CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 51, Number 2, 467–480
Effect of Exercise on
Pregnancy Outcome
JEFFREY A. GAVARD, PhD and RAUL ARTAL, MD
Department of Obstetrics, Gynecology, and Women’s Health,
St Louis University School of Medicine, St Louis, Missouri
Abstract: The purpose of this review was to critically
evaluate the scientific literature for the effects of
exercise on pregnancy outcome. Evidenced-based stu-
dies were reviewed. Maternal outcomes analyzed in
this review were gestational diabetes mellitus, pree-
clampsia, and weight gain, fetal outcomes evaluated
were birth weight, time of delivery, and mode of
delivery. Despite methodological pitfalls in the studies
published, the evidence suggests a benefit of exercise in
pregnancy. Exercise in pregnancy could prevent and
limit adverse maternal and fetal morbidities and pro-
vide a long-term benefit through reduction of mater-
nal weight gain during pregnancy, and improvement
in cardiovascular fitness. Pregnancy emerges as a
unique time for behavior modification.
Key words: exercise, pregnancy, gestational diabetes
mellitus, maternal outcomes, fetal outcomes, weight-
gain restriction in pregnancy
Introduction
The American College of Obstetricians
and Gynecologists (ACOG) in 2002 re-
commended 30 minutes or more of mod-
erate exercise on most, if not all, days of
the week for pregnant women in the ab-
sence of either medical or obstetric com-
plications.1 These recommendations are
similar to those issued by the Centers for
Correspondence: Raul Artal, MD, Department of Ob-
stetrics, Gynecology, and Women’s Health, Saint Louis
University School of Medicine, 6420 Clayton Road,
Suite 290, St Louis, MO 63117. E-mail: artalr@slu.edu
CLINICAL OBSTETRICS AND GYNECOLOGY
r 2008, Lippincott Williams & Wilkins
Disease Control and Prevention and the
American College of Sports Medicine for
the nonpregnant population. The ACOG
recommendation was not without contro-
versy. A comprehensive review of the
literature at that time decreed that a re-
commendation of aerobic exercise in
pregnancy could not be made owing to
the paucity of studies conducted on the
topic and their methodological pro-
blems.2 These methodological issues in-
cluded inconsistent definitions in the type,
intensity, and duration of physical activ-
ity, and small sample sizes precluding
accurate statistical assessment. The
ACOG recommendation was perceived
to largely reflect expert opinion rather
than scientific evidence.3
The literature on exercise in pregnancy
has expanded since 2002. The purpose of
this review is to critically evaluate the
effects of exercise before and during preg-
nancy on maternal and fetal outcomes.
Research Design and Methods
A computer-generated literature review
published in English of all available exist-
ing studies on the effects of exercise before
or during pregnancy was undertaken. No
time constraints were imposed on when
/ VOLUME 51 / NUMBER 2 / JUNE 2008
467
468 Gavard and Artal
the papers had to have been published or
presented. Individual case reports were
not considered.
Articles were cited that could provide
the best evidence for the relationship of
exercise in pregnancy on maternal and
fetal outcomes. Maternal outcomes in-
cluded were gestational diabetes mellitus
(GDM), preeclampsia, and weight gain.
Fetal outcomes included were birth
weight, time of delivery, and mode of
delivery. Articles were favored having
larger sample sizes and a comparison
group that was contrasted with the phy-
sically active group. Review articles
summarizing the overall relationship of
physical activity with a particular mater-
nal or fetal end point were also consid-
ered.
The effects of exercise in pregnancy
are summarized and critically evaluated
for methodological strengths and weak-
nesses.
Maternal Outcomes
GDM
It is well-recognized that to optimize preg-
nancy outcome, normoglycemia is essen-
tial. Exercise and diet (ED) are a safe and
effective preventive measure and thera-
peutic alternative for normalizing glucose
levels during pregnancy. Several studies
have examined this approach. In one of
the first studies performed in pregnant
diabetic patients, we conducted a rando-
mized clinical trial to evaluate the efficacy
of an ED program to attain euglycemia in
patients with GDM compared to patients
with GDM treated with insulin.4 The
study included 41 GDM-A2 patients with
abnormal fasting glucose levels after 1
week of failed American Diabetes Associa-
tion diet therapy. Subjects were random-
ized to either ED therapy or insulin and diet
therapy. The ED subjects also were
encouraged to engage in physical activ-
ities and maintain an active lifestyle at
home. No significant differences in glyce-
mic control between the groups were
observed; euglycemia was obtained within
1 week of intervention. Both groups had
similar maternal and fetal outcomes, sug-
gesting that an exercise/diet regimen can
be a safe and effective therapeutic inter-
vention during pregnancy. This pilot
study served as the impetus to others to
investigate and expand on alternative
therapeutic interventions and preventive
measures during pregnancy with an em-
phasis on exercise.
The influence of recreational physical
activity on GDM risk was examined in a
case-control study of 155 GDM cases and
386 normotensive nondiabetic pregnant
controls.5 Physical activity was assessed
during the year before pregnancy and the
first 20 weeks of pregnancy. Women who
reported physical activity during the year
before pregnancy had a significantly re-
duced risk of GDM compared with inac-
tive women [odds ratio (OR) = 0.45, 95%
confidence interval (CI) = 0.28-0.74,
after adjusting for maternal age, race,
parity, smoking, and prepregnancy body
mass index (BMI)]. Weekly time and en-
ergy expended on physical activity before
pregnancy were associated with lower
GDM risk, although significant trends
were not found. Women who engaged in
vigorous recreational physical activity be-
fore pregnancy had a significantly lower
risk of GDM compared with inactive
women (OR = 0.29, 95% CI = 0.16-
0.51). Findings were similar for physical
activity performed during the first 20
weeks of pregnancy. The adjusted OR
for any recreational physical activity
was 0.52 (95% CI = 0.33-0.80) compared
with inactive women. A significant trend
was found for increasing stair climbing
with lower GDM risk (P<0.05), although
no clear benefit of walking or walking
pace was apparent. The protective effect
of physical activity was found largely in
women whose prepregnancy BMI was
Z25 and in women who were physically

