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Warner Huh, MD (Host): Hello. This is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama, Birmingham, and I'd like to welcome you, yet again, to another episode of Women's Health with Dr. Huh. Today, we're going to talk about a really relevant topic. Something that I think most women would like to hear about, which is the topic of exercise in pregnancy.

And as you're going to learn in here shortly, it's actually remarkable to me how limited our understanding is about exercise in pregnancy, including what is reasonable. What's not reasonable? What's maximally tolerated? I think this podcast is going to shed a lot of information in terms of exactly how women exercise during pregnancy.

So, before we get into that, I want to welcome our two guests. First, I want to welcome Dr. Sara Gould, who's an Associate Professor in the Department for Orthopedic Surgery, who's involved with Sports Medicine here at UAB, as well as Dr. Chase Cawyer who is a Physician, as well as an MBA, who's an Assistant Professor of the Division of Maternal Fetal Medicine in the Department of Obstetrics and Gynecology here at UAB.

So, welcome Dr. Gould and Dr. Cawyer.

Chase Cawyer, MD (Guest): Thanks for having us.

Host: So, I want to just talk to you a little bit about exercise in pregnancy. You know, even though I'm in the department of OBGYN, and I did some research on this area, it's remarkable to me, how little information there really is about how much can women exercise when they're pregnant. What's reasonable. What's not reasonable. And so Dr. Cawyer, I thought maybe you could lead by saying or talking about what are the current recommendations regarding exercise in pregnancy and what, like how much, how often that kind of thing?

Dr. Cawyer: Well, it's kind of interesting because right now ACOG just recommends physical activity and exercise more days than not during pregnancy. And so often that gets interpreted and kind of in your own way. And typically this is specified as doing some type of activity around four to five times per week for at least 30 minutes each time. But it's kind of important to realize that when we're talking about exercise, we're not just specifically talking about an exercise class or routine or anything like that, but really anything that involves physical activity.

So, for most women, 30 minutes of exercise a day may seem like a lot, but really this could include something as simple as just a brisk 30 minute walk after lunch or dinner, most days of the week. And really kind of all pregnant women need to be evaluated by an OB to help establish some kind of physical activity or exercise routine to ensure that there's really no medical reasons to avoid this.

And the truth is, there really are few reasons to actually avoid exercise in pregnancy. Most of these are obstetrical complications, such as preeclampsia, placenta previa, preterm labor, and these typically develop kind of throughout the pregnancy and are unlikely to be experienced at the beginning when a lot of women are seeking this information. And especially women with pre-existing medical complications, like high blood pressure, diabetes, or obesity, are some patients that can benefit the most with a mild to moderate exercise routine. Because what we know is that exercise helps lower the risk of pregnancy complications.

In women who begin their pregnancy with a lifestyle that includes moderate to vigorous exercise, you know, those that you consider highly physically active, should really continue all these healthy habits. Most exercise routines are fine to continue during pregnancy. The main ones to discontinue are those that involve major contact, kind of have a high risk of falling or abdominal trauma. And it's important to know that during exercise, you know, the things you'll experience like sweating with strenuous activity, as well as the increased fatigue and nausea, this is to be expected.

But if obstetrical problems like fluid leakage, vaginal bleeding, contractions, or new pains, like muscle cramps or worsening shortness of breath are experienced; exercise should stop and they should notify their doctor immediately and determine if they can continue with this. And what's important is that adjustments are often needed once women get into the later part of mid trimester and third trimester. These women benefit greatly from a visit with someone who's experienced in adjusting and monitoring these exercise routines for pregnant women. For women who categorize themselves as elite athletes, or those that engage in more extreme sports or activities, adjustments will definitely need to be made, after the second trimester, after consulting with one of these who provides service for these type of athletes. But I guess in general, just a good rule of thumb is that women should look for ways to initiate or continue exercising throughout their pregnancy just given its benefit.

Host: Wow. So, I mean, so what I'm hearing from you, and this is important for our listeners to understand is that there's really, with some exceptions, there'snothing wrong with women exercising and exercising regularly. That's what I'm hearing from you, Dr. Cawyer.

Dr. Cawyer: Yeah, that's right. And we want women to exercise or be physically active during pregnancy.

