Protocol for the INFORMED (Individualised Patient Care and Treatment for Maternal Diabetes) Study: a randomised controlled trial embedded within routine care

INTRODUCTION

Diabetes in pregnancy presents a unique physiological challenge to manage glycaemia while maintaining adequate nourishment for the growing fetus. Women with diabetes who become pregnant are at greater risk of adverse maternal and newborn outcomes, compared with women without diabetes. Evidence suggests that control of (postprandial) glycaemia is key to manage maternal and offspring health but it is not yet clear (1) how diet and lifestyle moderate these shifts across the full duration of pregnancy or (2) what aspects of maternal and offspring health are associated with dysglycaemia.

METHODS AND ANALYSIS

To investigate these gaps, a cross-over randomised clinical trial has been embedded within routine clinical care. Seventy-six pregnant women in their first trimester with type 1 or type 2 diabetes (with or without medication) attending their routine antenatal appointments at National Health Service (NHS) Leeds Teaching Hospitals will be recruited. Following informed consent, data on women's health, glycaemia, pregnancy and delivery will be shared by the NHS with researchers. At each visit in the first (10-12 weeks), second (18-20 weeks) and third (28-34 weeks) trimester, participants will be asked for consent to: (1) lifestyle and diet questionnaires, (2) blood for research purposes and (3) analysis of urine collected at clinical visits. Additionally, participants will be asked to consume two blinded meals in duplicate in second and third trimester. Glycaemia will be assessed by continuous glucose monitoring as part of routine care. The primary outcome is the effect of experimental meals (high vs low protein) on postprandial glycaemia. Secondary outcomes include (1) the association between dysglycaemia and maternal and newborn health, and (2) the association between maternal metabolic profiles in early pregnancy with dysglycaemia in later pregnancy.

ETHICS AND DISSEMINATION

The Leeds East Research Ethics Committee and NHS (REC: 21/NE/0196) approved the study. Results will be published in peer-reviewed journals and disseminated to participants and the wider public.

TRIAL REGISTRATION NUMBER

ISRCTN57579163.

Beneficial Effects of Maternal Physical Activity during Pregnancy on Fetal, Newborn, and Child Health: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

The objective of this work is to synthesize current knowledge about the effects of maternal physical activity during pregnancy on children's health. During the prenatal and postnatal periods, maternal physical activity has protective effects against the risks of macrosomia, obesity, and other associated cardiometabolic disorders. Even though longitudinal studies in humans are still necessary to validate them, these effects have been consistently observed in animal studies. A remarkable effect of maternal physical activity is its positive role on neurogenesis, language development, memory, and other cognitive functions related to learning.

Effects of physical exercise on blood pressure during pregnancy

Objective

Effect of physical exercise on pregnant women currently has become a hot topic in prenatal health care. In this study, A meta-analysis was conducted on account of Randomized Controlled Trial (RCT). It focused on evaluating the effect of physical exercise intervention on blood pressure so that could provide certain evidence for health care during pregnancy.

Methods

Results of relevant studies were retrieved from PubMed, Embase, Web of Science and the Cochrane Library, and all of these included studies were evaluated according to the Cochrane collaboration’s tool for assessing the risk of bias. Stata 15.1 was used for meta-analysis, and mean difference (MD) was used as statistic for pooled analysis. The effect values were combined by conventional meta-analysis and Bayesian meta-analysis respectively, and the consistency of pooled results was considered as well.

Results

A total of 18 RCT studies were included in the quantitative analysis. The conventional meta-analysis showed differences in blood pressure between intervention group and control group (P < 0.05). Systolic and diastolic blood pressures of intervention group were 3.19 mmHg (95% CI: -5.13, -1.25) and 2.14 mmHg (95% CI: -4.26, -0.03) lower than that of control group, respectively. Bayesian meta-analysis showed that both systolic and diastolic pressure among intervention group decreased by 3.34 mmHg (95% CrI: -5.15, -1.56) and 2.14 mmHg (95% CrI: -3.79, − 0.50), respectively. Subgroup analysis supported that as long as healthy pregnant women participated in exercises, their blood pressure could be slightly regulated, while hypertension susceptible pregnant women significantly lowered blood pressure.

Conclusion

Exercise intervention during pregnancy is beneficial to lower or normalize blood pressure, and this research provides clues for follow-up studies.

