ONLINE SUPPLEMENT

Elite Athletes and Pregnancy Outcomes: A Systematic Review and Meta-Analysis

Jenna B. WOWDZIA, MSc Student

Program for Pregnancy and Postpartum Health.
Faculty of Kinesiology, Sport and Recreation, Women and Children’s Health Research Institute,
Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada.

Tara-Leigh, MCHUGH, PhD

Faculty of Kinesiology, Sport and Recreation.
University of Alberta, Edmonton, Alberta, Canada.

Jane THORNTON, MD
Fowler Kennedy Sport Medicine Clinic
Department of Family Medicine, Schulich School of Medicine and Dentistry
Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry
Western University, London, ON, Canada

Allison SIVAK, Public Services Librarian

University of Alberta Libraries
University of Alberta, Edmonton, Alberta, Canada

Michelle F. MOTTOLA, PhD FACSM

R. Samuel McLaughlin Foundation - Exercise and Pregnancy Laboratory, School of Kinesiology,
Faculty of Health Sciences, Department of Anatomy and Cell Biology, Schulich School of Medicine and
Dentistry, Children’s Health Research Institute, Western University, London, ON, Canada

Margie H. DAVENPORT, PhD

Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory,
Faculty of Kinesiology, Sport and Recreation, Women and Children’s Health Research Institute,
Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada.

Corresponding Author
Margie H. Davenport, PhD
Program for Pregnancy and Postpartum Health
Faculty of Kinesiology, Sport, and Recreation
University of Alberta

1-059D Li Ka Shing Centre for Health Research Innovation

8602 - 112 St
Edmonton, Alberta, Canada
T6G 2E1
Tel: (780)492-0642
Email: margie.davenport@ualberta.ca
Table 1: Summary of prenatal outcomes; Meta-analyses

Author, year Number of Elite to Number of Pregnant Prenatal Outcomes

pregnant Recreational pregnant Control physical
athletes athlete (E:R) Controls activity activity
level level*
Beilock et al., 26 Mixed (Elite and n/a n/a 89% were Low birthweight; preterm birth; lower back pain
2001 Recreational) still
** training
trimester
1; 65%
were
training in
trimester
3
Bo et al., 31 Elite Athletes 46 No n/a Birthweight; preterm birth; caesarian section;
2007 Only physical instrumental delivery; lower back pain
(31:0) activity
criteria
given.
Bung et al., 1 Elite Athletes n/a n/a 6x/wk (no Birthweight, fetal heart rate, maternal weight gain
1991 Only duration
(1:0) listed)
Davies et al., 1 Elite Athletes n/a n/a 107  19 Low birthweight
1999 Only km/wk @
(1:0) an
intensity
equivalent
to 130 –
140 bpm
Hegaard et 36 Mixed (Elite and 217 Sedentary n/a Birthweight, low birthweight, macrosomia,
al., 2017 Recreational) sedentary lifestyle maternal weight gain, excess maternal weight gain
 **
1298 light At least 4
intensity hours of
light
exercise
per week
276 Rec sports
moderate or heavy
intensity gardening
at least 4
hours a
week
Salvesen et 6 Elite Athletes n/a n/a n/a Low birthweight; fetal heart rate; pulse index
al., 2012 Only
(6:0)
Sigurdardottir 41 low- Elite Athletes 118 controls Active L: Birthweight; caesarian section; duration of labor;
et al., 2018 impact (L) Only (C) non- 10.2hr/wk perineal tears.
(130:0) athlete (SD: 12.7)
control H:
group. 8.5hr/wk
89 high- (SD: 7.4)
impact (H) C:
0.2hr/wk
(SD:1.2)
Solli et al., 1 Elite Athletes n/a n/a 12.9  7.3 Maternal weight gain
2018 Only hr/wk
(1:0) (SD: 10.0)
Sundgot- 28 Elite Athletes 29 Regularly n/a Birthweight, preterm birth, caesarian section,
Borgen et al., Only physical lower back pain, pelvic girdle pain, miscarriages
2019 (28:0) active
(>150
min/wk) at
least 2
years
 before
pregnancy.
Zaharieva, 13 Elite Athletes n/a n/a n/a Perineal tears; miscarriages
1965 Only
(13:0)
Zaharieva, 150 Elite Athletes n/a n/a n/a Low birthweight; duration of labor; perineal tears.
1972 Only
(150:0)
*As reported by author