active during both time periods (OR =
0.40, 95% CI = 0.23-0.68 compared with
women who were physically inactive
during both time periods). A significant
protective effect was not found for recrea-
tional physical activity that was
performed only during the year before
or during the first 20 weeks of pregnancy.
Corroboration of the above findings
was sought by the same authors in a pro-
spective study design of 909 normotensive
nondiabetic women.6 Women were inter-
viewed before 16 weeks gestation (mean
gestational age of 12.7 wk) regarding re-
creational physical activity during the year
before pregnancy and in the 7 days of
pregnancy before interview. GDM was
assessed through review of maternal med-
ical records approximately 7 to 9 months
after enrollment. Women who reported
physical activity during the year before
pregnancy had a significantly reduced risk
of GDM compared with inactive women
[relative risk (RR) = 0.44, 95% CI =
0.21-0.91, after adjusting for maternal
age, race, parity, and prepregnancy
BMI]. Weekly time and energy expended
on recreational physical activity were sig-
nificantly associated with lower GDM risk
when women having values on these vari-
ables above the median were compared
with inactive women (RR = 0.24, 95%
CI = 0.10-0.64 and RR = 0.26, 95%
CI = 0.10-0.65, respectively). Although
corresponding risk indices were lower for
women reporting any recreational physi-
cal activity during early pregnancy than
for women reporting no such activity,
none were statistically significant. Women
who reported physical activity during both
time periods had a significantly lower in-
cidence of GDM than women who were
inactive during both time periods (RR =
0.31, 95% CI = 0.12-0.79). Despite having
lower GDM risk, a significant protective
effect again was not found in this study
for recreational physical activity that was
performed only during the year prior or
during early pregnancy.
Exercise in Pregnancy 469
A prospective study examined the re-
lationship between pregravid physical ac-
tivity and GDM in 21,765 women having
at least 1 singleton pregnancy from 1990
to 1998 in the Nurses Health Study II.7
Demographic information, health beha-
viors, physical activity, and gestational
diabetes were assessed by self-report ques-
tionnaire. Women were queried about
weekly time spent in vigorous recreational
physical activities such as jogging, run-
ning, bicycling, calisthenics, lap swim-
ming, racquetball, or tennis; weekly
walking time and pace; and flights of
stairs climbed daily. Weekly prepreg-
nancy total and vigorous activity scores
were calculated from the hours and calo-
ric expenditure of the various activities
and averaged from several questionnaires
during the follow-up period beginning in
1989. Women with the highest quintile
prepregnancy total activity score had a
borderline reduced risk of GDM com-
pared to women with the lowest quintile
score (RR = 0.81, 95% CI = 0.68-1.01,
after adjusting for maternal age, race,
smoking, family history of diabetes, par-
ity, alcohol consumption, dietary factors,
and prepregnancy BMI). Women with the
fourth and fifth highest quintile prepreg-
nancy, vigorous activity score had signifi-
cantly reduced risk of GDM compared to
women with the lowest quintile score
(RR = 0.75, 95% CI = 0.64-0.87, and
RR = 0.77, 95% CI = 0.69-0.94, respec-
tively). When women who did not report
vigorous activity were examined, brisk
walking (3.0 to 3.9 mph) or very brisk
walking (Z4.0 mph) was associated with
a significantly reduced risk of GDM com-
pared with women whose walking pace
was casual (<2.0 mph) (RR = 0.66, 95%
CI = 0.46-0.95). Women who climbed
Z15 flights of stairs a day also had a
significantly lower risk of GDM than
women who climbed r2 flights of stairs
a day (RR = 0.50, 95% CI = 0.27-0.90).
Recreational physical activity was eval-
uated for a protective effect against GDM
470 Gavard and Artal
in a prospective study of 1805 women who
received prenatal care at Harvard Pilgrim
Health Care, a multispecialty group prac-
tice in eastern Massachusetts, from 1999
to 2002.8 Women were recruited during
their initial prenatal care visit (mean ge-
stational age of 10.4 wk) and completed
questionnaires regarding recreational
physical activity performed during the
year before pregnancy. Women were
asked about average weekly hours spent
in walking; light to moderate physical
activities such as yoga, bowling, stretch-
ing classes, and skating; and vigorous
physical activities such as running, jog-
ging, swimming, aerobic classes, and cy-
cling. When women were evaluated for
GDM at 26 to 28 weeks gestation, they
provided the same information on physi-
cal activity performed during the preced-
ing 3 months. Data were analyzed
separately for walking, light/moderate
activity, vigorous activity, light/moderate
or vigorous activity, and total activity
hours for women both before and during
pregnancy. Although most findings
showed lower GDM risk, the only finding
that achieved statistical significance in
this study was for women who engaged
in vigorous recreational physical activity
before pregnancy compared with women
who had no such activity before preg-
nancy (OR = 0.56, 95% CI = 0.33-0.95,
adjusting for maternal age, race, family
history of diabetes, history of GDM, and
prepregnancy BMI). Adjustment for
weight gain before 26 weeks gestation
did not appreciably change risk estimates.
Women who reported vigorous activity
before pregnancy and light/moderate or
vigorous activity during pregnancy had a
borderline lower risk of GDM compared
with women who reported no vigorous
activity before pregnancy and no light/
moderate or vigorous activity during
pregnancy (OR = 0.49, 95% CI = 0.24-
1.01). No other combinations of physical
activity during both time periods were
significant.
The influence of physical activity on
GDM risk was examined in the Central
New York Regional Perinatal Data Sys-
tem, a population-based birth registry col-
lecting information on all live births
occurring in a 15-county region of central
New York state.9 A total of 12,776 women
who delivered a live birth from October 1,
1995 to July 31, 1996 were included in the
study. GDM and BMI were abstracted
from medical records. Physical activity
was assessed by personal interview after
delivery in which women were asked how
many times per week on average during
their pregnancy they engaged in exercise
for 30 minutes or more above their usual
activities. Women were grouped accord-
ing to any exercise (Z1 time/wk) versus no
exercise. Similar risk of GDM was found
for women reporting physical activity and
women not reporting physical activity
when the group was considered collec-
tively (OR = 1.0, 95% CI = 0.8-1.3).
When stratified by prepregnancy BMI,
the only significant difference was found
in the BMI >33 group, where nonexerci-
sers were at greater risk for GDM than
exercisers (OR = 1.9, 95% CI = 1.2-3.1).
The risk of GDM was virtually equivalent
for exercisers and nonexercisers through a
BMI of 32. These risk estimates, however,
were not adjusted for potential confound-
ing variables.
SUMMARY OF GDM STUDIES
Numerous potential biases and methodo-
logical issues exist in the above studies
such as selection bias5,6,8; recall bias5–9;
not controlling for potential confounders,
such as maternal weight gain during preg-
nancy,5–7,9 family history of diabetes,5,6,9
prior history of GDM,5,6,9 or any poten-
tial confounders at all9; the relationship
between exercise and GDM potentially
being influenced by an additional preg-
nancy during the assessment period
before pregnancy5–8; no assessment of
occupational physical activity5–9; the po-
tential inaccuracy of metabolic equivalent

