With socioeconomic development and changes in people’s lifestyles, the incidence of gestational diabetes mellitus (GDM) has increased significantly and has become the most common complication of pregnancy. Numerous studies have shown that abnormal glucose metabolism is an important factor leading to adverse pregnancy outcomes in mothers and children. Currently, the main clinical measures to regulate blood glucose include health education, medical nutrition therapy, pregnancy glucose monitoring, medication and pregnancy exercise. In this paper, we focus on the related contents of exercise therapy for GDM, in order to provide clinical reference.
I. Exercise during pregnancy
The health benefits of exercise have long been accepted by people. However, there is still no unified view on the advantages and disadvantages of exercise on pregnancy outcomes, which exercises are suitable for pregnancy, when to start exercise during pregnancy, and how to assess the amount of exercise during this special period of pregnancy. Early experimental animal studies have shown that heavy physical activity combined with poor nutrition may affect fetal growth and development. It has also been suggested that the increase in body temperature and energy transfer to the maternal skeletal muscular system due to exercise may affect normal fetal development, and that changes in body position during exercise may injure the abdominal muscles or joints of the pregnant woman and the placenta. However, these views lack evidence support from large sample clinical studies.
The current situation is that more and more pregnant women are reluctant or afraid to participate in various exercises throughout their pregnancy or during a certain period, and some pregnant women want to have a good maternal and child outcome through exercise but do not know which exercises are the most effective. These reasons have led to a decrease in maternal activity during pregnancy, while the good material living conditions have made pregnant women rich in nutrition or even excess, and more and more pregnant women are gaining too much weight during pregnancy, which has become an important factor in the increasing incidence of GDM. Clinical research on exercise during pregnancy has never stopped.
Studies in recent years have found that pregnant women can participate in regular exercise during pregnancy, and as long as the pregnant women themselves do not have special disease states, light to moderate exercise during pregnancy is beneficial to the health of pregnant women, such as exercise can improve skin sensitivity, can redistribute blood circulation, reduce back pain, reduce fluid retention in the lower extremities, reduce pressure on the cardiovascular system thus lowering blood pressure, improve oxygen supply, reduce GDM, prevention of lower extremity deep vein thrombosis, and weight control.
In addition, exercise is also helpful in terms of mood improvement, increasing the self-confidence of pregnant women, improving satisfaction with self-expression, and reducing the risk of postpartum depression. It is now believed that exercise during pregnancy should be encouraged and actively promoted as part of a healthy human life. Women should also participate in exercises that are aerobically demanding and of limited intensity after pregnancy and are part of their daily life. Studies have shown that aerobic and moderate-intensity exercise does not increase the rate of early pregnancy miscarriage, late obstetric complications, or abnormal fetal development and is not associated with adverse pregnancy outcomes in newborns. Moderate exercise can increase muscle strength and body energy, promote metabolism and blood circulation, increase placental blood flow, improve appetite, promote gastrointestinal motility, reduce constipation, enhance cardiopulmonary function and pelvic floor muscle strength, promote sleep, reduce the occurrence of postpartum depression, maintain normal body shape, and facilitate postpartum recovery, etc.
1, the form of pregnancy exercise Pregnancy exercise can be diversified, but should be more individualized, to encourage the development of pregnancy exercise suitable for their own physical conditions. Swimming, walking, cycling, gymnastics for pregnant women, yoga, upper body exercises, Kegel exercises, etc. are all forms of exercise that can be recommended for pregnant women. Forms of sports with certain risks and excitement, such as rugby, basketball, horseback riding, landslide sports, diving, etc., are not recommended. The altitude at 1800 m height should be safe when exercising, if it exceeds this height and the pregnant woman becomes unwell, she must be checked promptly.
2, the time to carry out pregnancy exercise After early pregnancy, into the middle pregnancy is the best time to carry out exercise. Pregnant women engaged in sports before pregnancy pregnancy can generally also be carried out. It is recommended that exercise during pregnancy be carried out in a gradual manner. At the beginning, aerobic exercise (mainly continuous exercise involving large muscle groups of the body, some simple aerobic exercises such as walking, etc.) is generally carried out three times a week for 15 min each time, gradually increasing to four times a week for 30 min each time, and the reasonable goal of exercise during pregnancy is to achieve the amount of exercise that can adapt to one’s own intensity. Consult your obstetrician, and when there is a special need, consult an exercise therapist, physiotherapist, etc., and listen to the advice of professionals.
