Filling the evidence void: exploration of coach and healthcare provider experiences working with pregnant and postpartum elite athletes - a qualitative study.

OBJECTIVE: Recent research grounded in the experiences of elite female athletes has shed light on the complex challenges of navigating sport environments that do not support or value pregnant or postpartum athletes. The purpose of this study was to explore the unique experiences of coaches and healthcare providers working with pregnant and postpartum elite athletes, and to identify actionable steps for research, policy and culture change to support them. METHODS: Sixteen participants (five coaches, three physicians and eight physiotherapists), who have worked with pregnant and/or postpartum elite athletes within the last 5 years, participated in this qualitative study. Thirteen participants self-identified as women, and three as men. Data were generated via semistructured one-on-one interviews that were audiorecorded, transcribed verbatim and analysed through a process of content analysis. RESULTS: The findings of this research are represented by five main themes: (a) lack of female athlete reproductive research, (b) need for evidence-informed education and training, (c) need to develop evidence-based progression for sport participation in pregnancy and postpartum, (d) open communication to support athlete-centred care and (e) essential supports and changes required for pregnant/postpartum athletes. CONCLUSION: Findings from this study, which are grounded in the unique perspectives of coaches and healthcare providers, outline specific recommendations to inform policy and practices that support athletes through the perinatal period, such as developing evidence-based return-to-sport protocols.

Pushing for change: a qualitative study of the experiences of elite athletes during pregnancy.

OBJECTIVES: Athletes train and compete at the elite level during their reproductive years, yet sport policies that support pregnant athletes are lacking. The experiences of elite athletes during pregnancy are vastly under-represented, and such voices are needed to support evidence-informed policy. Thus, the purpose of this qualitative study was to describe the experiences of elite female athletes as they navigate pregnancy, and to identify sport policy considerations regarding participation during pregnancy. METHODS: Twenty athletes (mean age 35±5 years) who, within the last 5 years, had trained or competed at the elite level immediately prior to becoming pregnant were included. Data were generated via one-on-one semistructured interviews that were audio-recorded, transcribed verbatim and analysed through a process of content analysis. RESULTS: The findings of this study are represented by one overarching message: mother versus athlete, and five main themes: (1) pregnancy planning and fertility, (2) pregnancy disclosure and discrimination, (3) training pregnant athletic bodies, (4) safety concerns, and (5) supportive network and equitable funding. CONCLUSION: In-depth stories shared by participants highlight the many significant decisions athletes must make as they navigate pregnancy alongside elite sport participation. The shared experiences of pregnant athletes highlight clear challenges that should be considered in the development of sport policy and practices that are inclusive and supportive of female athletes.

Shared decision making in pregnancy in inflammatory bowel disease: design of a patient orientated decision aid.

BACKGROUND: Research has indicated a lack of disease-specific reproductive knowledge among patients with Inflammatory Bowel Disease (IBD) and this has been associated with increased "voluntary childlessness". Furthermore, a lack of knowledge may contribute to inappropriate medication changes during or after pregnancy. Decision aids have been shown to support decision making in pregnancy as well as in multiple other chronic diseases. A published decision aid for pregnancy in IBD has not been identified, despite the benefit of pre-conception counselling and patient desire for a decision support tool. This study aimed to develop and test the feasibility of a decision aid encompassing reproductive decisions in the setting of IBD. METHODS: The International Patient Decision Aid Standards were implemented in the development of the Pregnancy in IBD Decision Aid (PIDA). A multi-disciplinary steering committee was formed. Patient and clinician focus groups were conducted to explore themes of importance in the reproductive decision-making processes in IBD. A PIDA prototype was designed; patient interviews were conducted to obtain further insight into patient perspectives and to test the prototype for feasibility. RESULTS: Issues considered of importance to patients and clinicians encountering decisions regarding pregnancy in the setting of IBD included fertility, conception timing, inheritance, medications, infant health, impact of surgery, contraception, nutrition and breastfeeding. Emphasis was placed on the provision of preconception counselling early in the disease course. Decisions relating to conception and medications were chosen as the current focus of PIDA, however content inclusion was broad to support use across preconception, pregnancy and post-partum phases. Favourable and constructive user feedback was received. CONCLUSIONS: The novel development of a decision aid for use in pregnancy and IBD was supported by initial user testing.

The Impact of Hospitalization on Physical Activity During Pregnancy.