(MET) scores in assessing caloric expen-
diture in that they do not account for
maternal BMI or aerobic fitness level5–7;
small sample sizes of GDM cases in sub-
group analyses such as intensity of physi-
cal activity, stair climbing, or active only
during pregnancy5,6; women being classi-
fied by maximum intensity of recreational
physical activity ever performed regard-
less of the frequency of that activity5;
limited generalizability of the findings in
that the study populations were predomi-
nately white,6–9 well-educated,6,8 or nulli-
parous6; physical activity being assessed in
fixed years and averaged over a potential
10-year follow-up period through mailed
questionnaires rather than being standar-
dized to the onset of pregnancy7; and
different assessment periods of physical
activity during pregnancy making com-
parison of studies difficult, such as the
first 20 weeks of pregnancy,5 7 days before
interview conducted at a mean gestational
age of 12.7 weeks,6 and 3 months before
interview conducted at a gestational age of
26 to 28 weeks.8 The protective effect of
exercise against GDM does not seem to be
realized unless physical activity occurs
both before and during pregnancy.5,6,8
The protective effect further was found
only in women whose BMI was Z255 or
>33.9 Inverse correlations between phy-
sical activity and GDM were found for all
BMI subgroup analyses (<25.0, 25.0 to
29.9, and Z30.0), but it is unknown if they
were statistically significant.7 Despite
these shortcomings, the balance of evi-
dence remains that exercise is protective
against GDM. Virtually all risk indices,
even if they were lacking statistical signifi-
cance, were in the direction of a protective
effect. The protective effect seems to be
particularly strong for vigorous or intense
exercise.5,7,8 Women reporting physical
activity both before and during pregnancy
having the lowest risk of GDM argue for a
cumulative exercise benefit. No deleter-
ious effects of exercise were mentioned in
the above studies.
Exercise in Pregnancy 471
PREECLAMPSIA
Historically, nonpregnant patients with
hypertensive disorders have been advised
to engage in physical activity to either
arrest or reverse hypertension. Conver-
sely, pregnant women with such disorders
are being advised to moderate their phy-
sical activities or altogether abandon
them. Women who engage in physical
activity during pregnancy or before preg-
nancy may be at reduced risk to develop
preeclampsia. In one case-control study,
the influence of recreational physical ac-
tivity on preeclampsia risk was examined
in 201 preeclampsia cases and 383 normo-
tensive pregnant controls.10 Physical ac-
tivity was assessed during the first 20
weeks of pregnancy and the year before
pregnancy. Women who reported physi-
cal activity during the first 20 weeks of
pregnancy had a significantly reduced risk
of preeclampsia compared with inactive
women (OR = 0.65, 95% CI = 0.43-0.99,
after adjusting for maternal age, race,
parity, smoking, and prepregnancy
BMI). Significant trends were found for
lower preeclampsia risk with weekly time
and energy expended on physical activity
during pregnancy. Women who were en-
gaged in vigorous physical activity during
the first 20 weeks of pregnancy had a
significantly lower risk of preeclampsia
compared with inactive women
(OR = 0.46, 95% CI = 0.27-0.79). A sig-
nificant trend was found for increasing
daily stair climbing with lower preeclamp-
sia risk (P<0.05), although no clear
benefit of walking or walking pace was
apparent. Findings were attenuated and
largely nonsignificant for physical activity
performed during the year before preg-
nancy. The adjusted OR for any recrea-
tional physical activity was 0.67 (95%
CI = 0.42-1.08) compared with inactive
women. Significant trends were no longer
found for weekly time and energy ex-
pended on physical activity or daily stair
