Short report
Exercise during pregnancy and risk of maternal
1
Facultad de Ciencias de la
Actividad Fsica y del Deporte-
INEF, Universidad Politecnica de
Madrid, Madrid, Spain;
2
Department of Biosciences and
Nutrition at NOVUM, Unit for
Preventive Nutrition, Karolinska
Institutet, Huddinge, Sweden;
3
Universidad Europea de
Madrid, Villaviciosa de Odon,
Spain
Correspondence to:
Dr A Lucia, Universidad Europea
de Madrid, 28670 Villaviciosa de
Odon, Spain; alejandro.lucia@
uem.es
Accepted 1 January 2009
Published Online First
21 January 2009
954
anaemia: a randomised controlled trial
R Barakat,1 J R Ruiz,2 A Lucia3
ABSTRACT
The purpose of this randomised controlled trial was to
examine the effect of regular exercise (three times/week)
performed during the second and third trimester of
pregnancy on the risk of prepartum maternal anaemia
(haemoglobin ,11 g/dl). 160 sedentary healthy women
were randomly assigned either to a training or a control
group (n = 80 each). Haematological variables were
recorded at baseline (first trimester) and the beginning of
the second and third trimesters. The frequency of
participants with maternal anaemia was similar in the two
groups over gestation (and consistently ,10%). The
course of haematological adaptations was normal and
similar in both groups, reflecting a steady fall in
haemoglobin concentration over the second trimester due
to haemodilution and a rise later in gestation due to
haemoconcentration. In summary, regular exercise during
the second half of pregnancy does not increase the risk of
maternal anaemia nor does it alter haematological
variables.
Pregnant women are at risk of developing anaemia
because of the extra iron required by the growing
fetus, the placenta and the increased maternal red
cell mass.1 2 Prepartum maternal anaemia, a condi-
tion characterised by impaired haeme synthesis
and hypoplastic erythropoiesis,3 is diagnosed when
the haemoglobin concentration falls below 11 g/dl
during gestation.4 Despite recommendations on
iron prophylaxis, maternal anaemia is still a major
antenatal health problem due to its high incidence
and potential medical consequences.5 6 In Europe,
the estimated number of pregnant women with
maternal anaemia is approximately 2.5 million.4 A
recent study showed a maternal anaemia incidence
of approximately 16% at delivery in pregnant
westerners receiving no iron supplements.6 The
potential health problems associated with mater-
nal anaemia are of importance as they include
increased fatigue and decreased work performance,
cardiovascular stress due to inadequate haemoglo-
bin and low oxygen saturation, impaired resistance
to infection and poor tolerance to heavy blood loss
and surgical interventions at delivery.6
The number of pregnant women engaging in
regular exercise is growing,7 a tendency supported
by recent scientific evidence. In healthy gravida,
regular exercise does not affect the main gesta-
tional outcomes, eg, gestational age or Apgar
scores.712 Recent guidelines by the American
College of Obstetricians and Gynaecologists do in
fact promote regular exercise during pregnancy for
its overall health benefits, including a decreased
risk of hypertension and gestational diabetes.13
Whether regular exercise influences the risk of
maternal anaemia, however, remains to be deter-
mined.
Especially during the second half of gestation,
regular exercise may superimpose increasing iron
and oxygen transport demands. In sportswomen,
additional iron losses can result from exercise-
related mechanisms such as haemolysis or sweat-
ing.14 Exercise-induced acute elevations in cytokine
levels increase the liver production of hepcidin.15
Hepcidin upregulation has a negative impact on
the iron transport and absorption channels within
the body.15 The purpose of this study was to
determine whether regular exercise performed over
the second half of pregnancy is associated with an
increased risk of maternal anaemia. To this end, we
conducted a randomised controlled trial (RCT) in
which the intervention consisted of regular,
supervised exercises and the main outcome was
the incidence of maternal anaemia (as defined
above) and changes in haematological variables
over pregnancy.
A complete description of the design and
methods of this RCT, which was in accordance
with CONSORT guidelines16 was published
recently.12 The research protocol was reviewed
and approved by our ethics committee and
followed the ethical guidelines of the Declaration
of Helsinki. All women provided written informed
consent. We initially contacted 480 Spanish
(white) pregnant women from a primary care
medical centre (Madrid, Spain). A total of 160
healthy gravida (2535 years old) who were
sedentary (exercising (20 minutes on (3 days/
week) and had no medical contraindication for
exercise practice during gestation13 was randomly
assigned to either a training or control group
(n = 80 each).12
Women in the training group were enrolled in
three sessions per week of individually supervised
resistance exercise training performed over the
second and third trimester of pregnancy as detailed
elsewhere (in total 26 weeks, approximately 80
training sessions).12 In brief, each session consisted
of 3540 minutes of light intensity resistance
exercises, which were performed with barbells
((3 kg per exercise) or low-to-medium resistance
bands (Therabands). They included one set of 10 or
less to 12 repetitions of abdominal curls, biceps
curls, arm extensions, arm side lifts, shoulder
elevations, seated bench press, seated lateral row,
lateral leg elevations, leg circles, knee extensions,
knee (hamstring) curls and ankle flexion and
extensions. Heart rate was carefully and individu-
ally controlled ((80% of age-predicted maximum
heart rate value, 220 minus age in years) through a
heart rate monitor (Accurex Plus; Polar Electro OY,
Br J Sports Med 2009;43:954956. doi:10.1136/bjsm.2008.055764
 Short report