The concept of prenatal physical activity has transitioned from a potentially risky behaviour to a prescription to improve maternal-fetal health. Pregnant women who are hospitalized because of a complication should continue to engage in light activities of daily living given the known adverse effects of maternal bedrest. Because the amount physical activity performed by pregnant women while in hospital not been documented; we compared levels of physical activity between women who were and were not hospitalized during pregnancy. We found that hospitalized pregnant women self-impose bedrest even in the absence of a medical recommendation.

The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis.

OBJECTIVE: Data: An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. The purpose of this study was to examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes. STUDY: Studies of all designs (except case studies and reviews) that contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birthweight, small for gestational age, miscarriage, gestational hypertension, preeclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction) were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Five electronic databases and 3 gray literature sources were searched up to March 15, 2019. RESULTS: Eighty observational studies (N=853,149) were included. Low-to-very low certainty evidence revealed that lifting objects ≥11 kg was associated with an increased odds ratio of miscarriage (odds ratio, 1.31; 95% confidence interval, 1.08-1.58; I2=79%), and preeclampsia (odds ratio, 1.35; 95% confidence interval, 1.07-1.71; I2=0%). Lifting objects for a combined weight of ≥100 kg per day was associated with an increased odds of preterm delivery (odds ratio, 1.31; 95% confidence interval, 1.11-1.56; I2=0%) and having a low birthweight neonate (odds ratio, 2.08; 95% confidence interval, 1.06-4.11; I2=73%). Prolonged standing was associated with increased odds of preterm delivery (odds ratio, 1.11; 95% confidence interval, 1.02-1.22; I2=30%) and having a small-for-gestational-age neonate (odds ratio, 1.17; 95% confidence interval, 1.01-1.35; I2=41%). A heavy physical workload was associated with increased odds of preterm delivery (odds ratio, 1.23; 95% confidence interval, 1.07-1.41; I2=32%) and having a low birthweight neonate (odds ratio, 1.79; 95% confidence interval, 1.11-2.87; I2=87%). All other associations were not statistically significant. Dose-response analysis showed women stand for >2.5 hours per day (vs no standing) had a 10% increase in the odds of having a preterm delivery. CONCLUSION: Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.

Thyroid function testing and management during and after pregnancy among women without thyroid disease before pregnancy.

BACKGROUND: Screening in pregnancy for subclinical hypothyroidism, often defined as thyroid-stimulating hormone (TSH) greater than 2.5 mIU/L or greater than 4.0 mIU/L, is controversial. We determined the frequency and distribution of TSH testing by gestational age, as well as TSH values associated with treatment during pregnancy and the frequency of postpartum continuation of thyroid hormone therapy. METHODS: We performed a retrospective cohort study of pregnancies in Alberta, Canada. We included women without thyroid disease who delivered between October 2014 and September 2017. We used delivery records, physician billings, and pharmacy and laboratory administrative data. Our key outcomes were characteristics of TSH testing and the initiation and continuation of thyroid hormone therapy. We calculated the proportion of pregnancies with thyroid testing and the frequency of each specific thyroid test. RESULTS: Of the 188 490 pregnancies included, 111 522 (59.2%) had at least 1 TSH measurement. The most common time for testing was at gestational week 5 to 6. Thyroid hormone therapy was initiated at a median gestational age of 7 (interquartile range 5-12) weeks. Among women with first TSH measurements of 4.01 to 9.99 mIU/L who were not immediately treated, the repeat TSH measurement was 4.00 mIU/L or below in 67.9% of pregnancies. Thyroid hormone was continued post partum for 44.6% of the women who started therapy during their pregnancy. INTERPRETATION: The findings of our study suggest that current practice patterns may contribute to overdiagnosis of hypothyroidism and overtreatment during pregnancy and post partum.

Blunted sympathetic neurovascular transduction during normotensive pregnancy.