climbing with lower preeclampsia risk.
Women reporting vigorous physical
472 Gavard and Artal
activity in the year before pregnancy,
however, had a significantly lower risk
of preeclampsia compared with inactive
women (OR = 0.40, 95% CI = 0.23-
0.69). A significant protective effect of
recreational physical activity again was
found only in women who were physically
active during both time periods
(OR = 0.59, 95% CI = 0.35-0.98 com-
pared with women who were physically
inactive during both time periods).
The effects of work activity and leisure-
time physical activity (LTPA) on pre-
eclampsia risk were examined in a nested
case-control study of 44 preeclampsia
cases and 2422 normotensive pregnant
controls.11 The women were recruited
from private obstetrical practices in New
Haven, Connecticut, from 1989 to 1991.
Information on work activity and LTPA
during the year before and early preg-
nancy was obtained through personal in-
terviews conducted at <16 weeks
gestation. Preeclampsia was assessed
through review of maternal antenatal re-
cords and hospital delivery charts. Wo-
men were classified as sedentary if they
spent the majority of their daily work time
sitting and nonsedentary if they spent the
majority of their daily work time standing
or walking. Women were further classi-
fied according to the proportion of their
daily work time spent sitting (<34%,
34% to 66%, and Z67%). Two classifi-
cations of LTPA were examined: any
LTPA (engaged in exercise or sports
Z1 time/wk) and no LTPA. The analyses
concentrated on work activity and LTPA
during early pregnancy. Although vir-
tually all risk indices indicated a protec-
tive effect, none were statistically
significant. Women who reported any
LTPA during pregnancy had a lower,
although nonsignificant, risk of pre-
eclampsia compared with inactive women
(OR = 0.66, 95% CI = 0.35-1.22, after
adjusting for work activity during preg-
nancy, education, parity, and prepreg-
nancy BMI). Women in nonsedentary
jobs had a lower, although nonsignificant,
risk of preeclampsia compared with wo-
men in sedentary jobs (OR = 0.71, 95%
CI = 0.37-1.36). The lack of significant
findings may be largely attributed to the
small number of preeclampsia cases and
crude measures for work activity and
LTPA.
The relationship of perceived exertion
during prepregnancy physical activity
with preeclampsia risk was studied in a
case-control study of 244 preeclampsia
cases and 470 normotensive pregnant con-
trols.12 In contrast to absolute intensity
measures of physical activity, such as time
or energy expended during specific activ-
ities, relative intensity measures such as
perceived exertion reflect the fitness level
of the woman and characteristics of the
activity. Women completed question-
naires during postpartum hospital visits
about perceived level of exertion when
performing recreational physical activity
in their usual manner in the year before
they became pregnant. Women selected a
score on the Borg scale of perceived exer-
tion according to these values: none to
weak (0 to 2), moderate (3, 4), strenuous
(5, 6), and very strenuous to maximal (7 to
10). Significant trends were found for in-
creasing usual perceived exertion during
recreational physical activity (P<0.001)
and the mean weekly energy expended
performing such activity (P<0.01) with
lower preeclampsia risk. Women having a
perceived very strenuous to maximal ex-
ertion had an especially significantly lower
risk of preeclampsia compared with wo-
men having a perceived exertion of none
to weak (OR = 0.22, 95% CI = 0.11-0.44,
after adjusting for maternal age, race,
parity, family history of chronic hyper-
tension, smoking, fruit and vegetable
consumption during pregnancy, and
prepregnancy BMI). The significant trend
for increasing usual perceived exertion
during prepregnancy physical activity
with lower preeclampsia risk was found
in women with a prepregnancy BMI of