**Author was contacted. No information ratio information was available.

Table 2: Risk of Bias for cross-sectional studies

Were the Were the

criteria for study subjects Was the Were objective, Were the
inclusion in and the exposure standard criteria Were Were strategies outcomes Was
the sample setting measured in a used for confounding to deal with measured in a appropriate
Cross- clearly described in valid and measurement of factors confounding valid and statistical
Sectional defined? detail? reliable way? the condition? identified? factors stated? reliable way? analysis used?

Bo 2007 y y n n n n n y

Beilock

2001 y y y n n n n y

Zaharieva

1972 y n n n n n n n

Zaharieva

1965 y n n n n n n n
Table 3: Risk of Bias for case control studies

Were the
groups Were
comparable outcome
other than s Was the
the Was Was assessed exposure
presence of exposure exposure in a period of
disease in Were the measured measure Were standard, interest
cases or Were cases same criteria in a d in the strategies to valid and long Was
the and controls used for standard, same way Were deal with reliable enough to appropriate
absence of matched identification valid and for cases confounding confoundin way for be statistical
disease in appropriately of cases and reliable and factors g factors cases and meaningful analysis
Case Control controls? ? controls? way? controls? identified?  stated? controls? ? used?
Sigurdardottir,

2019 Y Y Y n y y n y y y

Sundogt-

Borgen, 2019 Y Y Y n y y n y y y
Table 4: Risk of Bias for cohort studies

Was the Was

follow up follow up
Were the time complete
exposures reported , and if
measured and not,
Were the similarly Were the sufficient were the
two groups to assign Was the Were Were the outcome to be reasons Were
similar and people to exposure strategies groups/participan s long to loss to strategies
recruited both measure to deal ts free of the measure enough follow up to address Was
from the exposed d in a Were with outcome at the d in a for describe incomplet appropriat
same an valid and confoundin confoundin start of the study valid and outcome d and e follow e statistical
population unexpose reliable g factors g factors (or at the moment reliable s to explored up analysis
Cohort ? d groups? way? identified? stated? of exposure)? way? occur? ? utilized? used?

Hegaard

, 2017 y n y y y * n y n y y
Table 5: Risk of Bias for case report studies

Was the
patient’s Were
history Was the current diagnostic tests Was the Was the post-
Were patient’s clearly clinical condition or assessment intervention(s) or intervention Were adverse Does the
demographic described of the patient on methods and treatment clinical events (harms) or case report
characteristics and presentation the results procedure(s) condition unanticipated provide
Case clearly presented as clearly clearly clearly clearly events identified takeaway
Report described? a timeline? described? described? described? described?  and described? lessons?
Solli

2018 Y y Y y y n y Y

Salvesen,

2012 y n y y y y Y y

Davies,

1999 y y y y y y y y

bung

1991 y y y y y y y y

GRADE TABLES

Online Supplement Table 6: The association between engaging in competitive sport prior to pregnancy and misc outcomes
 Certainty assessment № of patients Effect Certainty Importance

№ of
studies Relative Absolute
Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations misc outcomes placebo
(95% CI) (95% CI)
*

Miscarriage

2 (pooled observational serious a serious b not serious not serious None 0 cases 0 controls OR 0.32 - CRITICAL
estimate of studies d (0.07 to 1.34) - ⨁◯◯◯
effect, n = VERY LOW
1 study; 1 - 0.0% 0 fewer per
study 1,000
reported (from 0
narratively) fewer to 0
fewer)

Narrative summary: (n = 13)

One cross-sectional study was included and showed no cases of

spontaneous abortion. (Zaharieva, 1965)

Low back pain

3 (pooled observational not serious not serious not serious not serious None 0 cases 0 controls 17/115 exposed OR 0.36 - CRITICAL
estimate of studies e 44/133 unexposed (0.19 to 0.69) ⨁⨁◯◯
effect, n = LOW
2 studies;
1 study - 0.0% 0 fewer per
reported 1,000
narratively) (from 0
fewer to 0
fewer)