Case Studies in Physiology: Adaptation of Loading-Bearing Tendons during Pregnancy

Pregnancy is characterized by hormone changes that could alter musculoskeletal (MSK) properties and temporarily increase soft tissue injury risk. Whilst the prevalence of MSK injuries in pregnancy has not yet proven itself to be a widespread problem, indirect evidence indicates an uptake in the prevalence of strength training and vigorous-intensity activity during pregnancy, which may result in increased MSK injury incidence. Combining this evidence with the association between sex hormones and MSK injury risk, we recognize the potential importance of this research area and believe the (prospective) examination of connective tissue properties in relation to hormonal changes in pregnancy are appropriate. Given the dearth of information on MSK adaptations to pregnancy, we present a variety of morphological, mechanical and functional tendon data from two consecutive pregnancies in one woman as a means of highlighting this under-researched topic. This data may be representative of the general pregnant population, or it may be highly individualized - more research is required for a better understanding of MSK adaptation and injury risk during and after pregnancy.

Physical therapists' experiences and perceptions of antepartum and postpartum care

Background

Little is known about the physical therapists’ practice and perceptions toward management of pregnancy/postpartum-related disorders in Taiwan. The aim of this study was to document current practice of physical therapy in antepartum and postpartum care in Taiwan.

Methods

An exploratory, cross-sectional study was conducted in registered physical therapists living in Taiwan. An anonymized online survey was designed, piloted, and advertised widely from March 2020 to March 2021. Data were analyzed using descriptive statistics, Chi square analysis and multivariate logistic regression.

Results

Of the 364 respondents, 37.6% had experience of treating pregnant or postpartum women in clinical practice. The most commonly treated pregnancy/postpartum-related disorder in practice was low back pain (61.3%). All respondents reported little to moderate level of confidence in their ability to manage pregnancy/postpartum-related disorder. Being female (p < 0.01); working at a regional hospital (p = 0.01), district hospital or district teaching hospital (p < 0.01), clinic (p = 0.01) or physiotherapy clinic (p = 0.01); and having prior experience of treating antepartum or postpartum women (p < 0.01) were significantly associated with willingness to provide customer-oriented service or health education to patients/clients with pregnancy/postpartum-related disorder after controlling for other confounding variables. The most commonly reported barrier was “lack of available training” (81.3%).

Conclusion

The majority of participating physical therapists indicated a positive attitude to antepartum and postpartum care but were not confident in management of various pregnancy/postpartum-related disorder in practices. The findings of this study highlight the educational needs related to antepartum and postpartum care in clinical practice for physical therapists in Taiwan.

Translation, Cultural Adaptation, and Reproducibility of the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+): The Brazilian Portuguese Version

Background: The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is the international standard for pre-participation risk stratification and screening. In order to provide a practical and valid screening tool to facilitate safe engagement in physical activity and fitness assessments for the Brazilian population, this study aimed to translate, culturally adapt, and verify the reproducibility of the evidence-based PAR-Q+ to the Brazilian Portuguese language.

Method: Initially, the document was translated by two independent translators, before Brazilian experts in health and physical activity evaluated the translations and produced a common initial version. Next, two English native speakers, fluent in Brazilian Portuguese and accustomed to the local culture, back-translated the questionnaire. These back translations were assessed by the organization in charge of the PAR-Q+, then a final Brazilian version was approved. A total of 493 Brazilians between 5 and 93 yr (39.9 ± 25.4 yr), 59% female, with varying levels of health and physical activity, completed the questionnaire twice, in person or online, 1–2 weeks apart. Cronbach's alpha was used to calculate the internal consistency of all items of the questionnaire, and the Kappa statistic was used to assess the individual reproducibility of each item of the document. Additionally, the intraclass correlation coefficient and its 95% confidence interval (CI) were used to verify the general reproducibility (reliability) of the translated version.

Results: The Brazilian version had an excellent internal consistency (0.993), with an almost perfect agreement in 93.8% of the questions, and a substantial agreement in the other 6.2%. The translated version also had a good to excellent total reproducibility (0.901, 95% CI: 0.887–0.914).

Conclusion: The results show this translation is a valid and reliable screening tool, which may facilitate a larger number of Brazilians to start or increase physical activity participation in a safe manner.

Cardiopulmonary exercise testing during pregnancy

The goal of this review is to examine practical considerations when conducting cardiopulmonary exercise testing during pregnancy. In a clinical and research setting, cardiopulmonary exercise testing during pregnancy is valuable in identifying underlying cardiopulmonary conditions, stratifying the risk of adverse pregnancy outcomes, as well as establishing exercise tolerance/limitations. This review encompasses information regarding the unique physiological adaptations that occur throughout gestation (e.g., changes in resting heart rate, blood pressure, glucose, etc.) and how these adaptations impact the interpretation of physiological measurements. There are also key concerns that are unique to pregnant populations that should be considered when participating in exercise (i.e., fetus, ventilation, thermoregulation, urinary incontinence, low back pain, and pelvic girdle pain). This step-by-step review of cardiopulmonary exercise testing outlines pregnancy related adjustments to standardized methods (i.e., screening/documentation, pre- and post-test measurements, protocol specifics, modality selection, and fetal monitoring) which should be considered for the safety of both the participant and fetus. Currently, pregnancy specific exercise testing guidelines are lacking. Therefore, we will be discussing the limitations of current recommendations such as a safe cut off for resting heart rate and pregnancy specific test termination criteria.