<25 and Z25, although the relationship
was most pronounced for women with a
BMI Z25. A significant protective effect
was found at every level of perceived ex-
ertion versus none to weak exertion in the
BMI Z25 group, whereas only very stren-
uous to maximal exertion versus none to
weak exertion was significantly protective
in the BMI <25 group.
SUMMARY OF PREECLAMPSIA
STUDIES
The evidence for a protective effect of
exercise before or during pregnancy
against preeclampsia is weaker than that
for GDM and many of the same potential
biases and methodological issues apply to
the above studies. Selection bias10,12; recall
bias10–12; not controlling for potential con-
founders, such as race,11 maternal weight
gain during pregnancy,10–12 family history
of hypertensive disorders,10,11 prior history
of preeclampsia,10–12 or history of major
depressive disorder or clinically significant
depression symtomatology10–12; the rela-
tionship between exercise and preeclamp-
sia potentially being influenced by an
additional pregnancy during the year
before pregnancy10–12; no assessment of
occupational physical activity10,12; the
potential inaccuracy of MET scores in
assessing caloric expenditure in that they
do not account for maternal aerobic fitness
level10–12; small sample sizes of preeclamp-
sia cases overall or in subgroup analyses
such as active only during pregnancy10,11;
women being classified by maximum in-
tensity of recreational physical activity
ever performed regardless of the frequency
of that activity10; limited generalizability
of the findings in that the study population
was predominately white and well-edu-
cated11; and different assessment periods
of physical activity during pregnancy mak-
ing comparison of studies difficult, such as
the first 20 weeks of pregnancy,10 inter-
views conducted <16 weeks gestation
(mean interview time not given),11 or no
assessments during pregnancy12 all could
Exercise in Pregnancy 473
have influenced study findings. The pro-
tective effect of exercise against preeclamp-
sia does not seem to be realized unless
physical activity occurs both before and
during pregnancy, although only one
study addressed activity during both peri-
ods.10 The balance of evidence still sup-
ports that exercise is protective against
preeclampsia. Although few risk indices
achieved statistical significance, virtually
all measures again were in the direction of
a protective effect. Similar to the findings
for GDM, the protective effect seems to be
particularly strong for vigorous or intense
exercise.10,12 No deleterious effects of ex-
ercise were mentioned in the above studies;
however, such citing may not have been
the purpose of the investigations.
WEIGHT-GAIN RESTRICTION DURING
PREGNANCY
The current obesity epidemic signals a
need for preventing excessive weight gain
during pregnancy. Women who gained
excessive weight during pregnancy and
failed to lose weight by 6 months post-
partum were found to be 15 lb heavier 10
years later.13 A 15-year follow-up study
designed to determine the long-range
consequences of weight gain during
pregnancy found that maternal weight at
1-year postpartum was the strongest pre-
dictor of long-term weight retention.14
This relationship held regardless of pre-
pregnancy BMI or the amount of weight
gained during pregnancy. A very recent
study found that maternal weight gain
during pregnancy was associated with
offspring adiposity at 3 years of age.15
Studies are needed to examine the effects
of exercise on weight-gain restriction dur-
ing pregnancy.
We have recently examined the effects
of a lifestyle intervention of weight-gain
restriction during pregnancy using ED in
a study of 96 obese women with GDM.16
Women were sequentially recruited and
self-enrolled into either an ED group
(n = 39) or a diet (D) group (n = 57).
474 Gavard and Artal
All women were prescribed a eucaloric
diet and instructed in diabetes self-man-
agement. Women in the ED group parti-
cipated in a moderate exercise program
equivalent to a 60% symptom-limited
VO2max. Maternal and fetal outcomes
were noted from the time of intervention
to the time of delivery. The percentage of
women who gained weight during the
study was significantly less in the ED
group than in the D group (53.8% vs.
78.9%, P<0.01). The mean weight gain
per week was significantly less in the ED
group than in the D group (0.1 ± 0.4 kg
vs. 0.3 ± 0.4 kg, P<0.05). Complica-
tions, infant birth weight, and the propor-
tion of cesarean deliveries were similar
between the 2 groups. Women who gained
weight over the course of the study had a
higher, although nonsignificant, percen-
tage of macrosomic infants than women
who lost weight or had no mean weight
change (17.9% vs. 4.2%, P = 0.12). These
findings are suggestive that favorable fetal
outcomes occur despite lower maternal
weight gain during pregnancy. The influ-
ence of selection bias which could have
been operating owing to lack of randomi-
zation seems to be minimal in that women
in the ED and D groups were not signifi-
cantly different on virtually all variables
measured at study entry (maternal age,
gravidity, parity, race, gestational age,
and maternal BMI). Although corrobora-
tion is needed from large population-
based clinical trials, this study provides
evidence that a lifestyle intervention of
weight-gain restriction in pregnancy using
diet and exercise in obese women with
GDM results in significantly reduced
weight gain, fewer macrosomic infants,
and no adverse pregnancy outcomes.
Current Institute of Medicine guide-
lines for obese women (prepregnancy
BMI Z30.00) advise an increase of at
least 15 lb during pregnancy, but neither
recommend an upper limit of weight gain
nor differentiate between women who are
class I obese (BMI 30.00 to 34.99), class II
obese (BMI 35.00 to 39.99), or class III
obese (BMI Z40). A review of Missouri
birth certificate data for women who de-
livered full-term, live born, singleton
births from 1990 to 2001 was performed
to examine the relationship between ge-
stational weight gain and pregnancy out-
comes for women in each of the 3 obesity
classes.17 Four outcomes were examined:
preeclampsia, cesarean delivery, large for
gestational age infants, and small for ge-
stational age infants. The absolute risk
(incidence) of the 4 outcomes by gesta-
tional weight gain category is given for
each of the obesity classes in Figures 1 to
3. Similar patterns of increasing risk for
preeclampsia, cesarean delivery, and large
for gestational age infants were found
with increasing gestational weight gain,
whereas the risk for small for gestational
age infants decreased with increasing
weight gain. The gestational weight cate-
gory for achieving optimal levels of all 4
outcomes was found to be a gain of 10 to
25 lb for class I obese women (Fig. 1), a
gain of 0 to 9 lb for class II obese women
(Fig. 2), and a loss of 0 to 9 lb for class III
obese women (Fig. 3). Although not di-
rectly including an exercise component,
this study supports that weight-gain re-
striction in obese women during preg-
nancy is associated with lower risk of
adverse maternal and fetal outcomes.
Prospective clinical trials are needed to
establish the efficacy of exercise for
weight-gain restriction during pregnancy
with resulting lower risk of maternal and
fetal comorbidities.
The above studies of the effect of ex-
ercise on pregnancy outcome are sum-
marized in Table 1.
Fetal Outcomes
BIRTH WEIGHT, TIME OF DELIVERY,
AND MODE OF DELIVERY
Birth weight and mode of delivery
have been mentioned to a degree in the
 Exercise in Pregnancy 475