Narrative summary: (n = 26)

One cross-sectional study was included reported 15.4% of elite athletes

perceived lower back pain to be a barrier to physical activity (Beilock et al.,
2001)

Pelvic girdle pain

 Certainty assessment № of patients Effect Certainty Importance

№ of
studies Relative Absolute
Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations misc outcomes placebo
(95% CI) (95% CI)
*

2 (pooled observational not serious not serious not serious serious c None 0 cases 0 controls 30/115 exposed OR 1.01 - CRITICAL
estimate of studies 41/133 unexposed (0.49 to 2.10) - ⨁◯◯◯
effect, n = VERY LOW
2)
- 0.0% 0 fewer per
1,000
(from 0
fewer to 0
fewer)

Urinary incontinence

1 (pooled observational serious a serious b not serious not serious None 7/31 (22.6%) 11/46 (23.9%) OR 0.93 13 fewer CRITICAL
estimate of studies (0.31 to 2.73) per 1,000 - ⨁◯◯◯
effect, n = (from 150 VERY LOW
1) fewer to
223 more)

3-4th Degree tearing

3 (pooled observational serious a serious b not serious not serious None 0 cases 0 controls 13/130 exposed OR 0.97 - CRITICAL
estimate of studies 14/118 unexposed (0.44 to 2.14) - ⨁◯◯◯
effect, n VERY LOW
=1; 2
studies - 0.0% 0 fewer per
reported 1,000
narratively) (from 0
fewer to 0
fewer)

Narrative summary: (n = 163)

Two cross-sectional studies were included (n = 163). Zaharieva (1972)

reported no substantial difference between elite athletes (n = 150) and non-
athletes (n = unreported). Zaharieva (1965) reported 50% of athletes
experienced ruptures; however due to the small sample size (n = 13) the
data should be interpreted with caution. Neither study classified the
degree/extent of the ruptures.
CI: Confidence interval; OR: Odds ratio

* Unless otherwise stated, all studies are included in the pooled estimate.

Explanations
a. Contributed to > 50% of the weight of the pooled estimate in the forest plots

b. When heterogeneity was high [I2 ≥ 50%] or when only one study was assessed

c. the 95% CI crossed the line of no effect and was wide, such that interpretation of the data would be different if the true effect were at one end of the CI or the other.
Online Supplement Table 7: The association between engaging in competitive sport prior to pregnancy and preterm delivery
Certainty assessment № of patients Effect Certainty Importance

№ of Relative Absolute
Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Preterm placebo
studies (95% CI) (95% CI)

Preterm

3 (pooled observational serious a not serious not serious serious b None 0 cases 0 controls 14/59 exposed OR 0.93 - CRITICAL
estimate of studies 21/75 unexposed (0.40 to 2.20) - ⨁◯◯◯
effect, n = VERY LOW
2; 1 study
reported - 0.0% 0 fewer per
narratively) 1,000
(from 0
fewer to 0
fewer)

Narrative Summary: (n = 26)

One cross-sectional study reported 11.5% of elite athletes delivering preterm

(Beilock et al., 2001)

CI: Confidence interval; OR: Odds ratio

Explanations
a. studies contributed to > 50% of the weight of the pool estimated in the forest plots

b. 95% CI crossed the line of no effect and was wide, such that interpretation of the data would be different if the true effect were at one end of the CI or the other.
Online Supplement Table 8: The association between engaging in competitive sport prior to pregnancy and delivery method
Certainty assessment № of patients Effect Certainty Importance

№ of Relative Absolute
Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations delivery placebo
studies (95% CI) (95% CI)

Instruments

1 observational serious a serious b not serious not serious None 3/31 (9.7%) 6/46 (13.0%) OR 0.71 34 fewer CRITICAL
(pooled studies (0.16 to 3.10) per 1,000 - ⨁◯◯◯
estimate (from 107 VERY LOW
of effect, fewer to
n = 1) 187 more)

C-section

3 observational not serious not serious not serious serious c None 0 cases 0 controls 22/189 exposed OR 1.21 - CRITICAL
(pooled studies 14/135 unexposed (0.58 to 2.55) - ⨁◯◯◯
estimate VERY LOW
of effect,
n = 3) - 0.0% 0 fewer per
1,000
(from 0
fewer to 0
fewer)

