Acta Obstet Gynecol Scand 2005: 84: 1150–1153 Copyright # Acta Obstet Gynecol Scand 2005

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Acta Obstetricia et
Gynecologica Scandinavica

ORIGINAL ARTICLE

Response of pregnancy leg edema to a

single immersion exercise session
SABINE HARTMANN AND RENATE HUCH

From the Perinatal Physiology Research Unit, Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland

Acta Obstet Gynecol Scand 2005; 84: 1150–1153. # Acta Obstet Gynecol Scand 84 2005

Background. To quantify the effect of a single immersion exercise session on uncompli-

cated dependent edema in pregnancy.
Methods. Lower leg volume was measured by water displacement volumetry and limb
circumference in nine women with marked dependent edema, but otherwise normal
second or third trimester pregnancy, before and after upright water immersion exercise
session (Aqua-Fit1) for 45 min. Maternal heart rate was monitored continuously through-
out the session. Blood pressure was measured before and after the session.
Results. Mean left leg volume decreased by 112 ml from 1665 to 1553 ml, and right leg
volume by 84 ml from 1665 to 1581 ml (P ¼ 0.007). Cardiovascular parameters fluctuated
within the normal range, well below the upper limits recommended in pregnancy.
Conclusions. A single immersion exercise session is a safe, effective, and enjoyable complement,
or alternative, to compression stockings for reduction of gestational dependent edema. Further
study is required to determine its duration of effect and the optimum interval between sessions.

Key words: pregnancy; edema; immersion; exercise; water

Submitted 9 December, 2004

Accepted 14 January, 2005

Dependent edema (water retention in the inter-
stitial space of the lower limbs) is a frequent and
unpleasant accompaniment to pregnancy, caus-
ing pain on foot strike in severe cases. The main-
stays of management are compression stockings
and elevation of the extremities. However,
immersion in water is also beneficial. The effect
of hydrostatic pressure is proportional to the
depth of immersion. Water pressure is exerted
uniformly from all sides and drives the extra-
vascular fluid into the intravascular space. The
resulting decrease in edema can be quantified
with relative accuracy by volumetry. Having
established the safety and tolerability for mother
and fetus of a 45-min upright exercise session in
water (1), our aim in this prospective study was to
determine whether immersion exercise decreases
pregnancy edema and, if so, by how much.
Materials and methods
Nine women with marked edema, aged 30.9  4.65 years
(range 32–36 years), weighing 84.9  11.8 kg (range
68–99.7 kg), and with an otherwise uncomplicated pregnan-
cies at 31 þ 5 weeks  35 days (range 25–39 weeks) (second
trimester: 25 weeks, n ¼ 2; third trimester: 29–39 weeks,
n ¼ 7), were recruited from the Zurich University Hospital
obstetric outpatient clinic. Eight were nulliparas. Exclusion
criteria were preeclampsia, HELLP (hemolysis, elevated
liver, low platelet) syndrome, hypertension, placental insuf-
ficiency, and multiple pregnancy.
The study was conducted in a Zurich swimming pool
(depth 4 m) at air and water temperatures of 30.9  C (range
30–31.8  C) and 30.0  C (range 27.8–30.8  C), and humidity
53.1% (range 48.4–56.1%). Each woman was studied at the
same time of day, 3–4 hr after the midday meal, having had
no diuretic drinks (tea, coffee, and cola) during this interval.
Subjects put on a wet vest (Aqua-Fit1, Ryffel Running
Versand AG, Uster 8612, Switzerland; http://www.ryffel.ch)
before entering the pool. The vest, worn like a backpack,
covered the upper body and back and kept the wearer afloat,
immersed to the axilla, without the need for arm or leg
movements. The exercise session was adapted for pregnancy
from the 45-min Aqua-Fit1 program (http://www.ryffel.ch)
and comprised warm-up exercises (5 min), coordination
exercises (10 min), and a variety of running sequences
(30 min) directed to music by the poolside investigator.
Lower leg volume, comprising the foot and approximately
10 cm of the lower leg, was measured in triplicate before
and after exercise according to the gold standard water