FIGURE 1. Absolute risk of pregnancy outcomes by gestational weight gain

category for class I obese women (BMI = 30.00 to 34.99): Missouri birth
certificate data for full-term, live born, singleton births from 1990 to 2001.
BMI indicates body mass index; LGA large for gestational age; SGA, small for
gestational age.

weight-gain restriction section. Findings mester in which exercise is performed;

have been very inconsistent in the litera-
ture regarding the influence of maternal
exercise on fetal birth weight. These dis-
crepancies may reflect other confounding
conditions and complications; the tri-
the type, intensity, and duration of exer-
cise; maternal eating habits and other
behaviors; and if active or sedentary con-
trol groups are used for comparison. A
meta-analysis based on 10 clinical trials

FIGURE 2. Absolute risk of pregnancy outcomes by gestational weight gain

category for class II obese women (BMI = 35.00 to 39.99): Missouri birth
certificate data for full-term, live born, singleton births from 1990 to 2001.
BMI indicates body mass index; LGA, large for gestational age; SGA, small for
gestational age.
476 Gavard and Artal

FIGURE 3. Absolute risk of pregnancy outcomes by gestational weight gain

category for class III obese women (BMI Z40.00): Missouri birth certificate data
for full-term, live born, singleton births from 1990 to 2001. BMI indicates body
mass index; LGA, large for gestational age; SGA, small for gestational age.