CI: Confidence interval; OR: Odds ratio

Explanations
a. contributed to > 50% of the weight of the pooled estimated in the forest plots.

b. Only one study was assessed.

c. the 95% CI crossed the line of no effect and was wide, such that interpretation of the data would be different if the true effect were at one end of the CI or the other.
Online Supplement Table 9: The association between engaging in competitive sport prior to pregnancy and birthweight
Certainty assessment № of patients Effect Certainty Importance

№ of Relative Absolute
Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Birth weight placebo
studies (95% CI) (95% CI)

birthweight >4000g

1 (pooled observational not serious serious a not serious serious b None 0 cases 0 controls 6/36 exposed OR 0.76 - CRITICAL
estimate of studies 335/1727 unexposed (0.31 to 1.86) - ⨁◯◯◯
effect, n = VERY LOW
1)
- 0.0% 0 fewer per
1,000
(from 0
fewer to 0
fewer)

birthweight

5 (pooled observational not serious not serious not serious serious b None 225 1920 - MD 20.55 CRITICAL
estimate of studies higher - ⨁◯◯◯
effect, n = (76.11 VERY LOW
4; 1 study lower to
reported 117.21
narratively) higher)

Narrative Summary: (n = 1)

One Case Report (n = 1) reported a healthy birth weight of 3200g (Bung et

al., 1991).

birthweight <3000g

5 (pooled observational not serious serious a not serious serious b None 3/36 (8.3%) 146/1727 (8.5%) OR 1.00 0 fewer per CRITICAL
estimate of studies (0.30 to 3.33) 1,000 - ⨁◯◯◯
effect, n = (from 58 VERY LOW
1, 4 fewer to
studies 151 more)
 Certainty assessment № of patients Effect Certainty Importance

№ of Relative Absolute
Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Birth weight placebo
studies (95% CI) (95% CI)

reported Narrative Summary: (n = 157)

narratively)
A case report (n = 6) reported only a single case of low birthweight due to
pregnancy complication of pre-eclampsia (Salvesen et al., 2012). Another
case report (n = 1) reported a healthy set of twins at a weight of 2.2kg and
2.3kg (Davies et al., 1999). Beilock et al. (2001) cross sectional reported 2
low birthweights and 1 unhealthy baby (n = 26). Zaharieva (1972) cross
sectional reported that elite athletes (n = 150) were more likely to have low
birthweights compared to non-athletes.

CI: Confidence interval; OR: Odds ratio; MD: Mean difference

Explanations
a. when heterogeneity was high [I2 ≥ 50%] or when only one study was assessed.

b. 95% CI crossed the line of no effect and was wide, such that interpretation of the data would be different if the true effect were at one end of the CI or the other.
Online Supplement Table 10: The association between engaging in competitive sport prior to pregnancy and weight gain
Certainty assessment № of patients Effect Certainty Importance

№ of Pregnancy weight Relative Absolute

Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations placebo
studies gain (95% CI) (95% CI)

excessive weight gain

1 (pooled observational serious a serious c not serious not serious None 21/36 (58.3%) 610/1727 OR 2.47 221 more CRITICAL
estimate of studies (35.3%) (1.26 to 4.85) per 1,000 ⨁◯◯◯
effect, n = (from 54 VERY LOW
1) more to
373 more)

prenatal weight gain

4 (pooled observational not serious serious c not serious serious b None 67 1773 - MD 0.81 CRITICAL
estimate of studies higher - ⨁◯◯◯
effect, n = (1.7 lower VERY LOW
2; 2 to 3.32
studies higher)
reported
narratively)
Narrative Summary: (n = 2)

A case report (n = 1) reported a 15kg increase in prenatal weight gain (Solli

et al., 2018). In comparison, Bung et al., (1991) reported a gestational weight
gain of 9kg (n = 1).

