdle (PGP) and lumbopelvic (LBPP) pain. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were eligible (except case studies and reviews) if they were published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (prevalence and symptom severity of LBP, PGP and LBPP). RESULTS: The analyses included data from 32 studies (n=52 297 pregnant women). 'Very low' to 'moderate' quality evidence from 13 randomised controlled trials (RCTs) showed prenatal exercise did not reduce the odds of suffering from LBP, PGP and LBPP either in pregnancy or the postpartum period. However, 'very low' to 'moderate' quality evidence from 15 RCTs identified lower pain severity during pregnancy and the early postpartum period in women who exercised during pregnancy (standardised mean difference -1.03, 95% CI -1.58, -0.48) compared with those who did not exercise. These findings were supported by 'very low' quality evidence from other study designs. CONCLUSION: Compared with not exercising, prenatal exercise decreased the severity of LBP, PGP or LBPP during and following pregnancy but did not decrease the odds of any of these conditions at any time point.

Prenatal exercise is not associated with fetal mortality: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review of the relationship between prenatal exercise and fetal or newborn death. DESIGN: Systematic review with random-effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (miscarriage or perinatal mortality). RESULTS: Forty-six studies (n=2 66 778) were included. There was 'very low' quality evidence suggesting no increased odds of miscarriage (23 studies, n=7125 women; OR 0.88, 95% CI 0.63 to 1.21, I2=0%) or perinatal mortality (13 studies, n=6837 women, OR 0.86, 95% CI 0.49 to 1.52, I2=0%) in pregnant women who exercised compared with those who did not. Stratification by subgroups did not affect odds of miscarriage or perinatal mortality. The meta-regressions identified no associations between volume, intensity or frequency of exercise and fetal or newborn death. As the majority of included studies examined the impact of moderate intensity exercise to a maximum duration of 60 min, we cannot comment on the effect of longer periods of exercise. SUMMARY/CONCLUSIONS: Although the evidence in this field is of 'very low' quality, it suggests that prenatal exercise is not associated with increased odds of miscarriage or perinatal mortality. In plain terms, this suggests that generally speaking exercise is 'safe' with respect to miscarriage and perinatal mortality.

Effects of prenatal exercise on incidence of congenital anomalies and hyperthermia: a systematic review and meta-analysis.

OBJECTIVE: To investigate the relationships between exercise and incidence of congenital anomalies and hyperthermia. DESIGN: Systematic review with random-effects meta-analysis . DATA SOURCES: Online databases were searched from inception up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were eligible (except case studies and reviews) if they were published in English, Spanish or French, and contained information on population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume or type of exercise) and outcome (maternal temperature and fetal anomalies). RESULTS: This systematic review and meta-analysis included 'very low' quality evidence from 14 studies (n=78 735) reporting on prenatal exercise and the odds of congenital anomalies, and 'very low' to 'low' quality evidence from 15 studies (n=447) reporting on maternal temperature response to prenatal exercise. Prenatal exercise did not increase the odds of congenital anomalies (OR 1.23, 95% CI 0.77 to 1.95, I2=0%). A small but significant increase in maternal temperature was observed from pre-exercise to both during and immediately after exercise (during: 0.26°C, 95% CI 0.12 to 0.40, I2=70%; following: 0.24°C, 95% CI 0.17 to 0.31, I2=47%). SUMMARY/CONCLUSIONS: These data suggest that moderate-to-vigorous prenatal exercise does not induce hyperthermia or increase the odds of congenital anomalies. However, exercise responses were investigated in most studies after 12 weeks' gestation when the risk of de novo congenital anomalies is negligible.

Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review of the relationships between prenatal exercise and maternal harms including labour/delivery outcomes. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATASOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]) and outcome (preterm/prelabour rupture of membranes, caesarean section, instrumental delivery, induction of labour, length of labour, vaginal tears, fatigue, injury, musculoskeletal trauma, maternal harms (author defined) and diastasis recti). RESULTS: 113 studies (n=52 858 women) were included. 'Moderate' quality evidence from exercise-only randomised controlled trials (RCTs) indicated a 24% reduction in the odds of instrumental delivery in women who exercised compared with women who did not (20 RCTs, n=3819; OR 0.76, 95% CI 0.63 to 0.92, I 2= 0 %). The remaining outcomes were not associated with exercise. Results from meta-regression did not identify a dose-response relationship between frequency, intensity, duration or volume of exercise and labour and delivery outcomes. SUMMARY/CONCLUSIONS: Prenatal exercise reduced the odds of instrumental delivery in the general obstetrical population. There was no relationship between prenatal exercise and preterm/prelabour rupture of membranes, caesarean section, induction of labour, length of labour, vaginal tears, fatigue, injury, musculoskeletal trauma, maternal harms and diastasis recti.

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

OBJECTIF: L'objectif est de guider les femmes enceintes et les professionnels de l'obstétrique et de l'exercice en ce qui concerne l'activité physique prénatale. RéSULTATS: Les issues évaluées étaient la morbidité maternelle, fœtale ou néonatale et la mortalité fœtale pendant et après la grossesse. DONNéES: Nous avons interrogé MEDLINE, Embase, PsycINFO, la Cochrane Database of Systematic Reviews, le Cochrane Central Register of Controlled Trials, Scopus et la Web of Science Core Collection, CINAHL Plus with Full Text, Child Development & Adolescent Studies, ERIC, SPORTDiscus, ClinicalTrials.gov de leur création jusqu'au 6 janvier 2017. Les études primaires de tous types étaient admissibles, à l'exception des études de cas. Seules les publications en anglais, en espagnol et en français ont été retenues. Les articles liés à l'activité physique durant la grossesse qui abordaient la morbidité maternelle, fœtale ou néonatale ou la mortalité fœtale étaient admissibles. La qualité des données probantes a été évaluée au moyen de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). VALEURS: Le groupe d'experts responsable des lignes directrices a recueilli les commentaires d'utilisateurs finaux (fournisseurs de soins obstétricaux, professionnels de l'exercice, chercheurs, organismes responsables de politiques, et femmes enceintes et en période postpartum). La directive clinique a été élaborée au moyen de l'outil Appraisal of Guidelines for Research Evaluation (AGREE) II. AVANTAGES, INCONVéNIENTS, ET COûTS: Les avantages de l'activité physique prénatale sont modérés, et aucun inconvénient n'a été relevé; la différence entre les conséquences désirables et indésirables (avantage net) devrait donc être modérée. La majorité des intervenants et des utilisateurs finaux ont indiqué qu'il serait faisable, acceptable et équitable de suivre ces recommandations, qui nécessitent généralement des ressources minimes de la part des personnes et des systèmes de santé. PRÉAMBULE: Les présentes lignes directrices contiennent des recommandations fondées sur des données probantes au sujet de l'activité physique durant la grossesse visant à favoriser la santé maternelle, fœtale et néonatale. En l'absence de contre-indications (voir la liste détaillée plus loin), le fait de suivre ces lignes directrices est associé à : 1) moins de complications pour le nouveau-né (p. ex., gros par rapport à l'âge gestationnel); et 2) des bienfaits pour la santé maternelle (p. ex., diminution du risque de prééclampsie, d'hypertension gravidique, de diabète gestationnel, de césarienne, d'accouchement opératoire, d'incontinence urinaire, de gain de poids excessif durant la grossesse et de dépression; amélioration de la glycémie; diminution du gain de poids total durant la grossesse; et diminution de la gravité des symptômes dépressifs et de la douleur lombo-pelvienne). L'activité physique n'est pas associée à la fausse couche, à la mortinaissance, au décès néonatal, à l'accouchement prématuré, à la rupture prématurée préterme des membranes, à l'hypoglycémie néonatale, au poids insuffisant à la naissance, aux anomalies congénitales, au déclenchement du travail, ou aux complications à la naissance. En général, une augmentation de l'activité physique (fréquence, durée ou volume) est liée à une augmentation des bienfaits. Cependant, nous n'avons pas trouvé de données probantes concernant l'innocuité ou l'avantage accru de l'exercice à des niveaux considérablement supérieurs aux recommandations. L'activité physique prénatale devrait être vue comme un traitement de première ligne pour réduire le risque de complications de la grossesse et améliorer la santé physique et mentale de la mère. Pour les