# Acta Obstet Gynecol Scand 84 (2005)

 Single immersion exercise for edema during pregnancy
displacement method (2) using a polyurethane vessel with an
overflow device (40  40  20 cm). The triplicate readings
were averaged to give one score. To ensure an identical
baseline volume, the vessel was filled to the overflow and
volumetry performed only after flow from the device had
ceased. Immediately before volumetry subjects sat for
15 min, after which the investigator held the leg horizontal
for 1 min to prevent swelling before measurement, then
flexed it to 90 , matching the angle of the other leg, before
immersing it in the vessel, without the foot touching the
bottom. After complete immersion, subjects were instructed
to fully relax their legs, with their thighs motionless, on the
seat to minimize wave movement in the vessel. The immersion
level was marked on the leg to standardize measurement
before and after exercise. The equilibrated overflow volume
(after 2 min) was determined using a measuring beaker.
Supine lower leg circumference was also measured before
and after immersion exercise, beginning at the lateral
malleolus, and then at five 4-cm intervals proximally, using
a marker pen, to a total of 20 cm. Foot circumference was
measured 10 cm proximal to the great toe.
Seated maternal blood pressure (systolic, diastolic, and
mean Riva-Rocci) was measured before and at 1 and 5 min
after completing the exercise via a computer-controlled,
inflatable cuff attached to the right upper arm (Dinamap,
http://www.gemedicalsystems.com). Maternal heart rate was
monitored continuously (Polar HRM watch, http://www.
polarusa.com), and averaged for the individual phases and
subphases, from the values stored every 5 seconds using a
computer program (InShape, Lüthi, Institute of Sports
Science, Swiss Sports School, Magglingen CH-2532).
All subjects but one wore compression stockings for their
edema up to the start of the study. Study time per subject
totalled just under 3 hr: the investigations (volumetry, and
circumference and cardiovascular measures) took 50 min
and occurred before and after exercise, the immersion exer-
cise lasted 45 min, and setting up and organization lasted
20 min. Bathroom visits were recorded, together with sub-
jects’ impression of the efficacy and acceptability of immer-
sion exercise. The study was approved by the specialist
subcommittee of the cantonal institutional review board.
The results were expressed as the arithmetic mean and
standard deviation and tested for significance (P < 0.05)
using Wilcoxon’s signed rank multiple comparisons of the
mean.
Results
A single session of immersion exercise significantly
decreased the volume of both legs (P ¼ 0.007,
Fig. 1), from 1665 ml (range 1293–2020 ml) to
1553 ml (range 1260–1880 ml), i.e. by 112 ml
(6.3%; range 33–297 ml), on the left and from
1665 ml (range 1367–2007 ml) to 1581 ml (range
1287–1917 ml), i.e. by 84 ml (4.9%; range 20–
160 ml), on the right.
Left lower leg circumference decreased signifi-
cantly 4 and 20 cm proximal to the malleolus, from
23.9 to 23.5 cm (P ¼ 0.017) and from 35.6 to
35.0 cm (P ¼ 0.018), respectively. Decrease on the
right was significant at 4 and 16 cm, from 23.6 to
23.3 cm (P ¼ 0.043) and from 33.7 to 33.0 cm
(P ¼ 0.028), respectively; the decrease at 16 cm
was from 28.9 to 28.5 cm (P ¼ 0.068).
1151
During the study, four subjects visited the
bathroom once and two subjects twice. The
remaining three subjects did not pass urine
during the study.
The pre-exercise maternal heart rate was
98.1  6.9 beats/min. It did not differ from the
postexercise values (5 min: 101.8  6.6 beats/min;
10 min: 101.2  5.7 beats/min). During exercise,
the heart rate increased by 15.4 beats/min.
Systolic blood pressure, which was 124.3 
15.3 mmHg pre-exercise, was significantly increased
1 min after exercise (129.7  14.8 mmHg; P ¼ 0.049)
and near-significantly at 5 min (131.6  13.9 mmHg;
P ¼ 0.051). Diastolic blood pressure remained
unchanged from 68.6  7.6 mmHg before, to 69.4 
7.4 mmHg and 67.2  10.9 mmHg, 1 and 5 min after
exercise.
The pregnant womens’ subjective impressions
of reductions in edema due to the single session of
immersion exercise were strongly positive.
Discussion
The immersion exercise in a 45-min Aqua-Fit1
session significantly decreased foot and lower leg
volume, as shown by the most reproducible
method, water displacement volumetry, and the
less-accurate circumference technique (2). The
coefficient of variation for the volume of the
lower legs measured by the water displacement
volumetry is 0.47% (2). Both sets of measure-
ments were made under strictly standardized con-
ditions. The decrease in volume was bilateral in
all subjects (Fig. 1) and within the clinically rele-
vant range (>1%). It would probably have been
greater, had it not been for the compression
stockings worn until the study by all subjects
but one. However, it was greater than the 71 ml
reported using the same measurement method
after manual lymph drainage following foot sur-
gery (3). That it was greater on the left may be
due to the fact that this leg was measured first
after the exercise session, giving some 20 min for
fluid to flow back into the interstitial space on the
right. Due to this result, and to the fact that six
subjects visited the bathroom after water exercise,