found no weighted mean difference for
birth weight or gestational age at delivery
between mothers who did and did not
engage in regular aerobic exercise during
pregnancy.3 Another meta-analysis ex-
amined birth weight by maternal exercise
endurance before and during pregnancy,
trimester of exercise, and type of con-
trols.18 Endurance exercisers were women
who reported vigorous exercise Z3 times
per week before and during pregnancy.
Sedentary controls were women who
reported no exercise before or during
pregnancy, whereas active controls were
women who reported moderate or low
levels of exercise <3 times per week. No
differences in mean birth weight were
found for either endurance or nonendur-
ance exercisers compared with controls
for women who did not exercise past the
second trimester. Women who engaged in
vigorous exercise into the third trimester,
however, had infants with a lower mean
birth weight (200 to 400 g less) than either
active or sedentary controls. Data, how-
ever, were not provided regarding energy
intake of the women; adequate energy
intake may offset this greater risk. Future
prospective clinical trials are needed to
determine the influence of maternal exer-
cise (type, frequency, and intensity of
exercise; the trimester of exercise) and
maternal energy intake on fetal macro-
somia or fetal growth restriction.
Most studies in the literature have
found no significant difference in the in-
cidence of preterm labor or gestational
age at delivery for women who exercised
during pregnancy compared with con-
trols. One study examined the relation-
ship between recreational physical
activity before and during pregnancy with
time of delivery in 9089 women from
the 1988 National Maternal and Infant
Health Survey.19 Women were asked if
they had exercised or played sports at
least 3 times per week before learning that
they were pregnant (conditioned vs. un-
conditioned) and after learning that they
were pregnant (exercisers vs. nonexerci-
sers). Time of delivery was denoted as
preterm (<37 wk), term (37 to 42 wk),
and postterm (>42 wk). No signifi-
cant relationship was found between
 Exercise in Pregnancy 477

TABLE 1. Studies Examining the Effects of Exercise on Pregnancy Outcome

Main Findings
Author, Year, Study Activity Activity Size of Study Relative Risks, Odds
and Outcome Type Type Period Population Ratios, and 95% CI
GDM
Dempsey et al Case- Recreational Year before 155 cases Any vs. none 0.45 (0.28-0.74)
(2004)5 control pregnancy 386 controls Vigorous vs. none 0.29
(0.16-0.51)
First 20 wk of Any vs. none 0.52 (0.33-0.80)
pregnancy Vigorous vs. none 0.34
(0.19-0.63)
Both periods Active both vs. inactive both
0.40 (0.23-0.68)
Dempsey et al Prospective Recreational Year before 909 Any vs. none 0.44 (0.21-0.91)
(2004)6 pregnancy Z4.2 h/wk vs. none 0.24
(0.10-0.64)
Z21.1 MET-h/wk vs. none
0.26 (0.10-0.65)
7 d before Any vs. none 0.69 (0.37-1.29)
interview Z6.0 h/wk vs. none 0.90
Held at mean (0.45-1.80)
gestational Z28.0 MET-hr/wk vs. none
Age of 0.67 (0.31-1.43)
12.7 wk
Both periods Active both vs. inactive both
0.31 (0.12-0.79)
Zhang et al Prospective Recreational, Potentially 10 y 21,765 Mean weekly total activity
(2006)7 walking, Before score
stair- pregnancy Highest vs. lowest quintile
climbing 0.81 (0.68-1.01)
Mean weekly vigorous
activity score
Highest vs. lowest quintile
0.77 (0.69-0.94)
Brisk/very brisk walking vs.
casual walking with no
vigorous activity 0.66 (0.46-
0.95)
Z15 flights stairs/d vs. r2
flights stairs/d with no
vigorous activity 0.50 (0.27-
0.90)
Oken et al Prospective Recreational Year before 1805 Vigorous vs. none 0.56
(2006)8 pregnancy (0.33-0.95)
3 mo before Vigorous vs. none 0.90
26-28 (0.47-1.70)
Weeks
gestation
Both periods Vigorous before and light/
moderate or
Vigorous during vs. light/
moderate before and
inactive during 0.49
(0.24-1.01)
Dye et al Case- Any exercise Entire 372 cases None vs. any 1.0 (0.8-1.3)
(1997)9 control pregnancy 12,404 BMI >33.0 none vs. any 1.9
controls (1.2-3.1)
Preeclampsia
Sorensen et al Case-control Recreational Year before 201 cases Any vs. none 0.67 (0.42-1.08)
(2003)10 pregnancy 383 controls Vigorous vs. none 0.40
(0.23-0.69)
 478 Gavard and Artal