femmes enceintes qui n'atteignent actuellement pas le niveau recommandé, nous recommandons une augmentation progressive pour l'atteindre. Les femmes déjà actives peuvent continuer de l'être tout au long de la grossesse. Elles pourraient devoir modifier le type d'activité à mesure que leur grossesse avance. Il peut devenir impossible de suivre les lignes directrices pendant certaines périodes en raison de la fatigue ou des inconforts de la grossesse; nous encourageons les femmes à faire ce qu'elles peuvent et à revenir aux recommandations lorsqu'elles en sont capables. Les recommandations qui suivent reposent sur une revue systématique approfondie de la littérature, l'opinion d'experts, la consultation d'utilisateurs finaux et des considérations de faisabilité, d'acceptabilité, de coût et d'équité. RECOMMANDATIONS: Les recommandations des Lignes directrices canadiennes sur l'activité physique durant la grossesse 2019 sont fournies ci-dessous avec des énoncés indiquant la qualité des données probantes utilisées et la force des recommandations (des explications suivent). CONTRE-INDICATIONS: Toutes les femmes enceintes peuvent faire de l'activité physique durant la grossesse, sauf celles qui présentent des contre-indications (voir ci-dessous). Celles présentant des contre-indications absolues peuvent poursuivre leurs activités quotidiennes habituelles, mais ne devraient pas faire d'activités plus vigoureuses. Celles présentant des contre-indications relatives devraient discuter des avantages et des inconvénients de l'activité physique d'intensité modérée à vigoureuse avec leur fournisseur de soins obstétricaux avant d'y prendre part. CONTRE-INDICATIONS ABSOLUES: Contre-indications relatives FORCE DES RECOMMANDATIONS: Nous avons utilisé le système GRADE pour évaluer la force des recommandations. Les recommandations sont jugées fortes ou faibles en fonction de : 1) l'équilibre entre les avantages et les inconvénients; 2) la qualité globale des données probantes; 3) l'importance des issues (valeurs et préférences des femmes enceintes); 4) l'utilisation de ressources (coût); 5) l'incidence sur l'équité en matière de santé; 6) la faisabilité et 7) l'acceptabilité. Recommandation forte : La majorité ou la totalité des femmes enceintes auraient avantage à suivre la recommandation. Recommandation faible : Les femmes enceintes n'auraient pas toutes avantage à suivre la recommandation; il faut tenir compte d'autres facteurs comme la situation, les préférences, les valeurs, les ressources et le milieu de chaque personne. La consultation d'un fournisseur de soins obstétricaux peut faciliter la prise de décisions. QUALITé DES DONNéES PROBANTES: La qualité des données probantes fait référence au degré de confiance dans les données et va de très faible à élevée. Qualité élevée : Le groupe d'experts responsable des lignes directrices est très convaincu que l'effet estimé de l'activité physique sur l'issue de santé est près de l'effet réel. Qualité moyenne : Le groupe d'experts responsable des lignes directrices a moyennement confiance en l'effet estimé de l'activité physique sur l'issue de santé; l'effet estimé est probablement près de l'effet réel, mais il est possible qu'il soit très différent. Qualité faible : Le groupe d'experts responsable des lignes directrices a peu confiance en l'effet estimé de l'activité physique sur l'issue de santé; l'effet estimé pourrait être très différent de l'effet réel. Qualité très faible : Le groupe d'experts responsable des lignes directrices a très peu confiance en l'effet estimé de l'activité physique sur l'issue de santé; l'effet estimé est probablement très différent de l'effet réel. a Il s'agit d'une recommandation faible parce que la qualité des données probantes était faible et que l'avantage net entre les femmes qui étaient physiquement actives et celles qui ne l'étaient pas était petit. b Il s'agit d'une recommandation forte parce que, malgré le fait que les données probantes appuyant l'activité physique durant la grossesse pour les femmes en surpoids ou obèses étaient de qualité faible, des données tirées d'essais cliniques randomisés démontraient une diminution du gain de poids durant la grossesse et une amélioration de la glycémie. c On parle d'intensité modérée lorsque l'activité est assez intense pour augmenter la fréquence cardiaque de façon perceptible; une personne peut parler, mais pas chanter durant les activités de cette intensité. Pensons par exemple à la marche rapide, à la gymnastique aquatique, au vélo stationnaire (effort modéré), à l'entraînement musculaire, au port de charges modérées et aux travaux ménagers (p. ex., jardinage, lavage de fenêtres). d Il s'agit d'une recommandation faible parce que l'incontinence urinaire n'était pas jugée comme étant une issue « critique ¼ et que les données étaient de qualité faible. e Il s'agit d'une recommandation faible parce que : 1) la qualité des données probantes était très faible; et 2) bien que nous ayons étudié les inconvénients, il y avait peu de renseignements disponibles sur l'équilibre entre les avantages et les inconvénients. Cette recommandation était principalement fondée sur l'opinion d'experts.

