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Exercise During Pregnancy

April 10, 2020
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Now that you’re pregnant, you’re probably wondering about exercise during pregnancy. I’m summarizing the Canadian guidelines for physical activity throughout pregnancy set by the SOGC.

By exercising during pregnancy, you’re positively affecting your and your baby’s health. If you don’t have any contraindications to pregnancy (which are posted below), now is the time to start doing something. Especially if you were previously inactive and/or considered overweight or obese.

How much and what type?

Ideally you should aim for about 150 mins of moderate-intensity activity over the week (think: 30 minutes, 5 days a week).

If you’ve been previously inactive, you may want to begin gradually at a lower intensity, and increase the duration and intensity as your body gets used to it.

Aerobic and resistance training, with a pinch of yoga are great options. And in terms of improving health outcomes for you and your baby, you should aim to do all of them within the week.

Some activities do carry a higher risk and are considered contraindicated during pregnancy – like scuba diving, any activities with physical contact, danger of falling, and non-stationary cycling. Avoiding high-heat activities like hot yoga – as it may cause dehydration.

What the F is DRA?

DRA, known as diastasis rectus abdominus, may occur in some people. Essentially, your abdominal muscles may begin to separate. If you’re noticing that this has happened, book a visit with your pelvic floor physiotherapist to see what you can do. This means that you may also want to avoid ab strengthening exercises for the time being.

One of my colleagues filmed a video about DRA a few years ago. Check it out if you’d like more info

What about the first trimester?

Studies show that exercise in the first trimester doesn’t increase the odds of miscarriage or congenital anomalies. In fact, not exercising during the first trimester increased the odds of pregnancy complications like gestational diabetes, gestational hypertension, excessive gestational weight gain and depressive symptoms.

Let’s keep it real though, most people are exhausted in their first trimester – so the idea of anything besides walking is absolutely not appealing. But, if your energy hasn’t taken a nose dive, or if you’ve reached the point in your second trimester where you feel like you can start your routine again – let’s get to it!

Should ALL pregnant people exercise?

Exercising during pregnancy can provide many health benefits, but there are women who shouldn’t engage in strenuous exercise as its contraindicated. Keep in mind, this doesn’t mean they’re not allowed to move and continue their activities of daily living.

Absolute contraindications to exercise include:

  • Ruptured membranes
  • Premature labour
  • Unexplained or persistent vaginal bleeding
  • Placenta previa after 28 weeks
  • Preeclampsia
  • Incompetent cervix
  • Intrauterine growth restriction
  • High-order multiple pregnancy – like triplets
  • Uncontrolled type 1 diabetes
  • Uncontrolled hypertension
  • Uncontrolled thyroid disease
  • Other serious cardiovascular, respiratory or systemic disorder

Relative contraindications to exercise include:

  • Recurrent pregnancy loss
  • Gestational hypertension
  • A history of spontaneous preterm birth
  • Mild/moderate cardiovascular or respiratory disease
  • Symptomatic anemia
  • Malnutrition
  • Eating disorder
  • Twin pregnancy after week 28
  • Other significant medical conditions

Obviously, if you fall into any of these categories you’ll want to check in with your OB/Gyn or Midwife to see about your specific health situation – especially if you fall into the ‘relative’ category. You’ll want to figure out the advantages and disadvantages of exercise with your care provider before you start to exercise.

Tell me about KEGELS

During pregnancy, you may start noticing some urinary incontinence – perhaps some leaking will occur when you’re running, jumping, and laughing. Although this is common, it’s not considered normal. Many books or other professionals will tell you to start doing kegels. Do NOT do this. Instead, visit a pelvic floor physiotherapist so they can assess your pelvic floor. The reason being is that your pelvic floor may be “tight” yet weak (hence the leaking), and doing kegels can cause your pelvic floor to become tighter, not stronger. However, sometimes kegels can be helpful – but it’s super important to get a professional assessment before starting these.

Never heard of kegels before? Check out this video filmed by one of my colleagues!

Final Thoughts

Exercise during pregnancy is a great thing if you don’t have any of the above absolute/relative contraindications – but always speak to your care provider if you have any questions.

If you’ve been a bit sedentary in the first trimester (that’s okay, pregnancy is tiring!), start slow with low intensity and shorter durations and increase as you go.

If you happen to notice any abdominal separation or even leaking while jumping/running/laughing, be sure to book an appointment with a pelvic floor physiotherapist. I’m writing this post during the COVID-19 pandemic and a lot of health care practitioners have transitioned to virtual visits, so there’s still an opportunity to see a pelvic floor physiotherapist or naturopathic doctor if you have the ability to do so.

