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New ACOG Recommendations Encourage Exercise in Pregnancy

Earlier this year the American College of Obstetrics and Gynecology (ACOG) published its newest exercise and pregnancy recommendations,1 replacing an advisory that it published on the topic in 1994.2 The changes promote regular exercise for its overall health benefits. In a nutshell, the older recommendations state that healthy pregnant women can exercise; the recent recommendations suggest that healthy, pregnant women should exercise.

Exercise as Prevention and Treatment

The new recommendations state that healthy pregnant women can adopt the activity recommendation for the general population: 30 minutes or more of moderate exercise on most, if not all, days of the week. Raul Artal, MD, principal author of the ACOG recommendations, says pregnancy is a unique time for behavior modification, and that healthy behaviors maintained or adopted during pregnancy may improve health for the rest of a woman's life. And he notes that the excess weight gained in pregnancy, which many women never lose, is a major public health concern. Artal is professor and chairman of the Department of Obstetrics and Gynecology at St Louis University in St Louis and an editorial board member of The Physician and Sportsmedicine.

James F. Clapp III, MD, an obstetrician and emeritus professor in the Department of Reproductive Biology and the Schwartz Center for Metabolism and Nutrition at Case Western Reserve University in Cleveland, says the 2021 recommendations are more flexible than before. "They do not recommend in a dictatorial fashion exercise type and target heart rate," he says. "This makes it more difficult for the doctor, but easier on the woman."

For the first time, the recommendations highlight a possible role for exercise in the prevention and treatment of gestational diabetes. "From my own clinical experiences, exercise can prevent gestational diabetes, even in morbidly obese patients," Artal says.

The recommendations emphasize that previously inactive women or those with medical or obstetric complications be evaluated before prescribing exercise.

Useful Clinical Tools

The new recommendations contain three useful tables: absolute contraindications to exercise, relative contraindications to exercise, and, for the first time, a listing of warning signs to terminate exercise. Many of the new contraindications that were not specified in the 1994 recommendations are general medical conditions, such as heart disease, lung disease, and orthopedic limitations.

The new recommendations offer more sports-specific guidance than the previous version. It lists examples of contact sports, such as ice hockey, soccer, and basketball, that could cause abdominal trauma and activities that have a high risk of falling, such as downhill skiing. The recommendations advise that competitive pregnant athletes be closely supervised by their physicians.

Recommendations note that scuba diving should be avoided because it puts the baby at increased risk of decompression sickness. At the other end of the spectrum, the recommendations note that women who are active at altitudes greater than 6,000 ft be aware of the signs of altitude sickness and seek medical attention if symptoms arise.

Acknowledging the Gray Areas

The report highlights areas that don't have a strong research basis for recommendations, such as the effect of strenuous activity on fetal growth and the effects of exercise on core temperature during pregnancy. More research is needed in additional areas, says Clapp.

Postpartum Reassurance

Several postpartum concerns are now addressed in the recommendations. They note that there are no known complications of return to training. Though rapid resumption has not demonstrated adverse effects, a gradual return to activity is advised.

Lactation and postpartum depression are covered for the first time in the new recommendations: They report that moderate weight reduction while nursing does not compromise neonatal weight gain and that exercise has been associated with decreased incidence of postpartum depression—but only if the exercise is not stress provoking.

Lisa Schnirring


  1. ACOG Committee on Obstetric Practice: Exercise during pregnancy and the postpartum period, Committee Opinion No. 267, January 2021. Int J Gynaecol Obstet 2021;77(1):79-81
  2. ACOG Committee on Obstetric Practice: Exercise during pregnancy and the postpartum period, Committee Opinion No. 189, February 1994. Int J Gynaecol Obstet 1994;45(1):65-70

Field Notes

A Timely Report on Repellents

Researchers at the University of Florida tested a variety of widely available insect repellents—including some botanical products—to determine which ones provide the best protection. Their trials, reported in the July 4 issue of The New England Journal of Medicine, overwhelmingly showed that products containing N,N-diethyl-3-methylbenzamide (DEET) are most reliable and protective.

Products containing different concentrations of DEET were tested; researchers found that higher doses resulted in longer-lasting protection. The only botanical repellent that came close to the efficacy of the lowest concentration of DEET was one that contained soybean oil. Products containing eucalyptus oil were introduced after the study was completed, and initial evaluation in six of the study subjects suggests that among botanical products, it may offer the longest-lasting protection.

Researchers concluded that products containing DEET—rather than botanical preparations—should be used in areas where diseases, such as malaria, encephalitis, or West Nile virus, can be transmitted in a single bite.

Golf's Cardiac Component

Is playing golf a good cardiac rehab exercise? According to researchers from Johns Hopkins and Wake Forest universities, it can be, depending on the patient's fitness level.

The researchers, reporting in the March-April issue of the Journal of Cardiopulmonary Rehabilitation, evaluated the metabolic cost of playing nine holes of golf while pulling a cart. They compared 20 male golfers ages 49 to 78, half with heart disease. (They matched each heart disease participant with an age-matched control.) Each pair completed nine holes of golf while pulling a cart and wearing portable oxygen consumption monitors.

Players who had heart disease averaged 57% of their exercise capacity, while the healthier controls averaged only 46%—not enough for a training stimulus. Some of the less fit patients with heart disease exceeded their exercise capacity. Researchers concluded that the least fit heart patients should consider modifying their golf game to include use of a motorized cart, and that the more fit healthy people play golf more regularly to meet the moderate physical activity recommendation from the American College of Sports Medicine.