KEY POINTS: Normotensive pregnancy is associated with elevated sympathetic nervous system activity yet normal or reduced blood pressure. It represents a unique period of apparent healthy sympathetic hyperactivity. The present study models the blood pressure and heart rate (ECG R-R interval) responses to fluctuations in sympathetic nervous system activity aiming to understand neurocardiovascular transduction. The reported data clearly demonstrate that transduction of sympathetic nervous system signalling to systemic cardiovascular outcomes is reduced in normotensive pregnancy. These data are important for understanding how blood pressure regulation adapts during normotensive pregnancy and set the foundation for exploring similar mechanisms in hypertensive pregnancies. ABSTRACT: Previously, we described sympathetic nervous system hyperactivity yet decreased blood pressure responses to stress in normotensive pregnancy. To address the hypothesis that pregnant women have blunted neurocardiovascular transduction we assessed the relationship between spontaneous bursts of sympathetic nerve activity (SNA) and fluctuations in mean arterial blood pressure and R-R interval. Resting SNA, blood pressure and ECG were obtained in pregnant (third trimester, n = 18) and non-pregnant (n = 18) women matched for age and pre-/non-pregnant body mass index. Custom software modelled beat-by-beat pressure (photoplethysmography) and R-R interval in relation to sequences of SNA bursts and non-bursts (peroneal microneurography). Sequences were grouped by the number of bursts and non-bursts [singlets, doublets, triplets and quadruplet (four or more)] and mean blood pressure and R-R interval were tracked for 15 subsequent cardiac cycles. Similar sequences were overlaid and averaged. Peak mean pressure in relation to sequences of SNA was reduced in pregnant vs. non-pregnant women (doublets: 1.6 ± 1.1 mmHg vs. 3.6 ± 3.1 mmHg, P < 0.05; triplets: 2.4 ± 1.2 mmHg vs. 3.4 ± 2.1 mmHg, P < 0.05; quadruplets: 3.0 ± 1.0 mmHg vs. 5.5 ± 3.7 mmHg, P < 0.05). The nadir R-R interval following burst sequences was also smaller in pregnant vs. non-pregnant women (singlets: -0.01 ± 0.01 s vs. -0.04 ± 0.04 s, P < 0.05; doublets: -0.02 ± 0.03 s vs. -0.05 ± 0.04 s, P < 0.05; triplets: -0.02 ± 0.01 s vs. -0.07 ± 0.04 s, P < 0.05; quadruplets: -0.01 ± 0.01 s vs. -0.09 ± 0.09 s, P < 0.05). There were no differences between groups in the mean arterial pressure and R-R interval responses to non-burst sequences. Our data clearly indicate blunted systemic neurocardiovascular transduction during normotensive pregnancy. We propose that blunted transduction is a positive adaptation protecting pregnant women from the cardiovascular consequences of sympathetic hyperactivity.

The impact of occupational shift work and working hours during pregnancy on health outcomes: a systematic review and meta-analysis.

BACKGROUD: An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicting and inconclusive. OBJECTIVE: To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. DATA SOURCES: Five electronic databases and 3 gray literature sources were searched up to March 15, 2019. METHODS OF STUDY SELECTION: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm and 11:00 am] or longer working hours [>40 hours per week]);comparator (fixed day shift [typical working period is between 8:00 am and 6:00 pm] or standard working hours [≤40 hours per week]); and outcomes (preterm delivery, low birthweight [birthweight <2500 g], small for gestational age, miscarriage, gestational hypertension, preeclampsia, intrauterine growth restriction, stillbirth, and gestational diabetes mellitus). TABULATION, INTEGRATION, AND RESULTS: From 3305 unique citations, 62 observational studies (196,989 women) were included. "Low" to "very low" certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (odds ratio, 1.13; 95% confidence interval, 1.00-1.28, I2 = 31%), an infant small for gestational age (odds ratio, 1.18, 95% confidence interval, 1.01-1.38, I2 = 0%), preeclampsia (odds ratio, 1.75, 95% confidence interval, 1.01-3.01, I2 = 75%), and gestational hypertension (odds ratio, 1.19, 95% confidence interval, 1.10-1.29, I2 = 0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; I2 = 36%) and miscarriage (odds ratio, 1.23; 95% confidence interval, 1.03-1.47; I2 = 37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (odds ratio, 1.38; 95% confidence interval, 1.08-1.77; I2 = 73%), preterm delivery (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; I2 = 30%), an infant of low birthweight (odds ratio, 1.43; 95% confidence interval, 1.11-1.84; I2 = 0%), or an infant small for gestational age (odds ratio, 1.16, 95% confidence interval, 1.00-1.36, I2 = 57%). Dose-response analysis showed that women working more than 55.5 hours (vs 40 hours) per week had a 10% increase in the odds of having a preterm delivery. CONCLUSION: Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Activity of muscle sympathetic neurons during normotensive pregnancy.