CI: Confidence interval; OR: Odds ratio; MD: Mean difference

Explanations
a. Contributed to > 50% of the weight of the pooled estimate in the forest plots

b. the 95% CI crossed the line of no effect and was wide, such that interpretation of the data would be different if the true effect were at one end of the CI or the other.

c. when heterogeneity was high [I2 ≥ 50%] or when only one study was assessed
Online Supplement Table 11: The association between engaging in competitive sport prior to pregnancy and fetal health
Certainty assessment № of patients Effect Certainty Importance

№ of Pregnancy weight Relative Absolute

Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations placebo
studies gain (95% CI) (95% CI)

Fetal bradycardia

2 (n = 2 observational Not serious Not serious Not serious Not serious None Narrative Summary: (n = 7) CRITICAL
study studies ⨁⨁◯◯
reported In a case report of 6 elite athletes, 2 women exercising at an intensity of > LOW
narratively) 90% HRmax experienced decelerated fetal heart rates post exercise
(Salvesen et al., 2012). Another case report (n = 1) reported fetal heart rate
dropping to 70bpm after a short burst of maternal exercise at 87% maternal
HRmax (Bung et al., 1991).

High Pulsitility Index and Decreased uterine artery blood flow

1 (n = 1 observational Not serious Serious a Not serious Not serious None Narrative Summary: (n = 6) CRITICAL
study studies ⨁◯◯◯
reported In a case report of 6 elite athletes, 2 women exercising at intensities of >90% VERY LOW
narratively) HR max had fetuses with a high PI of 1.67 and 1.65. The same fetuses
experienced a decrease in uterine artery blood flow of 37% and 42%
respectively (Salvesen et al., 2012).

CI: Confidence interval; OR: Odds ratio; MD: Mean difference

Explanations
a. when heterogeneity was high [I2 ≥ 50%] or when only one study was assessed
Online Supplement Table 12: The association between engaging in competitive sport prior to pregnancy and duration of labor
Certainty assessment № of patients Effect Certainty Importance

№ of Pregnancy weight Relative Absolute

Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations placebo
studies gain (95% CI) (95% CI)

Stage 1: Duration of labor

2 (pooled observational serious a serious b not serious not serious None Narrative Summary: (n = 150) CRITICAL
estimate of studies - ⨁◯◯◯
effect n = A cross-sectional study, (Zaharieva, 1972) reported insignificant finds that VERY LOW
1; 1 study elite athletes (n = 150) had a slightly longer first phase of labor.
reported
narratively)

Stage 2: Duration of labor

2 (pooled observational serious a serious b not serious not serious None Narrative Summary: (n = 150) CRITICAL
estimate of studies - ⨁◯◯◯
effect n = A cross-sectional study (Zaharieva, 1972) reported the second phase of VERY LOW
1; 1 study labor was 1 and ½ times shorter for elite athletes (n = 150).
reported
narratively)

CI: Confidence interval; OR: Odds ratio; MD: Mean difference

Explanations
a. Contributed to > 50% of the weight of the pool estimate in the forest plots.
b. when heterogeneity was high [I2 ≥ 50%] or when only one study was assessed
FOREST PLOTS

Online Supplement Figure 1: The effect of engagement in elite sports prior to pregnancy on low birthweight (<2,500 g or author defined) in elite

athletes vs. controls (active/sedentary). Data reported as a odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI,

confidence interval.
Online Supplement Figure 2: The effect of engagement in elite sports prior to pregnancy on macrosomia (>4,000g or author defined) in elite

athletes vs. controls (active/sedentary). Data reported as a odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI,

confidence interval.

Online Supplement Figure 3: The effect of engagement in elite sports prior to pregnancy on preterm delivery in elite athletes vs. controls

(active/sedentary). Data reported as an odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence interval
Online Supplement Figure 4: The effect of engagement in elite sports prior to pregnancy on caesarian sections in elite athletes vs. controls

(active/sedentary). Data reported as an odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence interval

Online Supplement Figure 5: The effect of engagement in elite sports prior to pregnancy on instrumental deliveries in elite athletes vs. controls

(active/sedentary). Data reported as an odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence interval
Online Supplement Figure 6: The effect of engagement in elite sports prior to pregnancy on 1st phase of labor in elite athletes vs. controls (active)

reported as a mean difference. Analysis conducted using a random-effect model. IV, inverse variance, CI, confidence interval.
Online Supplement Figure 7: The effect of engagement in elite sports prior to pregnancy on 2nd phase of labor in elite athletes vs. controls

(active) reported as a mean difference. Analysis conducted using a random-effect model. IV, inverse variance, CI, confidence interval.