TABLE 1. (continued)
Main Findings
Author, Year, Study Activity Activity Size of Study Relative Risks, Odds
and Outcome Type Type Period Population Ratios, and 95% CI
First 20 wk of Any vs. none 0.65 (0.43-0.99)
pregnancy Vigorous vs. none 0.46
(0.27-0.79)
Both periods Active both vs. inactive both
0.59 (0.35-0.98)
Saftlas et al Nested Work activity Year before 44 cases Virtually none assessed
(2004)11 Case- Leisure time pregnancy 2422 Any LTPA vs. no LTPA
control Physical <16 wk controls 0.66 (0.35-1.22)
activity gestation Nonsedentary jobs vs.
(LTPA) sedentary jobs 0.71
(0.37-1.36)
Rudra et al Case-control Recreational Year before 244 cases Perceived very strenuous to
(2005)12 pregnancy 470 controls maximal exertion vs.
perceived exertion of none
to weak 0.22 (0.11-0.44)
BMI <25 trend of lower
risk with
Increasing perception of
exertion (P<0.001)
BMI Z25 trend of lower
risk with
Increasing perception of
exertion (P<0.001)
Weight-gain restriction
Artal et al Intervention Moderate Enrolled Obese with Percentage gaining weight
(2007)16 exercise <33 wk GDM during study
Program Gestation to Exercise+ ED vs. D (53.8% vs. 78.9%,
equivalent delivery diet (ED) P<0.01)
to 60% n = 39 Mean weight gain/wk ED
symptom- Diet (D) vs. D
limited n = 57 (0.1 ± 0.4 kg vs.
VO2max 0.3 ± 0.4 kg, P<0.05)
Percentage macrosomic
infants born to women
gaining weight during study
(ED or D) vs. to women
losing weight or having no
mean weight change during
study (17.9% vs. 4.2%,
P = 0.12)
Normalization of blood glucose
Bung et al Randomized Moderate Enrolled Hispanic Normalization of blood
(1991)4 Clinical exercise <33 wk women with glucose achieved and
trial Program Gestation to GDM maintained in EXE and INS
equivalent delivery Exercise+ groups within 1 wk
to 50% VO2 diet (EXE)
max n = 17
Insulin+
diet (INS)
n = 17

CI indicates confidence interval; GDM, gestational diabetes mellitus.

recreational physical activity before or tant to point out that women at risk for
during pregnancy with either preterm or premature labor are traditionally advised
postterm delivery. However, it is impor- not to engage in physical activities.

Studies examining the influence of ex-
ercise in pregnancy on mode of delivery
have generally found no relationship or a
lower rate of cesarean delivery among
exercising women. This may be correlated
with maternal weight gain during preg-
nancy. The mean weight gain per week in
the above intervention trial of obese
women with GDM was significantly less
in the ED group than in the D group
(0.1 ± 0.4 kg vs. 0.3 ± 0.4 kg, P<0.05);
no significant difference was found, how-
ever, in the percentage of cesarean deliv-
eries between the 2 groups (50.0% vs.
44.7%, P = 0.80).16 In contrast, a pro-
spective study of 800 women found a
cesarean delivery rate of 28% in sedentary
controls compared with a rate of only
6.7% in high-exercising women.20 Poten-
tial explanations for the lack of consistent
results could be different prepregnancy
fitness levels, different types and intensi-
ties of exercise, and control groups used.
Conclusions
This review critically evaluated the scien-
tific literature for the effects of exercise on
certain pregnancy outcomes. Maternal
outcomes included in this review were
GDM, preeclampsia, and weight gain.
Fetal outcomes included were birth
weight, time of delivery, and mode of
delivery. Despite numerous potential
biases and methodological problems, the
balance of evidence suggests a benefit of
exercise in pregnancy, especially for ma-
ternal outcomes. Conversely, there are no
reports in the literature linking adverse
fetal outcomes to maternal exercise. Vir-
tually all risk indices, even if they were
lacking statistical significance, were in the
direction of a protective effect; the effects
of intense and vigorous exercise were
especially strong; and no adverse preg-
nancy outcomes were reported. The
effects of exercise on fetal outcomes were
inconsistent, but generally did not seem to
have an adverse impact, and may provide
a protective effect in outcomes such as
Exercise in Pregnancy 479
cesarean delivery. Randomized clinical
trials are needed to further elucidate the
protective effect of different types, fre-
quencies, and intensities of exercise on
maternal and fetal outcomes. The protec-
tive effect may vary with maternal aerobic
capacity, the trimester of exercise, and
maternal energy intake. Prospective clin-
ical trials to establish the efficacy of ex-
ercise for weight-gain restriction during
pregnancy with resulting lower risk of
maternal and fetal comorbidities are per-
haps the greatest research need. Finally,
the above relationships should be exam-
ined and perhaps different exercise regi-
mens should be developed for pregnant
women in general, different prepregnancy
weight classes of women, and women at
risk for particular adverse pregnancy out-
comes, such as GDM and preeclampsia.
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