In pathological populations, elevated sympathetic activity is associated with increased activity of individual sympathetic neurons. We used custom action potential detection software to analyze multiunit sympathetic activity in 18 normotensive pregnant women (third trimester; 33 ± 5 wk) and 19 nonpregnant women at rest and a subset (10 and 13, respectively) during a cold pressor challenge. Although the number of action potentials per burst and number of active amplitude-based "clusters" were not different between groups, the total number of sympathetic action potentials per minute was higher in pregnant women at rest. Individual clusters were active predominately once per burst, suggesting they represent single neurons. Action potentials occurred in closer succession in normotensive pregnant (interspike interval 36 ± 10 ms) versus nonpregnant women (50 ± 27 ms; P < 0.001) at rest. Pregnant women had a lower total peripheral resistance (11.7 ± 3.0 mmHg·l-1·min) than nonpregnant women (15.1 ± 2.7 mmHg·l-1·min; P < 0.001), indicating a blunted neurovascular transduction. The cold pressor reduced the number of action potentials per burst in both groups due to shortening of the R-R interval in conjunction with increased burst frequency; total neural firing per minute was unchanged. Thus elevated sympathetic activity during normotensive pregnancy is specific to increased incidence of multiunit bursts. This is likely due to decreased central gating of burst output as opposed to generalized increases in central drive. These data also reinforce the concept that pregnancy appears to be the only healthy state of chronic sympathetic hyperactivity of which we are aware.

Muscle sympathetic nerve activity and volume-regulating factors in healthy pregnant and nonpregnant women.

Healthy, normotensive human pregnancies are associated with striking increases in both plasma volume and vascular sympathetic nerve activity (SNA). In nonpregnant humans, volume-regulatory factors including plasma osmolality, vasopressin, and the renin-angiotensin-aldosterone system have important modulatory effects on control of sympathetic outflow. We hypothesized that pregnancy would be associated with changes in the relationships between SNA (measured as muscle SNA) and volume-regulating factors, including plasma osmolality, plasma renin activity, and arginine vasopressin (AVP). We studied 46 healthy, normotensive young women (23 pregnant and 23 nonpregnant). We measured SNA, arterial pressure, plasma osmolality, plasma renin activity, AVP, and other volume-regulatory factors in resting, semirecumbent posture. Pregnant women had significantly higher resting SNA (38 ± 12 vs. 23 ± 6 bursts/min in nonpregnant women), lower osmolality, and higher plasma renin activity and aldosterone (all P < 0.05). Group mean values for AVP were not different between groups [4.64 ± 2.57 (nonpregnant) vs. 5.17 ± 2.03 (pregnant), P > 0.05]. However, regression analysis detected a significant relationship between individual values for SNA and AVP in pregnant (r = 0.71, P < 0.05) but not nonpregnant women (r = 0.04). No relationships were found for other variables. These data suggest that the link between AVP release and resting SNA becomes stronger in pregnancy, which may contribute importantly to blood pressure regulation in healthy women during pregnancy.NEW & NOTEWORTHY Sympathetic nerve activity and blood volume are both elevated during pregnancy, but blood pressure is usually normal. Here, we identified a relationship between vasopressin and sympathetic nerve activity in pregnant but not nonpregnant women. This may provide mechanistic insights into blood pressure regulation in normal pregnancy and in pregnancy-related hypertension.

Antepartum dalteparin versus no antepartum dalteparin for the prevention of pregnancy complications in pregnant women with thrombophilia (TIPPS): a multinational open-label randomised trial.