A role for maternally derived myokines to optimize placental function and fetal growth across gestation

Exercise during pregnancy is associated with improved health outcomes for both mother and baby, including a reduced risk of future obesity and susceptibility to chronic diseases. Overwhelming evidence demonstrates a protective effect of maternal exercise against fetal birth weight extremes, reducing the rates of both large- and small-for-gestational-age infants. It is speculated that this protective effect is mediated in part through exercise-induced regulation of maternal physiology and placental development and function. However, the specific mechanisms through which maternal exercise regulates these changes remain to be discovered. We hypothesize that myokines, a collection of peptides and cytokines secreted from contracting skeletal muscles during exercise, may be an important missing link in the story. Myokines are known to reduce inflammation, improve metabolism and enhance macronutrient transporter expression and activity in various tissues of nonpregnant individuals. Little research to date has focused on the specific roles of the myokine secretome in the context of pregnancy; however, it is likely that myokines secreted from exercising skeletal muscles may modulate the maternal milieu and directly impact the vital organ of pregnancy—the placenta. In the current review, data in strong support of this potential role of myokines will be presented, suggesting myokine secretion as a key mechanism through which maternal exercise optimizes fetal growth trajectories. It is clear that further research is warranted in this area, as knowledge of the biological roles of myokines in the context of pregnancy would better inform clinical recommendations for exercise during pregnancy and contribute to the development of important therapeutic interventions.

[Should physical activity be contraindicated during pregnancy in relation to its potentially related risks?]

OBJECTIVE

This paper aimed at providing a critical analysis of data on the risks associated with physical activity of women during their pregnancy.

METHODS

Cochrane Library, Google Scholar, PubMed (Medline) and Web of Sciences were searched using a combination of MeSH terms associated to "Physical activity", "Pregnancy" and "Adverse events" or "Risks". Only review papers published from inception of these databases to November 2016 were used in the present analysis.

RESULTS

The electronic search yield a total of 104 citations. After a critical analysis of abstracts and/or full-texts, only a systematic review and cohort study on injuries related to physical activity during pregnancy appeared relevant for the current study. Data reveals a very small proportion (<1 %) of adverse events in direct link with the physical activity behavior of pregnant women. Furthermore, there would be less than one serious adverse event per 5000hours of physical activity. The only serious adverse event attributable to physical activity during pregnancy was uterine contractions. The threat of preterm labor and miscarriage risk cannot be primarily attributed to the participation of pregnant women in a physical activity, even vigorous. Moreover, no adverse effects of maternal physical activity on neonatal outcomes were found.

CONCLUSION

Physical activity-related risks during pregnancy appear to be infrequent and of minor severity. Though further studies are required to better understand the risk/benefit balance of physical activity during pregnancy, current data do not support the contraindication of this behavior in pregnant women.

Translational studies for exercise in high-risk pregnancy: Pre-eclampsia model

OBJECTIVE

Reviewed literature regarding exercise effects on pregnancy-related hypertensive disorders, analyzing basic science perspectives and clinical studies.

METHODS

Scientific databases were accessed by research strategy combining Medical Subject Headings terms. Studies published between 2000 and 2015, in English, Portuguese, and Spanish language, were considered.

RESULTS

Studies were classified into: recommendations for exercise on high-risk pregnancy; animal models for hypertension in pregnancy; exercise on hypertensive disorders in animal models and pregnant women.

CONCLUSION

There are several animal models to mimic hypertensive disorders in pregnancy; however, clinical studies are still needed for exercise recommendation in pregnant women with hypertensive disorders.

Physical efficiency and activity energy expenditure in term pregnancy females measured during cardiopulmonary exercise tests with a supine cycle ergometer

OBJECTIVES

To evaluate physical efficiency and activity energy expenditure (AEE) in term pregnancy females during cardiopulmonary exercise tests with a supine cycle ergometer.

MATERIAL AND METHODS

The study comprised 22 healthy full-term pregnancy women with uncomplicated pregnancies hospitalized in the Department of Gynecology and Obstetrics, Specialist Teaching Hospital in Tychy, Poland. All subjects underwent cardiopulmonary exercise tests (CPET) on a supine cycle ergometer. The 12-min, three-stage, progressive, symptom-limited submaximal test protocol (up to 80% HRmax) was used. Pulsometry was used to record HR on a beat-to-beat analysis and to calculate AEE. Respiratory responses were measured by ergospirometer and a computer system on a breath-by-breath basis at rest, during exercise and at restitution.

