The effect of walking on pregnancy blood pressure disorders in women susceptible to pregnancy hypertension: A randomized clinical trial

[Fetal death: Expert consensus from the College of French Gynecologists and Obstetricians]

Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient's wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it's the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.

Exercise effects on maternal vascular health and blood pressure during pregnancy and postpartum: a systematic review and meta-analysis

AIMS

This systematic review aimed to assess the effects of exercise training during pregnancy and the postpartum period on maternal vascular health and blood pressure (BP).

METHODS AND RESULTS

The outcome of interest was pulse wave velocity (PWV), flow-mediated dilation (FMD), and BP from pregnancy to 1-year postpartum. Five databases, including Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library, were systematically searched from inception to August 2023. Studies of randomized controlled trials (RCTs) comparing the effects of prenatal or postpartum exercise to a non-exercise control group were included. The risk of bias and the certainty of evidence were assessed. Random-effects meta-analyses and sensitivity analyses were conducted. In total, 20 RCTs involving 1221 women were included. Exercise training, initiated from Week 8 during gestation or between 6 and 14 weeks after delivery, with the programme lasting for a minimum of 4 weeks up to 6 months, showed no significant impact on PWV and FMD. However, it resulted in a significant reduction in systolic BP (SBP) [mean difference (MD): -4.37 mmHg; 95% confidence interval (CI): -7.48 to -1.26; P = 0.006] and diastolic BP (DBP) (MD: -2.94 mmHg; 95% CI: -5.17 to -0.71; P = 0.01) with very low certainty. Subgroup analyses revealed consistent trends across different gestational stages, types of exercise, weekly exercise times, and training periods.

CONCLUSION

Exercise training during pregnancy and the postpartum period demonstrates a favourable effect on reducing maternal BP. However, further investigations with rigorous methodologies and larger sample sizes are needed to strengthen these conclusions.

It's time to increase physical activity promotion among pregnant women in France

BACKGROUND

The lockdown linked to COVID-19 was shown to have negative effects on healthy behaviors in the general population, prompting the implementation of adapted public health measures. However, more vulnerable populations, such as pregnant women, were not specifically taken into account. At the time of writing this study, we know little about how the COVID-19 pandemic impacted the physical activity (PA) behavior of pregnant women in France. Given the many reports in the literature about women's low level of PA throughout pregnancy and the negative effects of the COVID-19 lockdown on behaviors in the general population; however, we might assume that their sedentary behaviors increased. The current study aimed to analyze the French recommendations and PA promotion among pregnant women.

MATERIALS AND METHODS

A literature search was done using PubMed for the key terms "physical activity/physical activity promotion," "pregnant women/pregnancy,", and "French population/France." All the relevant studies were included to support the argument for this narrative review.

RESULTS

Efforts to promote PA for pregnant women often seem ineffective and even unrealistic, and many women become overweight or obese during pregnancy. Health professionals need evidence-based guidelines and continuous training and skills development in order to convincingly encourage women to be more active during pregnancy and the postpartum period.

CONCLUSION

Health policies should strengthen PA promotion among pregnant women with detailed evidence-based guidelines on PA during postpartum.

Exercise during pregnancy for preventing gestational diabetes mellitus and hypertensive disorders: An umbrella review of randomised controlled trials and an updated meta-analysis

OBJECTIVE

This study aimed to provide, through an umbrella review, an overview of the effect of single exercise interventions during pregnancy on gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP). Also, to update the current evidence through an updated meta-analysis.

DESIGN

Umbrella review.

SETTING

PubMed, EMBASE, Web of Science, Cochrane database of systematic reviews, Epistemonikos, SPORTDiscus, Clinicaltrials.gov, and PROSPERO register were searched from the database inception until August 2021.

POPULATION

Peer-reviewed systematic reviews and meta-analyses of randomised controlled trials (RCTs) and RCTs samples.

METHODS

Random-effects model was used to calculate relative risk with 95% confidence interval in the updated meta-analysis. The reference category was the groups that received usual prenatal care. AMSTAR 2 and the Cochrane Collaboration tool were used to assess the quality and GRADE approach was used to assess the overall certainly of evidence.

MAIN OUTCOME MEASURES

GDM and HDP relative risk.

RESULTS

Twenty-three systematic reviews and meta-analyses; and 63 RCTs were included. Single exercise interventions reduced the incidence of GDM and HDP in most systematic reviews and meta-analyses. Moreover, exercise interventions during pregnancy decrease the incidence of developing GDM and GH, particularly when they are supervised, have a low to moderate intensity level, and are initiated during the first trimester of pregnancy.

CONCLUSION

Based on the findings, obstetric and physical exercise professionals could recommend exercise interventions during pregnancy as an effective strategy to improve maternal outcomes.