A simple measure of the appropriate amount of exercise is to be able to talk normally during exercise (talk test). The intensity of exercise during pregnancy is classified according to the changes in the body after each exercise of at least 15 minutes. High-intensity exercise is defined as exercise with rapid heartbeat and fatigue, such as running, swimming and climbing; moderate-intensity exercise is defined as exercise with rapid heartbeat but no fatigue, such as gymnastics, brisk walking, dancing, walking up and down stairs and upper body weight lifting (up to 5 kg); light-intensity exercise is defined as exercise with no rapid heartbeat and no fatigue, such as walking, gardening and light housework. Light to moderate intensity exercise is appropriate during pregnancy, and a small amount of high-intensity exercise can be appropriate for pregnant women who have previous exercise habits. More quantitative indicators can also be used to judge the intensity of exercise.
At present, the heart rate during exercise is mostly used as an indicator to evaluate the intensity of exercise internationally. Clinically, the heart rate that can achieve a better exercise effect and ensure the safety of exercise is called target heart rate (THR). The best way to determine the target heart rate is to obtain it through an exercise test, that is, to take 70% to 80% of the highest heart rate in the exercise test as the target heart rate, or a simpler method is to calculate the target heart rate according to age: target heart rate = 170 – age (years) or (220 – age) × 70%. 140-155 beats/min for pregnant women under 20 years old, 135-150 beats/min for pregnant women 20-29 years old, and 130-145 beats/min for pregnant women 30-39 years old. The target heart rate for exercise intensity for pregnant women aged 30 to 39 years is 130 to 145 beats/min, and for those aged 40 years or older is 125 to 140 beats/min; the target heart rate for exercise intensity for obese or overweight pregnant women is 110 to 131 beats/min for pregnant women aged 20 to 29 years, and 108 to 127 beats/min for those aged 30 to 39 years.
It should be noted that as the pregnancy week increases, the amount of exercise should be gradually reduced, especially the intensity of exercise and exercise should also be adjusted according to their own conditions.
4.Implementation of exercise during pregnancy Pregnant women who have no exercise habits should start exercising with a small amount of exercise, starting from 5 min per day or 15 min per time three times a week, and gradually increasing. Pregnant women with previous exercise habits can start with the original amount of exercise and adjust it according to their own situation. Have a fixed regular exercise time of about half an hour a day or 30~45 min 3~5 times a week (about 120~150 min in total). Usually 5-10 min of preparatory activities, including the limbs and the whole body and stretching activities, such as walking, to start with a slow walk, while doing some low-intensity, light stretching activities, and gradually increase the intensity of exercise, so that the muscles gradually move, its role is to gradually adapt to cardiovascular exercise, and can improve and improve the effect of joint and muscle activity. Exercise in cold temperatures, the preparation time for the activity must be extended accordingly.
Then enter the exercise session, which is the core part of pregnancy exercise, determined by the intensity of the exercise, using the principle of individualization, according to personal preferences to choose different ways. After each exercise should be relaxation activities, relaxation activities include 5-10 min of slow walking, self-massage or other low-intensity activities, the role of which is to promote blood return, to prevent sudden stop exercise caused by the limb stasis, back to the heart blood volume decreased, causing fainting or arrhythmia. If the exercise in the summer, the time of relaxation activities can be extended accordingly.
5, pregnancy exercise precautions Pregnancy exercise to choose a better exercise environment, indoor exercise to keep the air circulation; outdoor exercise to choose lush flowers and plants, fewer people and cars, try to avoid 10 a.m. to 7 p.m., the general temperature during this time is higher, the intensity of ultraviolet light, air pollution is more obvious, the temperature is too high or too low should be suspended when exercising.