RESULTS

In the studied population, VO2max was established at the level of 2.19 ± 0.33 L/min in ergospirometry and 2.04 ± 025 L/min in pulsometry. Physical efficiency calculated for sub-maximal exercise by use of the Davis equation was 30.52 ± 0.12%. AEE, based on VO2 in various phases of the CPET, was 0.47, 0.71 and 0.88 L/min for phases 25, 50 and 75 W. Based on ergospirometer readouts, AEE was 10.60, 16.11 and 20.94 kJ/min for phases 25, 50 and 75 W. Overall mean AEE (determined by pulsometry) was 10.59  kJ/min. CPET testing did not have any negative effect upon the health or life of the neonates involved in the study.

CONCLUSIONS

Submaximal CPET up to 80% HRmax with a supine cycle ergometer is a safe and precise method for assessing work efficiency in term pregnancy women.

Exercise in Pregnancy: A Clinical Review

Context:

Health professionals who care for pregnant women should discuss potential health benefits and harms of exercise. Although most pregnant women do not meet minimal exercise recommendations, there are a growing number of physically active women who wish to continue training throughout pregnancy.

Evidence Acquisition:

A search of the Web of Science database of articles and reviews available in English through 2014. The search terms exercise pregnancy, strenuous exercise pregnancy, and vigorous exercise pregnancy were used.

Study Design:

Clinical review.

Level of Evidence:

Level 3.

Results:

With proper attention to risk stratification and surveillance, exercise is safe for the mother and fetus. Benefits of exercise in pregnancy include reduction in Cesarean section rates, appropriate maternal and fetal weight gain, and managing gestational diabetes. Exercise as a means of preventing gestational diabetes, preeclampsia, or perinatal depression cannot be reliably supported. Overall, the current evidence suffers from a lack of rigorous study design and compliance with physical activity interventions.

Conclusion:

Research thus far has been unable to consistently demonstrate proposed benefits of exercise in pregnancy, such as preventing gestational diabetes, preeclampsia, or perinatal depression. However, moderate- and high-intensity exercise in normal pregnancies is safe for the developing fetus and clearly has several important benefits. Thus, exercise should be encouraged according to the woman’s preconception physical activity level.

[International recommandations on physical exercise for pregnant women]

Benefits of physical exercise on the physical and psychological health lead to specifics guidelines during pregnancy. For pregnant women, to take part in aerobics exercise (walking, biking) (i.e. 30 minutes, three times per week at 60-90% of the maximal heart rate) and strength training (i.e. one to two times per week) is recommended. Physical exercise programs during pregnancy have shown benefits for preventing and treating complications pregnancy (e.g. gestational diabetes mellitus, overweight). Benefits of exercise and risks associated with sedentary should be widely diffused among pregnant women and prenatal caregivers.

Benefits of exercise during pregnancy

There is a direct link between healthy mothers and healthy infants. Exercise and appropriate nutrition are important contributors to maternal physical and psychological health. The benefits and potential risks of exercise during pregnancy have gained even more attention, with a number of studies having been published after the 2002 American College of Obstetrics and Gynecologists guidelines. A review of the literature was conducted by using PubMed, Scopus, and Embase to assess the literature regarding the benefits of exercise during pregnancy. The search revealed 219 publications, which the authors then narrowed to 125 publications. The purpose of this review is to briefly summarize the known benefits of exercise to the mother, fetus, and newborn.

Enhancing the effectiveness of clearance for physical activity participation: background and overall process1This paper is one of a selection of papers published in the Special Issue entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal's usual peer-review process

Recent feedback from physical activity (PA) participants, fitness professionals, and physicians has indicated that there are limitations to the utility and effectiveness of the existing PAR-Q and PARmed-X screening tools for PA participation. The aim of this study was to have authorities in exercise and chronic disease management to work with an expert panel to increase the effectiveness of clearance for PA participation using an evidence-based consensus approach and the well-established Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Systematic reviews were conducted to develop a new PA clearance protocol involving risk stratification and a decision-tree process. Evidence-based support was sought for enabling qualified exercise professionals to have a direct role in the PA participation clearance process. The PAR-Q+ was developed to use formalized probes to clarify problematic responses and to explore issues arising from currently diagnosed chronic disease or condition. The original PARmed-X tool is replaced with an interactive computer program (ePARmed-X+) to clear prospective PA participants for either unrestricted or supervised PA or to direct them to obtain medical clearance. Evidence-based validation was also provided for the direct role of highly qualified university-educated exercise professionals in the PA clearance process. The risks associated with exercise during pregnancy were also evaluated. The systematic review and consensus process, conforming to the AGREE Instrument, has provided a sound evidence base for enhanced effectiveness of the clearance process for PA participation of both asymptomatic populations and persons with chronic diseases or conditions.