Pregnancy Health: Exercise Programs to Prevent Gestational Hypertension

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to pregnancy health:

Magro-Malosso E, Saccone G, Di Tommaso M, Roman A, Berghella V. Exercise during pregnancy and risk of gestational hypertension disorders: a systematic review and meta-analysis. Acta Obstetrica et Gynecologica Scandinavica 2017;96:921-31.

The published review included 17 studies (search period through February 2017). The CPSTF finding is based on results from the published review, additional analyses of data from included studies, and expert input from team members and the CPSTF.

Regular physical activity is recommended for women before, during, and after pregnancy (DHHS 2018). Physical activity during pregnancy has minimal risks and has been shown to benefit most women (ACOG 2017).

Participation in structured exercise programs can help women, especially those who are not otherwise active, obtain regular physical activity throughout pregnancy. Exercise initiated early in pregnancy can help reduce excessive weight gain and prevent gestational diabetes (CPSTF 2017).

This systematic review assessed the effectiveness of exercise programs in preventing gestational hypertensive disorders, defined as new onset high blood pressure during pregnancy. There are four different types of gestational hypertensive disorders: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension (Vest et al., 2014). This CPSTF finding is specific to one type gestational hypertension without the development of preeclampsia-eclampsia.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review and meta-analysis included 17 randomized controlled trials.

• Compared to interventions without an exercise program or to usual care, exercise programs reduced the development of high blood pressure during pregnancy by 46% (17 studies)

Additional analyses of a subset of 16 studies showed the following:

• The cesarean delivery rate for program participants was 16% lower than the rate for comparison groups (14 studies).
• The rate of preeclampsia was 21% lower among program participants when compared with control groups, though the difference was not statistically significant (7 studies).

A systematic review of economic evidence has not been conducted.

Based on results from the review, findings should be applicable to healthy women with uncomplicated pregnancies in the United States. The CPSTF expressed concern, however, about the need for further evaluation in specific U.S. settings and populations.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• What are the pathways between exercise and preeclampsia?
• How does program effectiveness vary by population and setting (e.g., participant income, education, race/ethnicity; rural or urban setting)?
• How effective are community-based interventions when women are referred from their first pre-natal visit?
• What are the best ways to efficiently assess pregnant women for exercise program eligibility and refer them to clinic- or community-based programs?
• What is the dose-response relationship between supervised group-format exercise and effectiveness? What are the minimum requirements for program effectiveness?

• Included studies were conducted in Spain (8 studies), the United States (2 studies), Norway (2 studies), Denmark (2 study), Italy (1 studies), and Brazil (1 study).
• Exercise programs included supervised aerobic exercise classes (8 studies), a mix of supervised and unsupervised exercise (4 studies), or monitored walking sessions (4 studies).
• Exercise sessions were typically 3 times per week (11 studies), and they lasted 30-60 minutes (14 studies).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Magro-Malosso E, Saccone G, Di Tommaso M, Roman A, Berghella V. Exercise during pregnancy and risk of gestational hypertension disorders: a systematic review and meta-analysis. Acta Obstetrica et Gynecologica Scandinavica 2017;96:921-31.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Barakat R, Ruiz JR, Stirling JR, Zakynthinaki M, Lucia A. Type of delivery is not affected by light resistance and toning exercise training during pregnancy: a randomized controlled trial. Am J Obstet Gynecol. 2009;201:590.e1 6.

Barakat R, Pelaez M, Montejo R, Luaces M, Zakynthinaki M. Exercise during pregnancy improves maternal health perception: a randomized controlled trial. Am J Obstet Gynecol. 2011;204:402.e1 7.

Barakat R, Pelaez M, Lopez C, Montejo R, Coteron J. Exercise during pregnancy reduces the rate of cesarean and instrumental deliveries: results of a randomized controlled trial. J Matern Fetal Neonatal Med. 2012;25:2372 6.

Barakat R, Cordero Y, Coteron J, Luaces M, Montejo R. Exercise during pregnancy improves maternal glucose screen at 24 28 weeks: a randomised controlled trial. Br J Sports Med. 2012;46:656 61.

Barakat R, Perales M, Bacchi M, Coteron J, Refoyo I. A program of exercise throughout pregnancy. Is it safe to mother and newborn? Am J Health Promot. 2014;29:2 8.

Barakat R, Pelaez M, Montejo R, Refoyo I, Coteron J. Exercise throughout pregnancy does not cause preterm delivery: a randomized, controlled trial. J Phys Act Health. 2014;11:1012 7.

Barakat R, Pelaez M, Cordero Y, Perales M, Lopez C, Coteron J, et al. Exercise during pregnancy protects against hypertension and macrosomia: randomized clinical trial. Am J Obstet Gynecol. 2016;214:649.e1 8.

de Oliveria Melo AS, Silva JL, Tavares JS, Barros VO, Leite DF, Amorim MM. Effect of a physical exercise program during pregnancy on uteroplacental and fetal blood flow and fetal growth: a randomized controlled trial. Obstet Gynecol. 2012;120:302 10.

Haakstad LAH, Bo K. Exercise in pregnant women and birth weight: a randomized controlled trial. BMC Pregnancy Childbirth. 2011;30:66.