Host: And I guess what I'm also hearing is that, you know, for the most part, women can exercise regularly and at times intensely even potentially into the third trimester. But, you know, as an individual's body changes, there's probably some considerations regarding balance, heat tolerance all those kinds of things that are probably important, that are common sense to most people, right?

Dr. Cawyer: And that's where the visit with someone that's well versed in this and understands is going to be able to individualize what actually they need.

Host: So, Dr. Gould, let me ask you, do we know if exercise, even extreme exercise has a deleterious effect on the pregnant patient and the fetus? And what do we know about just high intensity exercise and what's maximally tolerated and the impact on the physiology during pregnancy?

Sara Gould, MD (Guest): So, that's a really important question. And I think to echo what Dr. Cawyer was saying, for the vast majority of women, the vast majority of exercise types are safe. And I think that's what the message needs to be. But the issue that you just brought up in terms of exercise intensity is near and dear to my heart. I'm very passionate about because I ran competitively in college and when I had my first pregnancy, I was told that I was not able to run half marathons during my pregnancy.

And I was so disappointed because I wanted to run in the New York half marathon. So, there was a paper that came out actually about that time, which was in the British Journal of Sports Medicine by Salveson. And that paper looked at elite athletes. So Olympic level endurance athletes, and they had the women exercise to about 90% of their maximum heart rate intensity. And they found that at that level, there was shunting of blood away from the placenta. They measured that by proxy through the uterine artery. And so that basically what they saw, to kind of summarize that, is they saw diminished blood flow with very high intensity exercise in elite athletes. And so, that was just one study, but it has been one of the major studies that's shown that maybe there is some type of threshold that we need to be concerned about.

Of course that was an elite athlete. Most of us are not Olympic level runners. Most of us would never even be capable of getting to that high of an intensity. That being said, there's also been studies that show that unconditioned athletes can switch to the lactic acid threshold at 50 to 60% of their VO 2 max.

So, the answer is we don't know. And that is why this is such an exciting field to be in. You know, we are looking at how to make these guidelines safer. Dr. Cawyer and I have been involved in several research projects looking at, actually we developed a technique to be able to look at 3D blood flow through the placenta during exercise. And so we actually can perform this technique in our clinic, which we're really excited about. And actually look at blood flow through the placenta during, even and after intense exercise.

Host: So, again, I just kind of want to recapture and unpack what you said. So, it's interesting because what you're talking about is really probably the top 0.5% of athletes that exercise at the most extreme level, which like you said, most of us could never dream of having that level of exercise or of tolerance, but, you know, going back. I think it's important for the listeners to understand that, because the data is limited, it's based on a very extreme group. But I have to ask you this question. I don't mean to put you on the spot, but do you think it's totally reasonable for you to have run that half marathon when you were pregnant?

Dr. Gould: Well, of course I did, which is why I started researching it. Because I didn't think that it was reasonable. Now I am in no way, shape or form. My obstetrician who gave me those recommendations when I was living in New York was practicing according to the national guidelines at that time. So, in no way, shape or form was the problem that physician. But I think the problem is the guidelines. And again, there's such limited research that people are basically just sitting in a room saying, well, what do we think is best? We don't actually know what is best, which is why this is such a really cool space to be working in and researching.

Host: I don't mean to put you on the spot, but that's, you know, I'm just kind of curious and again, we're not trying to dispense wide medical advice to our listeners who want to think about doing a half marathon during pregnancy. But to your point, I think the listeners have to understand that the recommendations are based on very loose data and information at best. Hence, the reason why we're doing this podcast and hence my next question to the two of you, which is, you know, I understand that you've just started or about to start this exercise in pregnancy clinic. So, I thought maybe you could tell us what really, what the goals are that clinic are and what you're trying to accomplish.

Dr. Gould: Yeah. So, again, I'm so excited about this clinic, cause it's my passion, exercise and particularly working with women who are pregnant. So, what we're trying to accomplish is the current guidelines as Dr. Cawyer mentioned, really talk a lot about how we need to be individualizing an exercise prescription. We need to be taking the entire individual into account. There's no one size fits all. And so our clinic is specifically to do just that, to meet with women, to perform exercise testing, to perform ultrasounds, which are going to show us on the cellular level, kind of what's going on.