Physical activity and pregnancy outcomes: an expert review

This expert review aimed to assess current literature on the effect and tracking of physical activity during pregnancy and associated outcomes. Self-reported physical activity may be inaccurate given the subjective nature of the questionnaires. The accelerometer ActiGraph is considered the "gold standard" to objectively measure physical activity. However, other more user-friendly wearable devices are now widely available and may accurately track physical activity. Conclusive data from both validated activity questionnaires and accelerometers indicate that physical activity is safe during pregnancy. In addition, studies of physical activity during pregnancy that evaluate pregnancy outcomes have found reduced risks of preterm birth, preeclampsia, and gestational diabetes mellitus and improved mental health among individuals who regularly engage in physical activity. In the United States, approximately 48% of pregnant individuals gain more than the recommended amount of weight during pregnancy; excessive gestational weight gain is associated with an increased risk of maternal and fetal complications, including preterm birth, preeclampsia, and gestational diabetes mellitus, and corresponding higher adverse short- and long-term maternal and offspring health outcomes. Although physical activity is safe during pregnancy and may reduce excessive gestational weight gain and resultant pregnancy complications, further research is needed to determine the frequency and duration of specific types of physical activity during pregnancy. Providers should encourage physical activity before and during pregnancy and educate patients regarding the benefits and safety of physical activity.

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.

Exercise versus Metformin to Improve Pregnancy Outcomes among Overweight Pregnant Women: A Systematic Review and Network Meta-Analysis

Being overweight is associated with pregnancy-related disorders such as gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), and excessive maternal weight gain (MWG). Exercise and metformin reduce the risk of these disorders. This network meta-analysis (NMA) aims to compare the effect of metformin and different types of exercise (aerobic, resistance and combined) on the risk of GDM, HDP, and MWG among overweight/obese pregnant women. Medline, EMBASE, Web of Science and Cochrane Library were searched from inception to June 2021. Meta-analyses and NMAs were performed. Sixteen randomized controlled trials were included. In the NMA, aerobic exercise showed an effect on GDM (RR = 0.51, 95% CI = 0.26, 0.97), and metformin a reduction in MWG (MWG = -2.93 kg, 95% CI = -4.98, -0.87). No intervention showed any effect on the reduction of HDP. Our study suggests that aerobic exercise may have the greatest effect in reducing the risk of GDM, and perhaps, the MWG. Strategies should be developed to increase adherence to this type of intervention among overweight women without contraindications. Although metformin could reduce MWG, medicalization of pregnancy in healthy women is not justified with the present results. More research is needed on the effect of the intensity and frequency of exercise sessions and the length of interventions.

The effect of walking during late pregnancy on the outcomes of labor and delivery: A randomized clinical trial

BACKGROUND

Exercising during pregnancy has various benefits for the mother and the fetus, but there are controversial results about its effect on labor and delivery. Therefore, the present study was conducted to evaluate the effect of walking during late pregnancy on the outcomes of labor and delivery.

MATERIALS AND METHODS

The present randomized clinical trial was conducted on 102 pregnant women who were referred to the comprehensive health service centers of Rafsanjan and were selected using convenient sampling method and randomly were allocated into two groups from August 2018 to February 2019. The intervention group performed walking from the 34^th week of pregnancy until the time of delivery 4 times per week, each time for 40 min. The control group just received the routine prenatal care. Information about the outcomes of delivery were gathered from the participants' medical files in the hospital and were analyzed using SPSS software version 22 and Chi-square and independent t-tests.

RESULTS

The results indicated that the Bishop score of the intervention group was significantly higher than the control group (P < 0.05). Furthermore, regarding the duration of the third phase of delivery, spontaneous labor, induced labor, cesarean section , and instrumental delivery, a statistically significant difference was observed between the intervention and the control groups (P < 0.05). There was no statistically significant difference between both the groups regarding the duration of the first and the second stages of delivery and Apgar score at 1^st and 5^th min (P > 0.05).

CONCLUSIONS

Walking during late pregnancy could improve Bishop score, increase spontaneous onset of labor, and decrease induction, cesarean, and instrumental delivery without having any adverse effect on the neonate's Apgar score.

Lifestyle intervention for gestational diabetes prevention in rural woman of Shoush city

BACKGROUND

Physical activity and nutrition interventions are the most important ways to prevent gestational diabetes. The purpose of the study was to determine the effect of healthy lifestyle intervention to promote preventive behaviors of gestational diabetes in the rural woman of Shoush city.

MATERIALS AND METHODS

In an experimental study, 60 pregnant women were selected using simple random sampling and allocate into intervention group (n = 30) and nutrition program. The study was conducted from September to June 2018. The data were collected in baseline and 1 month and 3 months of follow-up phase and were analyzed using Chi-square test, repeated-measure test, and generalized linear model (GLM). The α = 0.05 was considered as significance.

RESULTS

The mean age in the intervention and control group was 25.9 ± 5.6 and 27.2 ± 5.9, respectively. The GLM test showed a significant increase in the physical activity level and the mean of nutrition behaviors within the intervention group over time (P = 0.013). Further, based on the results of repeated-measure test, the mean of weekly MET-minute was increased in the intervention group in comparison to the control group at 1 month and 3 months of follow-up (P < 0.001).

DISCUSSION AND CONCLUSION

The lifestyle interventions are appropriate programs to the reduction of the risk of development of gestational diabetes in pregnant women.