BACKGROUND: Thrombophilias are common disorders that increase the risk of pregnancy-associated venous thromboembolism and pregnancy loss and can also increase the risk of placenta-mediated pregnancy complications (severe pre-eclampsia, small-for-gestational-age infants, and placental abruption). We postulated that antepartum dalteparin would reduce these complications in pregnant women with thrombophilia. METHODS: In this open-label randomised trial undertaken in 36 tertiary care centres in five countries, we enrolled consenting pregnant women with thrombophilia at increased risk of venous thromboembolism or with previous placenta-mediated pregnancy complications. Eligible participants were randomly allocated in a 1:1 ratio to either antepartum prophylactic dose dalteparin (5000 international units once daily up to 20 weeks' gestation, and twice daily thereafter until at least 37 weeks' gestation) or to no antepartum dalteparin (control group). Randomisation was done by a web-based randomisation system, and was stratified by country and gestational age at randomisation day with a permuted block design (block sizes 4 and 8). At randomisation, site pharmacists (or delegates) received a randomisation number and treatment allocation (by fax and/or e-mail) from the central web randomisation system and then dispensed study drug to the local coordinator. Patients and study personnel were not masked to treatment assignment, but the outcome adjudicators were masked. The primary composite outcome was independently adjudicated severe or early-onset pre-eclampsia, small-for-gestational-age infant (birthweight <10th percentile), pregnancy loss, or venous thromboembolism. We did intention-to-treat and on-treatment analyses. This trial is registered with ClinicalTrials.gov, number NCT00967382, and with Current Controlled Trials, number ISRCTN87441504. FINDINGS: Between Feb 28, 2000, and Sept 14, 2012, 292 women consented to participate and were randomly assigned to the two groups. Three women were excluded after randomisation because of ineligibility (two in the antepartum dalteparin group and one in the control group), leaving 146 women assigned to antepartum dalteparin and 143 assigned to no antepartum dalteparin. Some patients crossed over to the other group during treatment, and therefore for on-treatment and safety analysis there were 143 patients in the dalteparin group and 141 in the no dalteparin group. Dalteparin did not reduce the incidence of the primary composite outcome in both intention-to-treat analysis (dalteparin 25/146 [17·1%; 95% CI 11·4-24·2%] vs no dalteparin 27/143 [18·9%; 95% CI 12·8-26·3%]; risk difference -1·8% [95% CI -10·6% to 7·1%)) and on-treatment analysis (dalteparin 28/143 [19·6%] vs no dalteparin 24/141 [17·0%]; risk difference +2·6% [95% CI -6·4 to 11·6%]). In safety analysis, the occurrence of major bleeding did not differ between the two groups. However, minor bleeding was more common in the dalteparin group (28/143 [19·6%]) than in the no dalteparin group (13/141 [9·2%]; risk difference 10·4%, 95% CI 2·3-18·4; p=0·01). INTERPRETATION: Antepartum prophylactic dalteparin does not reduce the occurrence of venous thromboembolism, pregnancy loss, or placenta-mediated pregnancy complications in pregnant women with thrombophilia at high risk of these complications and is associated with an increased risk of minor bleeding. FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and Pharmacia and UpJohn.

Cardiovascular risk reduction and weight management at a hospital-based postpartum preeclampsia clinic.

OBJECTIVE: Women who develop preeclampsia during pregnancy are at high risk of developing future chronic diseases, including premature cardiovascular disease. We have established an interdisciplinary clinic that aims to prevent cardiovascular disease through educational counselling focused on lifestyle modifications in the early postpartum period. The objective of this study was to evaluate changes in weight and cardiovascular risk factors in participating women after six months of attendance at the clinic. METHODS: We conducted a retrospective chart review of women who had a pregnancy complicated by preeclampsia, and who subsequently attended the Postpartum Preeclampsia Clinic. Study subjects had baseline assessments of lifestyle, physical, and laboratory parameters. Individualized goals for cardiovascular risk reduction and lifestyle were established, centering on physical activity and dietary modifications. The primary outcome was change in weight. RESULTS: Over the study period, 21 women were seen for a minimum of six months of follow-up. At an average (± SD) of 4.4 ± 1.4 months postpartum, subjects showed a non-significant improvement in weight (mean weight loss of 0.4 ± 4.5 kg) and BMI (mean decrease in BMI 0.1 ± 1.7 kg/m2). Physical activity improved significantly, from 14% of subjects participating in physical activity before pregnancy to 76% at a mean of 4.4 months postpartum. CONCLUSION: This study has demonstrated the early benefits of a longitudinal interdisciplinary intervention with counselling about lifestyle modifications for prevention of cardiovascular disease in women with recent preeclampsia. A study with a larger sample size and longer duration of follow-up is planned to confirm these findings.