we assume that the decrease in volume is partly
due to both elimination of excess fluid and tem-
porary relocation of fluid.
Kent et al. (4), compared the effect on preg-
nancy edema of standing on land, static immer-
sion in water, and water aerobics, each for
30 min, in 18 women at weeks 20–33 of gestation.
Although static immersion and water aerobics
induced substantial diuresis (180 and 187 ml), sig-
nificantly exceeding that induced by standing on
# Acta Obstet Gynecol Scand 84 (2005)
1152 S. Hartmann & R. Huch
2100
2000
1900
1800
Water (ml)
1700
1600
1500
1400
1300
1200
Before After
land, only static immersion decreased leg volume,
although by so little (5 ml) as to be clinically
irrelevant. Leg volume was actually unchanged
after the water aerobics session. One explanation
for the discrepancy with our study is that subjects
in the study of Kent et al. (4) were without edema
and hence, the displacement of fluid was prob-
ably less pronounced. In addition, Kent et al. (4)
measured volumes in the standing position: shift-
ing of weight and changes of position can induce
substantial measurement error. A second explana-
tion is that Kent et al. took single measures only,
precisely because error can occur, multiple measures
are mandatory. Thirdly, the subjects in Kent et al.
(4) drank 8 oz of water at the start of the study.
The increase in maternal heart rate induced
by immersion exercise session was well within
the limits recommended by the American College
of Obstetricians and Gynecologists (ACOG) (5),
thus entirely non-critical. The other blood pres-
sure variables similarly remained in the normal
range. The ACOG recommends restricting the
maternal heart rate to 140 beats/min in exercise
on land. This rather cautious guideline is based
on the fear that intensive physical activity may
redistribute blood to the detriment of the feto-
placental unit, and that aerobic energy production
in muscle may cease, resulting in the maternal and
subsequently fetal accumulation of lactate. In men,
the heart rate during exercise in water is some 10
beats/min slower than during exercise on land.
Since this is also true of pregnant women (6), 130
beats/min is the recommended upper limit for
immersion exercise in pregnancy. We documented
the fetal tolerability of Aqua-Fit1 immersion exer-
cise in our earlier study (1). Pregnant subjects’
impressions of efficacy and tolerability were suffi-
# Acta Obstet Gynecol Scand 84 (2005)
ri
le
ri
le
ri
le
ri
le
ri
le
ri
le
ri
le
ri
le
ri Fig. 1. Absolute volumes (ml) of right
(blue) and left leg (red) before and after
le
45-min exercise in water.
ciently positive that they felt motivated to return for
further immersion exercise sessions.
Our study confirms the safety and acceptability
of a single immersion exercise session that we had
demonstrated in pregnant women without
marked edema in our earlier study (1); apart
from a slightly higher average heart rate
(125  6 beats/min) in pregnant women without
edema, the blood pressure before, during, and
after exercise were similar.
The duration of the volume reduction effect
remains to be determined. However, such a study
promises to be extremely difficult and labor-inten-
sive, as it requires controlling for multiple alterna-
tive factors (body position, exercise, fluid and solid
intake, etc.) over a considerable period. On the
evidence presented, a single immersion exercise
session is a simple and cost-effective method of
treating and preventing the unpleasant, but com-
mon, symptom of pregnancy edema. It is also a
welcome alternative to compression stockings,
which can be unpleasant in their own right, nota-
bly in hot weather. The challenge is to design a
study that investigates and, if possible, prolongs
the duration of the volume-reduction effect.
Conclusion
A single, safe, and well-tolerated 45-min water
exercise session significantly decreased severe
bilateral lower leg edema in nine women with
otherwise uncomplicated pregnancies.
References
1. Hartmann S, Kölble N, Rake A, Bung P, Huch A, Huch R. ‘Aqua-
Fit’ in der Schwangerschaft: Maternale und fetale hämodynamische
 Single immersion exercise for edema during pregnancy 1153
Reaktionen bei einem Trainingsprogramm im Wasser. Geburtshilfe 6. Katz VL, McMurray R, Goodwin WE, Cefalo RC. Nonweight-
Frauenheilkd 2002; 61: 977–82. bearing exercise during pregnancy on land and during immers-
2. Brijker F, Heijdra YF, van den Elshout FJ, Bosch FH, Folgering ion: a comparative study. Am J Perinatol 1990; 7: 281–4.
HT. Volumetric measurements of peripheral oedema in clinical
conditions. Clin Physiol 2000; 20: 56–61.
3. Kessler T, de Bruin E, Brunner F, Vienne P, Kissling R. Effect of
manual lymph drainage after hindfoot operations. Physiother Address for correspondence:
Res Int 2003; 8: 101–10. Sabine Hartmann
4. Kent T, Gregor J, Deardorff L, Katz V. Edema of pregnancy: a Perinatalphysiologische Forschungsabteilung
comparison of water aerobics and static immersion. Obstet Klinik für Geburtshilfe
Gynecol 1999; 94: 726–9. Universitätsspital Zürich
5. ACOG Committee Opinion. Number 267, January 2002: exercise Frauenklinikstr. 10
during pregnancy and the postpartum period. Obstet Gynecol 8091 Zurich, Switzerland
2002; 99: 171–3. e-mail: sabi.hartmann@t-online.de

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