Kong KL, Campbell CG, Foster RC, Peterson AD, Lanningham-Foster L. A pilot walking program promotes moderate-intensity physical activity during pregnancy. Med Sci Sports Exerc. 2014;46:462 71.

Perales M, Santos-Lozano A, Sanchis-Gomar F, Luaces M, Pareja-Galeano H, Garatachea N, et al. Maternal cardiac adaptations to a physical exercise program during pregnancy. Med Sci Sports Exerc. 2016;48:896 906.

Petrella E, Malavolti M, Bertarini V, Pignatti L, Neri I, Battistini NC, et al. Gestational weight gain in overweight and obese women enrolled in a healthy lifestyle and eating habits program. J Matern Fetal Neonatal Med. 2014;27:1348 52.

Price B, Amini SB, Kappler K. Exercise in pregnancy: effect of fitness and obstetric outcomes a randomized controlled trial. Med Sci Sports Exerc. 2012;44:2263 9.

Renault KM, N rgaard K, Nilas L, Carlsen EM, Cortes D, Pryds O, et al. The Treatment of Obese Pregnant Women (TOP) study: a randomized controlled trial of the effect of physical activity intervention assessed by pedometer with or without dietary intervention in obese pregnant women. Am J Obstet Gynecol. 2014;210:134.e1 9.

Ruiz JR, Perales M, Pelaez M, Lopez C, Lucia A, Barakat R. Supervised exercise-based intervention to prevent gestational weight gain: a randomized controlled trial. Mayo Clin Proc. 2013;88:1388 97.

Stafne SN, Salvesen K_A, Romundstad PR, Eggeb TM, Carlsen SM, M rkved S. Regular exercise during pregnancy to prevent gestational diabetes: a randomized controlled trial. Obstet Gynecol. 2012;119:29 36.

Vinter CA, Jensen DM, Ovesen P, Beck-Nielsen H, J rgensen JS. The LiP (Lifestyle in Pregnancy) study: a randomized controlled trial of lifestyle intervention in 360 obese pregnant women. Diabetes Care. 2011;34:2502 7.

Implementation Resource

Rural Health Information Hub, Maternal Health Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of maternal health programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Models Addressing Perinatal Health

Related Reviews and Recommendations

• The U.S. Department of Health and Human Services, Physical Activity Guidelines for Americans, 2^nd edition provides recommendations on frequency and duration of physical activity for women before, during, and following pregnancy.
• The American College of Obstetrics and Gynecology (ACOG) has a statement about Physical Activity and Exercise During Pregnancy and the Postpartum Period

Refer to the existing systematic review for information about the search strategy:

Magro-Malosso E, Saccone G, Di Tommaso M, Roman A, Berghella V. Exercise during pregnancy and risk of gestational hypertension disorders: a systematic review and meta-analysis. Acta Obstetrica et Gynecologica Scandinavica 2017;96:921-31.

Magro-Malosso E, Saccone G, Di Tommaso M, Roman A, Berghella V. Exercise during pregnancy and risk of gestational hypertension disorders: a systematic review and meta-analysis. Acta Obstetrica et Gynecologica Scandinavica 2017;96:921-31

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2^nd edition. Washington, DC: U.S. Department of Health and Human Services; 2018.

American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. Physical Activity and Exercise During Pregnancy and the Postpartum Period. Committee Opinion. December 2017 (Reaffirmed 2017); No. 650.

Vest AR, Cho LS. Hypertension in Pregnancy. Current Atherosclerosis Reports. 2014; 16: 395-405. (adapted from Table 1)

The following considerations for implementation are drawn from studies included in the evidence review, the broader literature, and expert opinion.

The CPSTF recommends similar interventions to reduce the risk of developing gestational diabetes, another common complication of pregnancy with similar risk factors (e.g., pre-pregnancy overweight or obese status, excessive weight gain during pregnancy).

The overall ratio of benefits to costs is likely to increase as more evidence shows interventions targeting pregnant women improve related outcomes (e.g., cesarean delivery). This will make programs more attractive to health systems and communities and also increase patient and provider demand for interventions.

The CPSTF identified four important considerations for real-world implementation of exercise programs.

• Interventions will likely depend on health plans or health systems to fund or provide facilities and supervision for exercise programs. Walking programs in community settings may reduce cost barriers for both health systems and women.
• Health system referral and enrollment systems will be required to ensure pregnant women can access exercise programs early in their pregnancies.
• Program retention may be increased if programs address barriers to participation, such as childcare.
• Preventive benefits are likely to be greater when women join programs early in their pregnancies. It will be challenging, yet important, to expand the goals of early pre-natal visits to include an assessment for moderate-intensity aerobic exercise, an exercise prescription with motivational counseling (ACOG 2017), and enrollment or referral to available programs.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Improve cardiovascular health in adults — HDS‑01
• Reduce cesarean births among low-risk women with no prior births — MICH‑06
• Increase the proportion of adults who do enough aerobic physical activity for substantial health benefits — PA‑02
• Increase the proportion of adults who do enough aerobic physical activity for extensive health benefits — PA‑03