Objectif : Les femmes qui en viennent à connaître une prééclampsie pendant la grossesse sont exposées à un risque élevé d'en venir par la suite à présenter des maladies chroniques, dont la maladie cardiovasculaire prématurée. Nous avons mis sur pied une clinique interdisciplinaire qui vise à prévenir la maladie cardiovasculaire par l'offre de services de counseling pédagogique axés sur les modifications à apporter au mode de vie aux débuts de la période postpartum. Cette étude avait pour objectif d'évaluer les modifications du poids et des facteurs de risque cardiovasculaire chez les participantes, après six mois de consultations à la clinique. Méthodes : Nous avons mené une analyse rétrospective des dossiers des femmes dont la grossesse avait été compliquée par la prééclampsie et qui avaient par la suite fréquenté la Postpartum Preeclampsia Clinic. Pour déterminer les paramètres de départ, les participantes à l'étude ont été soumises à des évaluations du mode de vie, à des examens physiques et à des analyses de laboratoire. Des objectifs personnalisés en matière de réduction du risque cardiovasculaire et de modification du mode de vie ont été établis, le tout étant axé sur l'activité physique et les modifications du régime alimentaire. La modification du poids constituait le critère d'évaluation principal. Résultats : Au cours de la période d'étude, 21 femmes ont fait l'objet d'un suivi d'une durée minimale de six mois. À 4,4 ± 1,4 mois postpartum en moyenne (± σ), les participantes présentaient une amélioration non significative en matière de poids (perte pondérale moyenne de 0,4 ± 4,5 kg) et d'IMC (diminution moyenne de l'IMC de 0,1 ± 1,7 kg/m2). Le niveau d'activité physique a connu une amélioration significative, passant de 14 % des participantes pratiquant des activités physiques avant la grossesse à 76 % après 4,4 mois postpartum en moyenne. Conclusion : Cette étude a démontré les avantages précoces d'une intervention interdisciplinaire longitudinale, s'accompagnant de services de counseling sur les modifications à apporter au mode de vie, pour assurer la prévention des maladies cardiovasculaires chez des femmes ayant récemment connu une prééclampsie. Nous prévoyons mener une étude comptant un échantillon plus large et un suivi de plus longue durée, en vue de confirmer ces constatations.

"Is It Realistic?": A Qualitative Study of the Experiences of Elite Women Athletes Considering Parenthood.

BACKGROUND AND OBJECTIVE: As the visibility and acceptance of athlete-mothers increase, so does the number of women athletes considering parenthood. Yet, many athletes struggle with the decision to become a parent while competing at the elite level due to the significant changes and uncertainties that have been reported by pregnant and parenting athletes. The experiences of women athletes considering parenthood are under-represented in the vast sport literature but are necessary for developing evidenced-based policies and practices that can support women's equitable participation in high-performance sport contexts. Thus, the purpose of this qualitative study was to describe the experiences of elite women athletes that are considering parenthood. METHODS: Participants were ten elite North American athletes (29-36 years) who are considering becoming parents in the next 5 years. Each participant self-identified as a woman and competed at the highest level in their respective sport. Data were generated via one-on-one semi-structured interviews that were audio-recorded, transcribed verbatim, and analyzed through a process of content analysis. RESULTS: The experiences of elite women athletes considering parenthood are represented by five themes: (a) calls for essential mandates and leadership, (b) how do you support yourself?, (c) hesitation of body changes, (d) age inequities, and (e) being proactive about reproductive health. Such findings support an in-depth understanding of gender-specific stressors that limit women's equitable participation in high-performance contexts. CONCLUSION: This research is grounded in the voices of elite women athletes and identifies actionable steps necessary for research and culture change. Findings provide necessary evidence to inform the development of sport policies to support those athletes that are considering becoming parents.

A comparison among oscillometric waveforms in healthy nonpregnant women, pregnancy and hypertensive disorders of pregnancy.

OBJECTIVE: Understanding of how oscillometric waveforms (OMW) vary between pregnant and nonpregnant individuals remains low. An exploratory analysis was completed to assess for quantitative and qualitative changes in OMW and oscillometric envelope features in pregnancy. DESIGN AND METHODS: Eighteen pregnant individuals (over 20 weeks gestational age) and healthy, nonpregnant (HNP) women were recruited. Six HNP were matched to six healthy pregnant (HP) women, and six pregnant women with a hypertensive disorder of pregnancy (HDP) by age, arm circumference, and cuff size. Blood pressure measurements were completed per the International Organization for Standardization (ISO) protocol using a custom-built oscillometric device as the test device and two-observer mercury auscultation as the reference measurement. Auscultatory blood pressure and blood pressure derived from slope-based and fixed ratio algorithms were determined. OMW and envelope features were compared among groups. RESULTS: In HNP, HP, and HDP groups respectively: mean auscultatory blood pressure (systolic mean ± SD/diastolic mean ± SD) was 103.4 ±â€…12.2/67.1 ±â€…7.9; 109.5 ±â€…3.1/58.1 ±â€…6.4; 135.6 ±â€…18.9/85.1 ±â€…14.2 mmHg. HDP had significantly higher auscultatory systolic and diastolic blood pressure than the HP group ( P  = 0.001). The pregnant groups had a lower average pulse width (mean ± SD: HNP = 0.8 ±â€…0 s, HP = 0.6 ±â€…0.1 s, HDP = 0.6 ±â€…0.1 s; HP vs. HNP mean difference [adjusted P value]: 0.2 [ P  = 0.004], HDP vs. HNP 0.1 [ P  = 0.018]) compared with the HNP group. The HDP group had a larger area under the OMW envelope than the HNP group (mean ± SD: HNP = 22.6 ±â€…3.4; HDP = 28.5 ±â€…4.2; HDP vs. HNP mean difference [adjusted P value]: 5.9 P  = 0.05). CONCLUSION: In this exploratory work, differences in the OMW morphology and parameters were found in pregnancy and in hypertensive disorders of pregnancy compared with healthy controls. Even small differences may have important implications in algorithm development; further work comparing OMW envelopes in pregnancy is needed to optimize the algorithms used to determine blood pressure in pregnancy.