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

OBJECTIVE: The objective is to provide guidance for pregnant women, and obstetric care and exercise professionals, on prenatal physical activity. OUTCOMES: The outcomes evaluated were maternal, fetal, or neonatal morbidity or fetal mortality during and following pregnancy. EVIDENCE: Literature was retrieved through searches of Medline, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection, CINAHL Plus with Full-text, Child Development & Adolescent Studies, ERIC, Sport Discus, ClinicalTrials.gov, and the Trip Database from database inception up to January 6, 2017. Primary studies of any design were eligible, except case studies. Results were limited to English, Spanish, or French language materials. Articles related to maternal physical activity during pregnancy reporting on maternal, fetal, or neonatal morbidity or fetal mortality were eligible for inclusion. The quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. VALUES: The Guidelines Consensus Panel solicited feedback from end-users (obstetric care providers, exercise professionals, researchers, policy organizations, and pregnant and postpartum women). The development of this guideline followed the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument. BENEFITS, HARMS, AND COSTS: The benefits of prenatal physical activity are moderate, and no harms were identified; therefore, the difference between desirable and undesirable consequences (net benefit) is expected to be moderate. The majority of stakeholders and end-users indicated that following these recommendations would be feasible, acceptable, and equitable. Following these recommendations is likely to require minimal resources from both individual and health systems perspectives. PREAMBLE: This guideline provide evidence-based recommendations regarding physical activity throughout pregnancy in the promotion of maternal, fetal, and neonatal health. In the absence of contraindications (see later for a detailed list), following this guideline is associated with: (1) fewer newborn complications (i.e., large for gestational age); and (2) maternal health benefits (i.e., decreased risk of preeclampsia, gestational hypertension, gestational diabetes, Caesarean section, instrumental delivery, urinary incontinence, excessive gestational weight gain, and depression; improved blood glucose; decreased total gestational weight gain; and decreased severity of depressive symptoms and lumbopelvic pain). Physical activity is not associated with miscarriage, stillbirth, neonatal death, preterm birth, preterm/prelabour rupture of membranes, neonatal hypoglycemia, low birth weight, birth defects, induction of labour, or birth complications. In general, more physical activity (frequency, duration, and/or volume) is associated with greater benefits. However, evidence was not identified regarding the safety or additional benefit of exercising at levels significantly above the recommendations. Prenatal physical activity should be considered a front-line therapy for reducing the risk of pregnancy complications and enhancing maternal physical and mental health. For pregnant women not currently meeting this guideline, a progressive adjustment toward them is recommended. Previously active women may continue physical activity throughout pregnancy. Women may need to modify physical activity as pregnancy progresses. There may be periods when following the guideline is not possible due to fatigue and/or discomforts of pregnancy; women are encouraged to do what they can and to return to following the recommendations when they are able. This guideline were informed by an extensive systematic review of the literature, expert opinion, end-user consultation and considerations of feasibility, acceptability, costs, and equity. RECOMMENDATIONS: The specific recommendations in this 2019 Canadian Guideline for Physical Activity Throughout Pregnancy are provided below with corresponding statements indicating the quality of the evidence informing the recommendations and the strength of the recommendations (explanations follow). CONTRAINDICATIONS: All pregnant women can participate in physical activity throughout pregnancy with the exception of those who have contraindications (listed below). Women with absolute contraindications may continue their usual activities of daily living but should not participate in more strenuous activities. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider prior to participation. Absolute contraindications to exercise are the following: Relative contraindications to exercise are the following: STRENGTH OF THE RECOMMENDATIONS: The GRADE system was utilized to grade the strength of the recommendations. Recommendations are rated as strong or weak based on the: (1) balance between benefits and harms; (2) overall quality of the evidence; (3) importance of outcomes (i.e., values and preferences of pregnant women); (4) use of resources (i.e., cost); (5) impact on health equity; (6) feasibility, and (7) acceptability. Strong recommendation: Most or all pregnant women will be best served by the recommended course of action. Weak recommendation: Not all pregnant women will be best served by the recommended course of action; there is a need to consider other factors such as the individual's circumstances, preferences, values, resources available, or setting. Consultation with an obstetric care provider may assist in decision-making. QUALITY OF THE EVIDENCE: The quality of the evidence refers to the level of confidence in the evidence and ranges from very low to high. High quality: The Guideline Consensus Panel is very confident that the estimated effect of physical activity on the health outcome is close to the true effect. Moderate quality: The Guideline Consensus Panel is moderately confident in the estimated effect of physical activity on the health outcome; the estimate of the effect is likely to be close to the true effect, but there is a possibility that it is substantially different. Low quality: The Guideline Consensus Panel's confidence in the estimated effect of physical activity on the health outcome is limited; the estimate of the effect may be substantially different from the true effect. Very low quality: The Guideline Consensus Panel has very little confidence in the estimated effect of physical activity on the health outcome; the estimate of the effect is likely to be substantially different from the true effect. aThis was a weak recommendation because the quality of evidence was low, and the net benefit between women who were physically active and those who were not was small. bThis was a strong recommendation because, despite low quality evidence supporting physical activity during pregnancy for women categorized as overweight or obese, there was evidence from randomized controlled trials demonstrating an improvement in gestational weight gain and blood glucose. cModerate-intensity physical activity is intense enough to noticeably increase heart rate; a person can talk but not sing during activities of this intensity. Examples of moderate-intensity physical activity include brisk walking, water aerobics, stationary cycling (moderate effort), resistance training, carrying moderate loads, and household chores (e.g., gardening, washing windows). dThis was a weak recommendation because urinary incontinence was was not rated as a "critical" outcome and the evidence was low quality. eThis was a weak recommendation because: (1) the quality of evidence was very low; and (2) although harms were investigated there was limited available information to inform the balance of benefits and harms. This recommendation was primarily based on expert opinion.