References

Mottola, M., Davenport, M., Ruchat, S., Davies, G., Poitras, V., & Gray, C. et al. (2018). No. 367-2019 Canadian Guideline for Physical Activity throughout Pregnancy. Journal Of Obstetrics And Gynaecology Canada40(11), 1528-1537. doi: 10.1016/j.jogc.2018.07.001

PCOS in Pregnancy

March 20, 2020

When people with PCOS become pregnant, this may lead to some pregnancy complications. Complications are dependent on which PCOS criteria the pregnant person fulfilled prior to pregnancy.

Polycystic ovary syndrome (PCOS) is the most common hormonal disorder in reproductive-aged women. To be diagnosed with PCOS, you need at least 2 of the 3 following criteria:

  1. Delayed ovulation or irregular menstrual cycles (oligomenorrhea)
  2. High androgenic hormones like testosterone
  3. Polycystic ovaries on ultrasound

Although not a criteria of PCOS, insulin resistance is also a hallmark of PCOS. High insulin (known as hyperinsulinemia) is more prevalent when features of high androgens (like testosterone) are present.

PCOS and Pregnancy Complications

Miscarriage

During pregnancy, miscarriage is more frequent in those with PCOS. It’s specifically influenced by BMI. High androgens as well as high insulin levels cause inflammation within the body that may lead to difficulties in embryo implantation, miscarriage and adverse pregnancy outcomes, some of which are outlined below.

Gestational Diabetes

Gestational diabetes is pregnancy-induced diabetes, that usually resolves in the postpartum. Studies show that women with PCOS have a 3x higher chance of gestational diabetes, from high androgen levels.

Risk Factors for developing gestational diabetes are:

  • Over 35 years old
  • Pre-pregnancy BMI is over 30 kg/m2
  • Ethnicity (Aboriginal, African, Asian, Hispanic, South Asian)
  • Family history of diabetes
  • Polycystic ovary syndrome, and acanthosis nigricans (a skin condition causing hyperpigmentation of skin, especially in the folds)
  • Corticosteroid use
  • Previous diagnosis of gestational diabetes
  • Previous ‘big’ baby

Around 24-28 weeks, pregnant people are offered screening for gestational diabetes. However, if there’s a high risk of gestational diabetes based on the above risk factors, screening or testing may be offered earlier and then repeated at 24-28 weeks if it was normal.

Pre-eclampsia

Pre-eclampsia is pregnancy-induced high blood pressure (formally known as hypertension) and protein in the urine, or other adverse symptoms; at or after 20 weeks gestation. Studies show that women with PCOS have a 3x higher chance of pre-eclampsia due to high androgen levels.

Symptoms of pre-eclampsia include:

  • Persistent headache
  • Visual disturbances
  • Abdominal pain at the upper right quadrant
  • Nausea and/or vomiting
  • Chest pain/shortness of breath

Risk factors in developing preeclampsia are:

  • Antiphospholipid antibodies
  • Previous pre-eclampsia
  • Pre-existing diabetes
  • Family history of pre-eclampsia
  • Raised pre-pregnancy BMI

Blood Work to Consider

If you’re planning on becoming pregnant or are in the early stages of pregnancy, it may be worthwhile to do some blood work to assess your risk and possibly decrease it.

  • Complete blood count
  • Blood lipids
  • Fasting insulin and fasting glucose
  • Free testosterone, total testosterone, Sex hormone binding globulin (SHBG)

Final Thoughts

Unfortunately there isn’t much treatment for people who have PCOS during pregnancy, although adopting a healthy diet and physical activity is recommended – check with your health care provider to see what’s right for you.

References

Christ, J., Gunning, M., Meun, C., Eijkemans, M., van Rijn, B., & Bonsel, G. et al. (2018). Pre-Conception Characteristics Predict Obstetrical and Neonatal Outcomes in Women With Polycystic Ovary Syndrome. The Journal Of Clinical Endocrinology & Metabolism104(3), 809-818. doi: 10.1210/jc.2018-01787

GESTATIONAL DIABETES MELLITUS: A review for midwives. Retrieved 20 March 2020, from https://www.ontariomidwives.ca/sites/default/files/Gestational-diabetes-mellitus-backgrounder-PUB_0.pdf

Hart, R. (2019). Generational Health Impact of PCOS on Women and their Children. Medical Sciences7(3), 49. doi: 10.3390/medsci7030049

Hypertensive Disorders of Pregnancy. Retrieved 19 March 2020, from https://www.ontariomidwives.ca/sites/default/files/CPG%20supplemental%20resources/HDP%20Summary.pdf