We're not Superhuman, We're Human: A Qualitative Description of Elite Athletes' Experiences of Return to Sport After Childbirth.

BACKGROUND: A growing number of athletes return to elite sport following childbirth. Yet, they face significant barriers to do so safely and successfully. The experiences of elite athletes returning to sport following delivery are necessary to support evidence-informed policy. OBJECTIVE: The purpose of this qualitative description was to describe the experiences of elite athletes as they returned to sport following childbirth, and to identify actionable steps for research, policy and culture-change to support elite athlete mothers. METHODS: Eighteen elite athletes, primarily from North America, who had returned to sport following childbirth in the last 5 years were interviewed. Data were generated via one-on-one semi-structured interviews that were audio-recorded, transcribed verbatim, and analyzed through a process of content analysis. RESULTS: The findings of this study are represented by one overarching theme: Need for More Time, and five main themes: (a) Training "New Bodies" Postpartum, (b) Injuries and Safe Return to Sport, (c) Breastfeeding While Training, (d) Critical Supports for Return to Sport, (e) Navigating Motherhood and Sport. The athletes identified the urgent need to develop best-practice policies and funding to support return to sport, as well as develop evidence-based return-to-sport protocols to support a safe and injury-free return. CONCLUSION: Athletes shared detailed stories highlighting the challenges, barriers and successes elite athletes experience returning to elite-level sport following childbirth. Participants provided clear recommendations for policy and research to better support the next generation of elite athlete mothers.

Optimizing Blood Glucose Control through the Timing of Exercise in Pregnant Individuals Diagnosed with Gestational Diabetes Mellitus.

This study aimed to evaluate the effectiveness of moderate intensity walking on postprandial blood glucose control for pregnant individuals with (GDM) and without gestational diabetes mellitus (NON-GDM). Using a randomized cross-over design, individuals completed 5 days of exercise (three 10-min walks immediately after eating (SHORT), or one 30-min walk (LONG) outside of 1 h after eating). These protocols were preceded and separated by 2-days of habitual exercise (NORMAL). Individuals were instrumented with a continuous glucose monitor, a physical activity monitor for 14-days, and a heart rate monitor during exercise. Participants completed a physical activity enjoyment scale (PACES) to indicate their protocol preference. The GDM group had higher fasting, 24-h mean, and daily peak glucose values compared to NON-GDMs across all conditions (effect of group, p = 0.02; p = 0.02; p = 0.03, respectively). Fasting, 24-h mean, and daily peak glucose were not influenced by the SHORT or LONG exercise (effect of intervention, p > 0.05). Blood glucose values were higher among the GDM group for at least 1 h after eating, yet the exercise intervention had no effect on 1 or 2 h postprandial glucose values (effect of intervention, p > 0.05). Physical activity outcomes (wear time, total activity time, and time spent on each intensity) were not different between the groups nor interventions (effect of group, p > 0.05; effect of intervention, p > 0.05,). There were no differences between the groups or interventions for the PACES score (effect of group, p > 0.05; effect of intervention, p > 0.05). To conclude, there were no differences between the groups or exercise protocols on blood glucose control. More research is warranted to elucidate higher exercise volumes in this outcome for individuals with GDM.

Glucose control during labour in diabetic women.