Online Supplement Figure 8: The effect of engagement in elite sports prior to pregnancy on 3rd and 4th degree perineal tears in elite athletes vs.

controls (active). Data reported as an odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence interval
Online Supplement Figure 9: The effect of engagement in elite sports prior to pregnancy on pelvic girdle pain in elite athletes vs. controls

(active/sedentary). Data reported as an odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence interval
Online Supplement Figure 10: The effect of engagement in elite sports prior to pregnancy on urinary incontinence in elite athletes vs. controls

(active/sedentary). Data reported as an odds ratio compared. Analysis conducted using a random-effect model. IV, inverse variance; CI,

confidence interval

Online Supplement Figure 11: The effect of engagement in elite sports prior to pregnancy on miscarriages in elite athletes vs. controls (active).

Data reported as an odds ratio. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence interval
Online Supplement Figure 12: The effect of engagement in elite sports prior to pregnancy on prenatal weight gain in elite athletes vs. controls

(active/sedentary). Data reported as a mean difference. Analysis conducted using a random-effect model. IV, inverse variance; CI, confidence

interval

Search Strategy

OVID
Pw: PregnantAthl3t3
Login: AthletesPregnancy
1. exp Athletes/ or athlete*.mp. or exp sports/   
2. ((athlet* or player* or sport*) adj5 (recreation* or amateur* or compet* or elite* or profession*)).mp. [mp=title, abstract,
original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism
supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique
identifier, synonyms]   
3. (highly active or marathon*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating
sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier, synonyms]   
4. ((recreation* or amateur* or compet* or elite* or profession*) adj3 (running or plyometric* or yoga or tai chi or weight
training or resistance training or swim* or sport* or walk or walking or running or runner* or marathon*)).mp. [mp=title,
abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word,
organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word,
unique identifier, synonyms]   
5. 1 or 2 or 3 or 4   
6. Pregnancy/ or exp Pregnancy Complications/ or Pregnancy Outcome/ or exp Pregnancy Trimesters/ or Peripartum Period/ or
Postpartum Period/   
7. pregnan*.hw. or (pregnan* or antenatal or prenatal or perinatal or postnatal or prepartum or antepartum or postpartum or pre
partum or ante partum or post partum or puerper* or primigravid* or primiparous or multiparous or nulliparous or
multigravid* or trimester* or obstetric*).ti,kf.   
8. 6 or 7   
9. exp birth weight/ or fetal weight/   
10. infant, low birth weight/ or infant, small for gestational age/ or exp infant, very low birth weight/ or infant, postmature/ or exp
infant, premature/   
11. ((preterm or pre matur* or prematur* or post matur* or postmatur*) adj2 birth).mp.   
12. Fetal Growth Retardation/ or fetal hypoxia/ or fetal macrosomia/   
13. exp Fetal Development/ or exp Congenital Abnormalities/ or exp Fetus/ or (f?etus or f?etal).ti,hw,kf.   