Palomba, S., de Wilde, M., Falbo, A., Koster, M., La Sala, G., & Fauser, B. (2015). Pregnancy complications in women with polycystic ovary syndrome. Human Reproduction Update21(5), 575-592. doi: 10.1093/humupd/dmv029

Fertility and Hypothyroidism

August 1, 2019
fertility hypothyroidism, fertility hashimotos, conception, ovulation, toronto naturopath, naturopathic doctor toronto

Becoming and staying pregnant can be difficult (and heartbreaking if the latter occurs). Oftentimes we don’t know exactly why miscarriage happens, but we do know about the involvement of the thyroid in some women. Recent studies have looked at the association between fertility and the thyroid gland and found that conditions like hypothyroidism and Hashimoto’s Thyroiditis are contributors to infertility. 

Thyroid disorders may affect your period in the following ways:

Hormones such as thyroid stimulating hormone (TSH) and thyroid hormones (T4 and T3) are important for menstrual regularity, egg development and implantation. 

Hypothyroidism

Hypothyroidism occurs when TSH levels are increased beyond their normal limits, when there is not enough T4 secretion, or when there isn’t enough conversion of T4 to T3. The latter means that you can have NORMAL TSH levels but T4 and T3 could be off.

Hypothyroidism signs and symptoms look like:

  • Low metabolism, which can lead to weight gain
  • Low basal body temperature
  • Low pulse or blood pressure
  • Dry and/or scaly skin
  • Dry hair and/or hair loss
  • Slowed reflexes
  • Intolerance to cold
  • Depression

Hashimoto’s Thyroiditis

Hashimoto’s is essentially an autoimmune version of hypothyroidism. It occurs when the body doesn’t recognize the thyroid gland as its own and attacks it, leading to the production of thyroid antibodies such as anti-TPO and thyroglobulin.

Additionally, there is also a connection between Hashimoto’s and gluten sensitivity/celiac disease. So if you’ve been looking for a reason to limit your gluten intake, here it is!

TSH During Pregnancy

During pregnancy, having ideal levels of TSH and thyroid hormones is important because they are associated with increased gestation (time between conception and birth), hypertension, growth restrictions, premature delivery and fetal hypothyroidism. It’s clear that the thyroid should be monitored throughout pregnancy.

Thyroid Testing

The American Thyroid Association recommends that TSH should be checked in all women experiencing infertility, and some groups indicate that TSH should be equal to or less than 2.5mIU/L to reduce miscarriage risk.

Here’s the thing though, usually only TSH will be tested but this isn’t good enough! It’s important to understand everything that’s going on with the thyroid so ask for a comprehensive workup that looks like:

  • TSH
  • T4
  • T3
  • Anti-TPO
  • Thyroglobulin

Thyroid and IVF

IVF can be a stressor to the thyroid. And although no studies have showed that treating hypothyroidism leads to an increase of live births, one study has shown that hypothyroid women have less of a response to ovarian stimulation and a lower rate of embryo transfer.

Next Steps

With infertility being so common nowadays, it’s important to take a good look at the thyroid – especially if you have a family history of thyroid disorders or experiencing any of the above signs or symptoms.

Treating thyroid conditions does not just require medication, particular nutrients like selenium or Vitamin D can also be helpful, as well as trying out some dietary changes if you happen to have high antibody levels. Speak to your naturopathic doctor to see how they can complement your treatment plan.

References

Busnelli, A., Somigliana, E., Benaglia, L., Leonardi, M., Ragni, G. and Fedele, L. (2013). In Vitro Fertilization Outcomes in Treated Hypothyroidism. Thyroid, 23(10), pp.1319-1325.

Biondi, B., Cappola, A. and Cooper, D. (2019). Subclinical Hypothyroidism. JAMA, 322(2), p.153.

Maraka, S., Singh Ospina, N., Mastorakos, G. and O’Keeffe, D. (2018). Subclinical Hypothyroidism in Women Planning Conception and During Pregnancy: Who Should Be Treated and How?. Journal of the Endocrine Society, 2(6), pp.533-546.

Green, K., Werner, M., Franasiak, J., Juneau, C., Hong, K. and Scott, R. (2015). Investigating the optimal preconception TSH range for patients undergoing IVF when controlling for embryo quality. Journal of Assisted Reproduction and Genetics, 32(10), pp.1469-1476.

Orouji Jokar, T., Fourman, L., Lee, H., Mentzinger, K. and Fazeli, P. (2017). Higher TSH Levels Within the Normal Range Are Associated With Unexplained Infertility. The Journal of Clinical Endocrinology & Metabolism, 103(2), pp.632-639.