OBJECTIVES: Glucose control during labour is important for mother and neonate, with high rates of neonatal hypoglycemia reported in offspring of women with pre-existing or gestational diabetes (48% and 19%, respectively). How glucose control can be achieved is rarely specified. We conducted a chart review of a standardized approach using an iterative intravenous insulin-glucose infusion. METHODS: We performed a retrospective review of the records of 274 diabetic women during labour. Fifty-five women had type 1 diabetes, 55 had type 2 diabetes, and 164 had gestational diabetes (GDM). The protocol used hourly capillary blood glucose determinations, each prompting changes in insulin-glucose infusion rates as required. Outcomes included maternal blood glucose levels three hours before delivery and neonatal hypoglycemia (blood glucose < 2 mmol/L). RESULTS: The insulin-glucose infusion was used in 47% of women with type 1, type 2, and gestational diabetes requiring ≥ 0.5 units/kg/day of insulin during pregnancy and in 8% of women with GDM treated by diet or < 0.5 units/kg/day of insulin. The overall rate of maternal hypoglycemia was low (6.6% with blood glucose ≤ 3.5 mmol/L and 1.5% ≤ 3.0 mmol/L) pre-delivery; 13.9% of women had a blood glucose level ≥ 7.0 mmol/L. The neonatal hypoglycemia rate was 7.3% (4.9% in the offspring of women with GDM and 10.9% in the offspring of women with pre-existing diabetes). In women with type 1 and type 2 diabetes and high-dose insulin-requiring GDM, the rate of blood glucose values outside the range of 3.6 to 6.9 mmol/L was lower in those using the intravenous protocol (16.7%) than in those not using it (34.8%), but this reduction was not statistically significant. CONCLUSION: Standardized management for diabetic women in labour using an intravenous insulin-glucose protocol was effective in achieving stable maternal blood glucose levels with low rates of neonatal hypoglycemia.

Physical Activity Behaviors and Barriers in Multifetal Pregnancy: What to Expect When You're Expecting More.

The health benefits of prenatal physical activity (PA) are established for singleton pregnancies. In contrast, individuals with multifetal pregnancies (twins, triplets or more) are recommended to restrict or cease PA. The objectives of the current study were to determine behaviors and barriers to PA in multifetal pregnancies. Between 29 May and 24 July 2020, individuals with multifetal pregnancies participated in an online survey. Of the 415 respondents, there were 366 (88%) twin, 45 (11%) triplet and 4 (1%) quadruplet pregnancies. Twenty-seven percent (n = 104/388) of respondents completed no PA at all during pregnancy, 57% (n = 220/388) completed PA below current recommendations, and 16% (n = 64/388) achieved current recommendations (150-min per week of moderate-intensity activity). Most respondents (n = 314/363 [87%]) perceived barriers to PA during multifetal pregnancy. The most prominent were physical symptoms (n = 204/363 [56%]) and concerns about risks to fetal wellbeing (n = 128/363 [35%]). Sixty percent (n = 92/153) felt that these barriers could be overcome but expressed the need for evidence-based information regarding PA in multifetal pregnancy. Individuals with multifetal pregnancies have low engagement with current PA recommendations but remain physically active in some capacity. There are physical and psychosocial barriers to PA in multifetal pregnancy and future research should focus on how these can be removed.

Cardiovascular function during triplet pregnancy.

Pregnancy is recognized as a natural physiological stressor to the maternal cardiovascular system. Cardiovascular adaptation is markedly greater in twin pregnancy compared with singleton pregnancy; however, these changes are sparsely documented in triplet pregnancy. The aim of this case series was to compare maternal cardiac function, cardioautonomic regulation, and blood pressure reactivity in healthy singleton, twin, and triplet pregnancies. Resting cardiac structure and function (echocardiography), beat-by-beat blood pressure variability (BPV; photoplethysmography), and heart rate variability (HRV; electrocardiogram) were measured in two triplet, three twin, and three singleton pregnancies (matched for maternal age, prepregnancy body mass index, and gestational age). Hemodynamic responses to a 3-min cold pressor test were also recorded to assess blood pressure reactivity. Due to the small sample size of this case series, statistical comparisons were not made between groups. Compared with singleton and twin pregnancies, individuals pregnant with triplets had greater resting cardiac output but lower cardiac deformation (longitudinal strain, basal circumferential strain, and torsion), sympathetic dominance in cardioautonomic regulation (lower HRV and higher BPV), and elevated blood pressure reactivity in response to the cold pressor test. Taken together, these observations suggest that females with triplet pregnancies may have reduced cardiovascular function, which may contribute to the heightened risk of complications in multifetal pregnancies.NEW & NOTEWORTHY Individuals with healthy triplet pregnancies had greater resting cardiac output but lower left ventricular mechanics when compared with singleton and twin pregnancies matched for gestational age. In addition, triplet pregnancies had greater blood pressure variability and lower overall heart rate variability compared with singleton pregnancies, as well as greater blood pressure reactivity to the cold pressor test. Healthy triplet pregnancies may have reduced cardiovascular function as well as a greater sympathetic contribution to cardiac control.