2019 Canadian guideline for physical activity throughout pregnancy.

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

Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis.

OBJECTIVE: Gestational weight gain (GWG) has been identified as a critical modifier of maternal and fetal health. This systematic review and meta-analysis aimed to examine the relationship between prenatal exercise, GWG and postpartum weight retention (PPWR). DESIGN: Systematic review with random effects meta-analysis and meta-regression. Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs in English, Spanish or French were eligible (except case studies and reviews) if they contained information on the population (pregnant women without contraindication to exercise), intervention (frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [eg, dietary; "exercise + co-intervention"]), comparator (no exercise or different frequency, intensity, duration, volume or type of exercise) and outcomes (GWG, excessive GWG (EGWG), inadequate GWG (IGWG) or PPWR). RESULTS: Eighty-four unique studies (n=21 530) were included. 'Low' to 'moderate' quality evidence from randomised controlled trials (RCTs) showed that exercise-only interventions decreased total GWG (n=5819; -0.9 kg, 95% CI -1.23 to -0.57 kg, I2=52%) and PPWR (n=420; -0.92 kg, 95% CI -1.84 to 0.00 kg, I2=0%) and reduced the odds of EGWG (n=3519; OR 0.68, 95% CI 0.57 to 0.80, I2=12%) compared with no exercise. 'High' quality evidence indicated higher odds of IGWG with prenatal exercise-only (n=1628; OR 1.32, 95% CI 1.04 to 1.67, I2=0%) compared with no exercise. CONCLUSIONS: Prenatal exercise reduced the odds of EGWG and PPWR but increased the risk of IGWG. However, the latter result should be interpreted with caution because it was based on a limited number of studies (five RCTs).

Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis.

OBJECTIVE: Gestational diabetes mellitus (GDM), gestational hypertension (GH) and pre-eclampsia (PE) are associated with short and long-term health issues for mother and child; prevention of these complications is critically important. This study aimed to perform a systematic review and meta-analysis of the relationships between prenatal exercise and GDM, GH and PE. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if published in English, Spanish or French, and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcomes (GDM, GH, PE). RESULTS: A total of 106 studies (n=273 182) were included. 'Moderate' to 'high'-quality evidence from randomised controlled trials revealed that exercise-only interventions, but not exercise+cointerventions, reduced odds of GDM (n=6934; OR 0.62, 95% CI 0.52 to 0.75), GH (n=5316; OR 0.61, 95% CI 0.43 to 0.85) and PE (n=3322; OR 0.59, 95% CI 0.37 to 0.9) compared with no exercise. To achieve at least a 25% reduction in the odds of developing GDM, PE and GH, pregnant women need to accumulate at least 600 MET-min/week of moderate-intensity exercise (eg, 140 min of brisk walking, water aerobics, stationary cycling or resistance training). SUMMARY/CONCLUSIONS: In conclusion, exercise-only interventions were effective at lowering the odds of developing GDM, GH and PE.

Glucose responses to acute and chronic exercise during pregnancy: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis to explore the relationship between prenatal exercise and glycaemic control. DESIGN: Systematic review with random-effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies and reviews) if they were published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of acute or chronic exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+cointervention') at any stage of pregnancy), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (glycaemic control). RESULTS: A total of 58 studies (n=8699) were included. There was 'very low' quality evidence showing that an acute bout of exercise was associated with a decrease in maternal blood glucose from before to during exercise (6 studies, n=123; mean difference (MD) -0.94 mmol/L, 95% CI -1.18 to -0.70, I2=41%) and following exercise (n=333; MD -0.57 mmol/L, 95% CI -0.72 to -0.41, I2=72%). Subgroup analysis showed that there were larger decreases in blood glucose following acute exercise in women with diabetes (n=26; MD -1.42, 95% CI -1.69 to -1.16, I2=8%) compared with those without diabetes (n=285; MD -0.46, 95% CI -0.60 to -0.32, I2=62%). Finally, chronic exercise-only interventions reduced fasting blood glucose compared with no exercise postintervention in women with diabetes (2 studies, n=70; MD -2.76, 95% CI -3.18 to -2.34, I2=52%; 'low' quality of evidence), but not in those without diabetes (9 studies, n=2174; MD -0.05, 95% CI -0.16 to 0.05, I2=79%). CONCLUSION: Acute and chronic prenatal exercise reduced maternal circulating blood glucose concentrations, with a larger effect in women with diabetes.

Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: a systematic review and meta-analysis.

OBJECTIVE: To examine the influence of prenatal exercise on depression and anxiety during pregnancy and the postpartum period. DESIGN: Systematic review with random effects meta-analysis and meta-regression. DATA SOURCES: Online databases were searched up to 6 January 2017. STUDY ELIGIBILITY CRITERIA: Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcome (prenatal or postnatal depression or anxiety). RESULTS: A total of 52 studies (n=131 406) were included. 'Moderate' quality evidence from randomised controlled trials (RCTs) revealed that exercise-only interventions, but not exercise+cointerventions, reduced the severity of prenatal depressive symptoms (13 RCTs, n=1076; standardised mean difference: -0.38, 95% CI -0.51 to -0.25, I2=10%) and the odds of prenatal depression by 67% (5 RCTs, n=683; OR: 0.33, 95% CI 0.21 to 0.53, I2=0%) compared with no exercise. Prenatal exercise did not alter the odds of postpartum depression or the severity of depressive symptoms, nor anxiety or anxiety symptoms during or following pregnancy. To achieve at least a moderate effect size in the reduction of the severity of prenatal depressive symptoms, pregnant women needed to accumulate at least 644 MET-min/week of exercise (eg, 150 min of moderate intensity exercise, such as brisk walking, water aerobics, stationary cycling, resistance training). SUMMARY/CONCLUSIONS: Prenatal exercise reduced the odds and severity of prenatal depression.