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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and joining me in this panel today is Dr. Sara Gould. She's a Sports Medicine Physician and an Associate Professor and Dr. Chase Cawyer. He's an Assistant Professor and a Maternal Fetal Medicine Specialist in the Department of Obstetrics and Gynecology. And they're both with UAB Medicine. Doctors, thank you so much for joining us today to talk about exercise in pregnancy and the clinic at UAB Medicine. Dr. Cawyer, I'd like to start with you. Can you start with a little bit about the impact of physical activity on course and outcome of pregnancy from pre and postnatal? I'd like you to speak about the most important aspects of exercise. When a woman is planning a pregnancy and beyond.

Chase Cawyer, MD (Guest): Yes, thanks for that question. One of the things that we've noticed with lot of our patients is for whatever reason, they get a little bit nervous about continuing exercise whenever they get pregnant. They get nervous to think that if they overdo anything or go out of their routine, they may end up actually harming the baby, and potentially themselves. But what we know is that women who exercise in pregnancy tend to have better prenatal outcomes, both for maternal health and for neonatal health. This has been studied well in morbidly obese patients and gestational diabetics.

However, there is research to believe that this can be beneficial for all pregnant women, not just those that have medical comorbidities. One of the most common things that we see, for maternal benefit is we see a decreased risk of Cesarean section. We see a decreased development of preeclampsia and a decreased development of gestational diabetes, which in turn improve maternal health during pregnancy and after delivery. And from a neonatal standpoint, we tend to see a decrease in large for gestational age babies, in preterm birth, as well as, some other things that can cause a potential extended NICU stay.

Melanie Cole (Host): Dr. Cawyer sticking with you for just a minute, because you just mentioned that you do see some women that don't, or haven't exercised or are a little bit nervous. To what do you attribute that decreased physical activity levels of pregnant women? Do you think that it's a lack of information? You mentioned just a little bit about nervousness, you know, concern about possible damage to the unborn child. And when you're speaking here to other providers, how would you like them to counsel their patients on just that exact point?

Dr. Cawyer: Yes. I absolutely think the main reason why women are hesitant is there is just not a lot of information readily available to the public as far as what's beneficial and what's harmful. And I'm going to have Dr. Gould chime in about this in just a second and in relation specific to pregnancy and what some studies have demonstrated, but from a pregnancy standpoint, women, immediately once they find out they have a positive pregnancy test, they get really unselfish and they want to do everything they can for their baby, even if it's potentially harmful for them. And what happens is a lot of times they think, well, this exercise could be helpful for me, but if I overdo it or my heart rate gets too high or I get too tired, is that going to harm the baby? And the truth is that it's very, very rare for a woman who has never exercised before, or just exercises somewhat on a regular basis to ever reach a point to where there is even a potential of harm to the baby from overdoing it. And that's something that I want Dr. Gould to just kind of speak about as far as just some of the lack of data, as far as why there's this misperception that potentially too much exercise is harmful.

Sara Gould, MD (Guest): So, that's definitely something that I think is really interesting to talk about. So there was a study done, as far as we know, the most impactful study that has been done was one that was done in, professional athletes, Olympians, in fact, and they were endurance athletes. And, this study did show that there was fetal bradycardia and decreased uterine artery blood flow at around 85th percentile of the maternal maximal heart rate. And so from that study, that's where a lot of our recommendations come. So, there've been a lot of guidelines that have come out.

ACOG has revised and does a great job of periodically updating the exercise in pregnancy guidelines. The most current guidelines are from bulletin 804, I believe. And, basically what ACOG recommends currently is 30 to 60 minutes per session, three to four times a week. And they want you to stay around 60 to 80% of your maximum predicted maternal heart rate. So this is going to be really hard for people who don't have a background in exercise physiology or exercise medicine, cause it's not something that we commonly get trained on in medical school. You know how to calculate maternal heart rates and maximum maternal heart rates.

And so I think we know that because we actually did a survey of obstetricians in Alabama, on their comfort level, and while all of them were familiar with what the guidelines say, putting it into practice because it's time consuming, because it's challenging, we found that not many of them were routinely counseling their women on how specifically to exercise.

And so that's where a lot of our interest comes from is how do we tell women to exercise? There's so many factors that go into it. So many difficult things, we want to tell women what to do and how to do it safely. But sometimes our advice is contradictory. Sometimes it's not feasible. For example, we're in the deep south in Alabama. In the summer, there are rarely any times where, women have access to a thermoneutral environment, especially in rural. So, you know, they don't have the ability to go outside and take a walk because that's not a thermoneutral setting. Now does that actually matter for someone who is acclimated to the heat?

That's whole other topic of controversy in terms of the effect of heat on fetal development. And most of our studies in that aspect have actually come from pathologic conditions. So women who were having fevers and is that the same thing as just being in a hot environment?

One of the most interesting stories that I have about that is I was presenting some research at an international conference once and a Finnish woman came up to me and said, we think it's really funny how all of you Americans are so worried about visiting saunas and your temperature because it's our custom and our habit to continue going to saunas throughout pregnancy and it's part of life and we consider it to be very healthy.