Before carrying out exercise during pregnancy, you should visit your obstetrician for examination and consultation to assess your general and obstetric condition and decide whether it is appropriate to exercise. An electrocardiogram (EKG) before exercise is useful to rule out cardiac disorders and to screen for complications such as macrovascular and microvascular lesions. Wear loose clothing, a suitable bra and well-fitting flat shoes when exercising. Exercise should not be overheated, the axillary body temperature after exercise should not exceed 38.3 ℃, after exercise bathing attention to keep warm. Replenish enough water and nutrition to meet the needs of exercise during pregnancy. Prevent hypoglycemic reaction and delayed hypoglycemia.
Exercise after 30 min of eating, time control at 30~45 min, rest 30 min after exercise, count fetal movement before and after exercise. The appropriate amount of carbohydrate should be supplemented 2~4 h after exercise. When lower abdominal pain, shortness of breath, vaginal bleeding, vaginal fluid, fatigue, dizziness, palpitations, shortness of breath, headache, chest pain, painful contractions, blurred vision, reduced fetal movement, painful swelling of gastrocnemius muscle, etc. occur during exercise, exercise should be stopped immediately and a doctor should be consulted if necessary.
Second, GDM pregnant women exercise therapy
Exercise therapy can reduce the basic insulin resistance during pregnancy, and has an important role in maintaining the stability of blood glucose levels and reducing the use of hypoglycemic drugs, which is one of the preventive and comprehensive treatment measures for GDM. Pregnant women with GDM can choose amateur sports or recreational sports as the main form of exercise if they are fully evaluated and contraindications are excluded.
Some of the simple aerobic exercises available include swimming, walking, cycling, maternal gymnastics, yoga, general housework, and Kegel exercises, all of which are suitable for pregnant women with GDM. Pregnant women with GDM cannot exercise during pregnancy when they have the following conditions: premature rupture of membranes, preterm labor, hypertensive disorders of pregnancy, cervical insufficiency, fetal growth restriction, 3 or more pregnancies, history of multiple preterm births, placenta praevia after 26-28 weeks of pregnancy, persistent vaginal bleeding in mid to late pregnancy, type 1 diabetes with poorly controlled blood glucose levels, thyroid disease or other serious cardiovascular, respiratory or systemic diseases. respiratory or systemic diseases, etc. Relative contraindications to exercise therapy for pregnant women with GDM include: history of spontaneous abortion in previous pregnancy, history of previous preterm delivery, mild to moderate cardiovascular disease such as undiagnosed arrhythmia, mild to moderate respiratory disease such as chronic bronchitis, anemia (hemoglobin <100 g/L), malnutrition or eating disorders or very low body mass index (BMI <12), twin pregnancies after 28 weeks of gestation, other significant medical disease, heavy smoking, extremely sedentary lifestyle, extreme morbid obesity, and uncontrolled epilepsy.
Precautions for exercise in pregnant women with GDM on insulin.
(1) Each exercise should avoid the peak period of insulin action, and if it is necessary to exercise during this period, appropriate diet can be supplemented before exercise.
(2) The insulin injection site should avoid the limb that will be exercised as much as possible, otherwise the movement of the limb can accelerate the absorption of insulin, especially after the injection of insulin that exercise is prone to hypoglycemic reaction.
(3) It is best to monitor blood glucose before exercise therapy begins, if fasting blood glucose <5.5>5.5 mmol/L, there is no need to supplement diet; if blood glucose >13.9 mmol/L, exercise should be suspended and urine ketones should be checked; if urine ketones are positive, insulin should be supplemented first to correct hyperglycemia and ketosis. After the condition improves, then consider exercise and exercise.
(4) Avoid exercising in the early morning before insulin injection on an empty stomach, because plasma insulin levels are very low at this time and exercise can induce ketosis.
(5) Carry some cookies or candies with you when you exercise, so that you can eat them in time when you have the aura of hypoglycemia. In conclusion, for pregnant women with GDM, once diagnosed, exercise therapy should be carried out simultaneously with medical nutrition therapy. 3~5 d later, blood glucose levels should be monitored, and medication should be added promptly for those who do not reach the glycemic control range during pregnancy. In 2012, the American Diabetes Association (ADA) stated in the GDM treatment guidelines that moderate intensity aerobic exercise at least 150 min no less than 3 times a week is one of the comprehensive treatment measures for GDM, with no adverse effects on the mother and child, and is recommended as level A evidence.