14. maternal fetal exchange/ or (exp Uterus/ and exp Regional Blood Flow/) or (placenta* or uteroplacenta* or ((maternal f?etal or
f?etomaternal or transplacental) adj2 (transfusion or exchange))).mp.   
15. ((f?etal or f?etus) adj2 (response or matur*)).mp.   
16. ((f?etal or f?etus or neonat* or newborn or infant) adj3 (growth or develop* or viability or viable or weight or wellbeing or
well being or health or heart rate or heartrate or bradycardia or hypoxi* or hypoglyc?emi* or movement or
oxygenation)).mp.   
17. (((uterine or uterus) adj2 (blood flow or circulat*)) or ((uterine or umbilical or mid* cerebral) adj2 doppler)).mp.   
18. (intrauterine growth or iugr).mp.   
19. ((perinatal or f?etal or f?etus or neonat* or newborn* or infant*) adj3 (mortality or morbidity or death or outcome* or
complication*)).mp.   
20. (still birth or stillbirth).mp.   
21. (birth weight or birthweight or macrosomia or gestational age or lga or sga or preterm or (prematur* adj2 (infant* or neonat*
or newborn* or birth or labo?r))).mp.   
22. ((neonatal or newborn* or infant* or f?etus or f?etal) and (fat* or abdominal circumference or body composition or bmi or
body mass index or waist circumference or skeletal size or height or anthropometric* or apgar or adipos* or ph or base excess
or metabolic or acidosis or insulin or diabet* or hyperbilirubin?emi*)).mp.   
23. (f?etus or f?etal).mp. and (adaptation, physiological/ or me.fs.)   
24. (((birth or delivery) adj3 (trauma or injur* or defect*)) or (dystocia or nicu or neonatal intensive care or brachial plexus)).mp.   
25. pelvic floor.sh. or pelvic floor.ti,ab.   
26. ((difficult* or poor or prolong*) adj3 (labor or delivery or labour)).ti,ab.   
27. exp Birth Injuries/   
28. ((neonat* or infant* or newborn*) and (ponderal index or skinfold or bmi or body mass index)).mp.   
29. Cerebral Palsy/ or exp Neural Tube Defects/ or Cleft Palate/ or (cerebral palsy or neural tube defect* or spina bifida or
anencephal* or encephalocele* or iniencephal* or spinal dyraphism or diastematomyel* or lipomingocele* or
lipmyelomeningocele* or meningomyelocele* or cleft palate* or cleft lip*).mp.   
30. (((development* or learning or intellectual* or cognitive* or language or communication or speech or motor) adj2 (disorder*
or disab* or delay*)) or behavio?r disorder* or attention deficit or autis* or asperger* or child development or developmental
milestone* or neurodevelopment* or cognitive development or motor development or motor skill* or psychosocial
development or chronic disease* or chronic illness* or cardiovascular or cardiometabolic or diabet* or heart disease*).mp. or
exp Heart Disease/ or exp Mental Disorders Diagnosed in Childhood/   
31. Pediatric Obesity/ or ((child* or p?ediatric) adj2 (obes* or overweight)).mp.   
32. or/9-31   
33. 5 and 8 and 32   
34. (animals/ not (animals/ and humans/)) or ((man or men or rat or rats or mouse or mice or cow or cows or bovine or sheep or
ewe*) not ((rat or rats or mouse or mice or cow or cows or bovine or cattle or sheep or ewe*) and (human* or
women))).ti,ab,kf. or (man or men or rat or rats or mouse or mice or cow or cows or bovine or cattle or sheep or ewe*).ti.   
35. 33 not 34   
 = 881