So I think that's a whole other area we have to study, because we are imposing a lot of barriers on women, in terms of our exercise recommendations. So that's what Dr. Cawyer and I are trying to do is put more literature out there and make it more feasible and, and break down barriers to exercise.

Dr. Cawyer: And I would just like to add, I think, from a provider who maybe has a newly diagnosed pregnant patient that they're seeing for other reasons, and they maybe ask a question about, well, what kind of activity can I do? A lot of them, I think, tend to just kind of hesitate and say, well, just take it easy. When I think right answer for most providers is just keep doing what you're doing.

It's likely going to be just fine. And I think even with the very limited data we have, we can feel very confident that a woman continuing to participate in her regular activity, however, that may be is going to be safe and even healthy for the prenancy.

Host: Well, I certainly couldn't agree with both of you more. As I know in graduate school, it was definitely limited. So Dr. Gould, because of the physiologic changes associated with pregnancy, and I find your Finnish story so interesting. As well as the hemodynamic response to exercise, we do recommend precautions. There are some that should be observed. Speak a little bit about contraindications. Dr. Cawyer mentioned gestational diabetes before, are there studies that have shown that exercise improves insulin sensitivity or lipid metabolism, glucose tolerance. And then there are questions surrounding relaxen. And when we talk about strength training or doing what you've done before, if you're an athlete different than if you are a new exerciser or somebody who is just in average shape. Can you speak to those precautions and what are the recommendations right now?

Dr. Gould: Typically, as Dr. Cawyer mentioned, historically recommendations have been it's okay to do what you've been doing. So if you're a conditioned athlete that's okay to keep doing at whatever intensity level you have went at before your pregnancy. For us, we know that obesity is really dangerous. There are all kinds of negative maternal and fetal outcomes associated with obesity. So anything we can do to combat weight gain, excessive weight gain during pregnancy, when we're starting out with an obese state is going to be helpful and important to do. And so, that becomes a real challenge. How do we tell people who haven't been exercising previously that they need to start when all of our guidelines say do what you were doing before. And so, that was actually why we started using this, ultrasound technology that we've developed, for this application, looking at the blood flow through the placenta as an organ, looking at the volume to try to document that there is not shunting of blood away from the placenta with either resistance training or cardiovascular intense exercise. And we've actually published our resistance data. And hopefully that will help guide people to understand that it's okay, that we're not shunting blood away from the placenta with certain levels of resistance training so they can feel comfortable, even if they haven't previously been doing that to start engaging in a program.

Dr. Cawyer: Just to go along with contraindications, really there's very few direct contraindications to exercise in pregnancy. And most of those that are going to be a contraindication, that patient should likely need to be seeing some kind of high-risk physician or an obstetrician who's experienced with medical co-morbidities or obstetrical co-morbidities in pregnancy. So that's something that really, it's pretty rare to tell a patient, hey, you have this condition, you shouldn't be exercising unless you are an obstetrician who has experienc with that.

Host: What a great point. So why don't you, Dr. Cawyer tell us about the Exercise and Pregnancy Clinic at UAB Medicine and why it's so important to seek appropriate prenatal care and discuss those guidelines in case someone is a high risk pregnancy or had a previous high risk pregnancy or is in some way contra-indicated for exercise.

Dr. Cawyer: So those that would benefit from the Exercise and Pregnancy Clinic, are multiple people. You can have those that are pretty active already with an exercise routine and want to make sure that they can safely continue it. That's a very popular patient for our clinic. You also have a woman that wants to try to avoid developing some kind of high risk condition, whether that be gestational diabetes or preeclampsia, and they would like to start an exercise routine because they have either been told to stop it with pregnancy, or they got busy with maybe a younger kid. And so they were unable to continue that, being a busy mom. And then there's also those people that we really want to try to get into clinic are those that have those high risk conditions like obesity, like, previous history of gestational diabetes, or hypertension that would really benefit from an improved exercise physiologic state that they can get with an exercise routine. And then Dr. Gould can kind of talk a little bit more about the clinic itself and how it's structured and why, with our technology that we utilize, how we can show a woman that, hey, what you would like to do can be safely done in pregnancy. And here's the effect that it has on the baby.

Dr. Gould: So, basically the experience that we have set up is it's a multidisciplinary clinic and I think that's really important for two reasons because you get access to both the maternal fetal medicine specialist, as well as someone with a background in sports medicine and exercise physiology. So we kind of start by making sure that women are aware of the benefits of exercise in pregnancy. We've kind of touched on that, but, lower incidence of excessive gestational weight gainthe diabetes, lower incidence of hypertensive disorders, as well as a host of other benefits. And then we kind of talk to them about what their goals are for exercise because, exercise is not a one size fits all.

And so we talk to them about what they desire to be doing, what they've been told they can do. They've been told if anything that they can't do. And then, Dr. Cawyer performs the screening ultrasound and an assessment on their prior pregnancy history. And, through that his evaluation, he then lets me know if there are any contra-indications, any recommendations or restrictions that he has on what I recommend for the exercise portion.