So, that we can look at blood flow and we can look at different measures of fetal wellbeing and give them very specific recommendations that will allow them to exercise as to the point that they want to safely. And we are all interested in working with elite athletes, but I think it's important also to mention that I'm really excited to be partnering with Dr. Cawyer because he does have an expertise in maternal fetal medicine, which means that we can also work with people who have risk factors, who aren't the people that you think of that are going to be out. You know, people who are struggling with obesity or diabetes or hypertension. Those are the people who can benefit the most from exercise during pregnancy.

And they are sometimes the ones that have the most barriers because nobody has expertise in this field because we just don't know that much. And then these people who have co-morbidities, which would make them really benefit from exercise, don't necessarily have access to someone who can guide them and monitor for fetal safety. So, this is like just really an incredible opportunity to be able to get in with sports medicine and with maternal fetal medicine at the same time in the same space.

Host: Yeah. I couldn't agree with you more. I would have to think that this is a topic that would resonate with many women who are pregnant. Right? They're always asking me at cocktail parties or other venues, hey, can I exercise? Can I not exercise? Just like Dr. Cawyer, I'm basing it on the same loose guidelines. But when we talk about exercise being such an important lifestyle modifier for our health, I think that we need to know more in terms of its interaction with pregnancy.

So, I really, I applaud the two of you for doing this. I know that you guys will come out with some really fascinating cool data, information that will inform us going forward. So, I'm really excited about that. So, Dr. Cawyer, I thought maybe can you just comment on exactly what resources, reliable resources that might be available for women who are pregnant and want to continue their exercise or start exercise?

Dr. Cawyer: Yeah. You know, if you can't catch the theme, unfortunately there's really not as much as we'd like it's hard to have a lot of resources when you don't have data, but, and this is just another reason why we're excited about this clinic. Cause you know, we can start getting some resources out there to those in the community specifically the personalized resources, but there are some that are available, you know, ACOG and the American Pregnancy Association, they have information you can find online that offers insight into a lot of the benefits and things to avoid while exercising in pregnancy. But one of the limitations of these sources is they don't really go into many specifics. They just offer general guidelines, kind of like I talked about, avoid contact or it's good to exercise more days than not.

But there are specific exercise recommendations or routines pregnant women can find. There's some good apps out there that target this demographic. Most of these have been developed by those who are well-educated or have a good amount of experience on this topic. But unfortunately many, if not most of these have never really been properly studied or evaluated.

And so it's difficult to name those that are better than others or to say which apps are really gonna make a benefit. But I, you know, just doing a quick search, you can, I'm sure you can find, I mean, I, there are plenty of apps that you can find. It's just hard for me to recommend a specific one.

But really one of the best resources is just women meeting with someone who has expertise in this or if not expertise, at least a good amount of experience in creating a personalized exercise regimen that they've done for other pregnant women. And we're happy to see as many pregnant women as we can that are interested in this topic, but there's a lot of good resources in the community with trainers also that may have some good insight into this, that can really help personalize a routine. Cause that's really what we're learning is that not everyone's the same. And we can really do a good job of making sure that right routine is right for the right person.

Host: Any thoughts or other comments that you want to pass onto our listeners today?

Dr. Cawyer: Yeah, just to echo what Dr. Gould said. This is, you know, just a really exciting field because the data is just, it's just lacking. It's lacking it in elite women. It's lacking in women that have multiple pregnancy complications. I mean, the basis of what we know is that it can improve pregnancy outcomes. And that's really it, but we don't know at what levels or how much and whatnot. And so it's just a really exciting field and excited to continue to let the women in Birmingham, specifically really contribute to national guidelines.

Host: Well, thanks to the two of you. I really, this is, like I said earlier, I think a much needed area of both clinical investigation, as well as bonafide solid recommendations for, you know, the millions and millions of current and future women that are pregnant, that want to continue to exercise. So, I applaud both of you. So, thank you for coming on board. So again, I want to thank both Doctors Gould and Cawyer for your time and sharing for your expertise in the topic of exercise and pregnancy.

And as always, you can rate this podcast and we welcome any comments, particularly on topics that you're interested in. And then for more information, about the new exercise and pregnancy clinic or any other clinical services that UAB provides, please check out uabmedicine.org and until next time, have a great day and peace out. Bye bye.