EMBASE
limit 35 to (exclude medline journals and embase and (article or article in press or erratum) and journal)

= 90

CINAHL
S34    ( S5 AND S8 AND S32 ) NOT SU animals NOT TI ( man or men or rat or rats or mouse or mice or cow or cows or bovine or
sheep or ewe* ) NOT AB ( man or men or rat or rats or mouse or mice or cow or cows or bovine or sheep or ewe* )    

S33    S5 AND S8 AND S32    

S32    S6 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR
S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31    
S31    MH Pediatric Obesity OR ( ((child* or p?ediatric) n2 (obes* or overweight)) )    
S30    ( (((development* or learning or intellectual* or cognitive* or language or communication or speech or motor) n2 (disorder* or
disab* or delay*)) or behavio?r disorder* or attention deficit or autis* or asperger* or child development or developmental milestone*
or neurodevelopment* or cognitive development or motor development or motor skill* or psychosocial development or chronic
disease* or chronic illness* or cardiovascular or cardiometabolic or diabet* or heart disease*) ) OR MH ( Heart Disease or Mental
Disorders Diagnosed in Childhood+ )
S29    MH ( Cerebral Palsy or Neural Tube Defects+ or Cleft Palate ) OR ( cerebral palsy or neural tube defect* or spina bifida or
anencephal* or encephalocele* or iniencephal* or spinal dyraphism or diastematomyel* or lipomingocele* or lipmyelomeningocele*
or meningomyelocele* or cleft palate* or cleft lip* )    
S28    ((neonat* or infant* or newborn*) and (ponderal index or skinfold or bmi or body mass index))    
S27    MH birth injuries+    
S26    TI ( ((difficult* or poor or prolong*) n3 (labor or delivery or labour)) ) OR AB ( ((difficult* or poor or prolong*) n3 (labor or
delivery or labour)) )    
S25    TI pelvic floor OR MH pelvic floor    
S24    (((birth or delivery) n3 (trauma or injur* or defect*)) or (dystocia or nicu or neonatal intensive care or brachial plexus))    
S23    ( (f?etus or f?etal) ) AND MH adaptation, physiological    
S22    ((neonatal or newborn* or infant* or f?etus or f?etal) and (fat* or abdominal circumference or body composition or bmi or body
mass index or waist circumference or skeletal size or height or anthropometric* or apgar or adipos* or ph or base excess or metabolic
or acidosis or insulin or diabet* or hyperbilirubin?emi*))    
S21    (birth weight or birthweight or macrosomia or gestational age or lga or sga or preterm or (prematur* n2 (infant* or neonat* or
newborn* or birth or labo?r)))    
S20    (still birth or stillbirth)    
S19    ((perinatal or f?etal or f?etus or neonat* or newborn* or infant*) n3 (mortality or morbidity or death or outcome* or
complication*)    
S18    (intrauterine growth or iugr)    
S17    (((uterine or uterus) adj2 (blood flow or circulat*)) or ((uterine or umbilical or mid* cerebral) n2 doppler))    
S16    ((f?etal or f?etus or neonat* or newborn or infant) n3 (growth or develop* or viability or viable or weight or wellbeing or well
being or health or heart rate or heartrate or bradycardia or hypoxi* or hypoglyc?emi* or movement or oxygenation))    
S15    ((f?etal or f?etus) n2 (response or matur*))    
S14    MH maternal fetal exchange or OR MH ( Uterus+ and Regional Blood Flow+ ) OR ( ((placenta* or uteroplacenta* or (maternal
f?etal or f?etomaternal or transplacental)) n2 (transfusion or exchange) )    
S13    MH ( Fetal Development+ or Congenital Abnormalities+ or Fetus+ ) OR TI ( f?etus or f?etal ) OR AB ( f?etus or f?etal ) OR
MW ( f?etus or f?etal )    
S12    MH Fetal Growth Retardation or fetal hypoxia or fetal macrosomia    
S11    (preterm or pre matur* or prematur* or post matur* or postmatur*) n2 birth    
S10    MH infant, low birth weight or infant, small for gestational age or infant, very low birth weight+ or infant, postmature or infant,
premature+    
S9    MH birth weight or fetal weight    
S8    S6 OR S7    
S7    MW pregnan* OR TI ( pregnan* or antenatal or prenatal or perinatal or postnatal or prepartum or antepartum or postpartum or
pre partum or ante partum or post partum or puerper* or primigravid* or primiparous or multiparous or nulliparous or multigravid* or
trimester* or obstetric* ) OR MW ( pregnan* or antenatal or prenatal or perinatal or postnatal or prepartum or antepartum or
postpartum or pre partum or ante partum or post partum or puerper* or primigravid* or primiparous or multiparous or nu ...   
S6    MH Pregnancy or Pregnancy Complications+ or Pregnancy Outcome or Pregnancy Trimesters+ or Peripartum Period or
Postpartum Period    
S5    S1 OR S2 OR S3 OR S4    
S4    (recreation* or amateur* or compet* or elite* or profession*) n3 (running or plyometric* or yoga or tai chi or weight training or
resistance training or swim* or sport* or walk or walking or running or runner* or marathon*)    
S3    AB ( highly active or marathon* ) OR TI ( highly active or marathon* )    
S2    (athlet* or player* or sport*) n5 (recreation* or amateur* or compet* or elite* or profession*)    
S1    SU ( athletes or sports ) OR athletes

Limit to journals = 355

SPORTDiscus = 112

ERIC = 1 [irrelevant article; on HIV and pregnancy]

Child Development & Adolescent Studies= 10

Global Health and Ovid HealthSTAR = 443 

[NOT (hiv or AIDS or antiretroviral).ti,ab,sh.]

Cochrane Library = 318

Clinical Trials = 20

Scopus = 7