That would be highly individualized to the woman and based on her ultrasound, of course, we also let them know kind of the general warning signs to discontinue exercise while pregnant, like, bleeding, pain, contractions, fluid leaking, things like that. But beyond that, he will very specifically give me recommendations and say either I don't see any reasons that you need to restrict exercise or he'll tell me specifically what he's concerned about. And then I can develop a program. Once we do that, we then perform together an ultrasound, 3D, power flow, color Doppler ultrasound, which allows us to measure the blood flow through the organ, through the placental organ at rest. Once we have that number, we go over to our exercise lab, and we perform a submaximal stress test.

And, once we get to the stopping point, whether that's the patient or physician termination point, we then perform another ultrasound looking at the blood flow through the placenta, and we make sure that there hasn't been decrease in flow, that there's no shunting occurring, that we don't have anything going on at either the fetal or placental level that would make us concerned that the submaximal exercise should be limited. And then based on that, we write an exercise prescription incorporating the woman's goals and perform exercise counseling.

Host: Well, Dr. Gould, what do we know about the relationship between postpartum physical activity, lifestyle parameters and postpartum weight retention or weight gain or weight lost. Can you speak about what happens after the baby is born and how you work with mothers at the clinic in that case?

Dr. Gould: So couple of points, number one, Dr. Cawyer kind of alluded to the fact that pregnancy is a time when women are making a lot of changes, to their behavioral health and their habits. And so, it's an optimal time to adopt an exercise routine. And we know from prior studies, not specifically in pregnancy, but other studies on exercise that if we can maintain an exercise program for a period of time, it's much more likely to be continued. So if we can get women exercising during pregnancy and sustain that, they're much more likely to continue in the postnatal period. Of course there does need to be recovery time and that's going to depend on whether they were vaginal or Cesarean deliveries and what sort of complications, if any, there were during the delivery process.

So it's definitely something that has to be highly individualized and based on a lot of delivery related factors. But in general, we do encourage women to continue exercising to some degree after pregnancy and after delivery. It's also important to note that exercise has been shown to help with PTSD and depression, postpartum depression in particular, something that women can be at risk for. And so, helping them have an exercise regimen already in place and counseling can be really beneficial for those reasons as well.

Host: I'd like to give you each a chance for a final thought here. So Dr. Gould, starting with you, what do you tell women every single day? And you're speaking to other providers here, you're working with these women one-on-one doing the exercise with them, helping them with their questions and their concerns. What would you like to tell other providers about recommendations, counseling their patients when you have a chance to speak to them, what do you say about how they should be speaking to their clients to counsel them on exercise guidelines, recommendations, contraindications, kind of wrap that part of it up for us.

Dr. Gould: Sure. I think that probably the two most useful tools for providers are the ACOG committee bulletins and opinion summaries. They're updated periodically. I believe that number 804 is the most recent, and that has a really good summary. The other tool that can be really, really helpful is the PPAQ, which is a pregnancy activity assessment survey.

And there's a diagram and tools as part of that survey that can talk about FIT principles. So fitness, intensity, time, and basically just kind of lays out for the providers, how to do an exercise prescription. So I think those two resources are going to be the most useful for providers who are looking to incorporate exercise counseling.

I also think that it's important, providers often talk about being very limited on time and their ability to counsel patients. So, I think it's important to document these activities, because you can bill for both your exercise counseling as well as survey administration. So I think those are important things to keep in mind and make it more feasible for providers to actually be able to incorporate this as part of their routine.

Melanie Cole (Host): And Dr. Cawyer last word to you. As you're speaking to obstetrician, gynecologists and primary care providers and medical home, speak to them and tell them the resources that are available at UAB Medicine in the Pregnancy Clinic and why you feel it's so important that they refer to the specialists at UAB Medicine.

Dr. Cawyer: One of the most important aspects of having a healthy maternal obstetrical and neonatal outcome is adequate care. There are very few obstetrical teams that have as much breadth and knowledge when it comes to all areas of obstetrical care, then those providers at UAB. Anytime you're dealing with an area such as exercise and pregnancy, where a lot of providers just don't feel completely comfortable adequately counseling patients; you can find those providers at UAB. The resources are there that Dr. Gould has mentioned. They are online with the American College of Obstetrics and Gynecology website, where providers can get a snapshot to make sure that where they are setting the table for how a patient can approach their pregnancy and how physically active they need to be.

Once they reach that point where they want that individualized care, then a referral to the Exercise and Pregnancy Clinic at UAB is going to be the best case for them, where they can get that multidisciplinary team to make sure they have a optimized care plan.

Host: What an informative podcast this was. Such great information and great points were made. I thank you both for joining us today and to refer a patient to the Exercise and Pregnancy Clinic at UAB Medicine, you can call the mist line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physician.

That concludes this episode of UAB Med Cast. I'm Melanie Cole.