Table 1 Haematological variables by group

Relative Relative Relative
Baseline 2nd Trimester 3rd Trimester change change change
(A) (B) (C) BA p Value* CA p Value* CB p Value*

Haemoglobin (g/dl)
Control 12.7 (9.1) 11.7 (7.0) 11.9 (7.7) 210.5% ,0.001 28.0% ,0.001 2.54% 0.005
Intervention 13.1 (8.6) 11.9 (7.3) 12.2 (8.2) 212.1% ,0.001 28.9% ,0.001 3.24% 0.019
p Value{ 0.022 0.132 0.070 0.462 0.437 0.226
Haematocrit (%)
Control 38.1 (2.6) 34.3 (2.1) 34.8 (2.5) 23.8% ,0.001 23.2% ,0.001 0.51% 0.156
Intervention 39.0 (2.4) 35.3 (2.3) 36.1 (2.4) 23.7% ,0.001 22.9% ,0.001 0.85% 0.061
p Value{ 0.034 0.011 0.002 0.906 0.389 0.458
Mean corpuscular volume (fl)
Control 89.4 (4.2) 91.8 (3.7) 92.2 (4.3) 2.4% ,0.001 2.8% ,0.001 0.37% .0.1
Intervention 88.8 (3.8) 91.4 (4.2) 91.4 (4.3) 2.6% ,0.001 2.6% ,0.001 20.08% .0.1
p Value{ 0.381 0.589 0.263 0.738 0.734 0.505
Mean corpuscular haemoglobin (pg)
Control 30.0 (1.6) 31.4 (1.6) 31.7 (1.4) 1.4% ,0.001 1.7% ,0.001 0.31% .0.1
Intervention 30.7 (7.4) 30.9 (1.4) 31.0 (1.4) 0.2% .0.1 0.3% .0.1 0.17% .0.1
p Value{ 0.4 0.044 0.005 0.174 0.123 0.552
Mean corpuscular haemoglobin concentration
(g/dl)
Control 33.6 (0.9) 34.2 (0.9) 34.4 (1.1) 0.6% ,0.001 0.8% ,0.001 0.24% .0.1
Intervention 33.6 (0.8) 33.8 (0.7) 33.9 (0.9) 0.1% .0.1 0.3% .0.1 0.16% .0.1
p Value{ 0.620 0.007 0.007 0.006 0.234 0.568
Iron (mg/dl)
Control 89.6 (32.7) 68.5 (25.7) 71.9 (21.8) 221.1% ,0.001 217.7% ,0.001 3.4% .0.1
Intervention 104.3 (41.2) 76.5 (31.1) 83.4 (27.7) 227.8% ,0.001 220.9% ,0.001 6.9% 0.017
p Value{ 0.022 0.097 0.007 0.048 0.509 0.274
Values are mean (SD). *p Value for within-group comparisons; {p value for between-group comparisons.

Finland) during the training sessions. Women in the non- second (x2 = 0.350, p = 0.554) or third trimesters (x2 = 0.115,
exercise control group maintained their level of activity during p = 0.735; fig 1). The proportion of participants with maternal
the study period. anaemia in both groups ((10%) was within the range previously
We found no between-group differences12 at the start of the reported in women treated with a similar iron dosage.19
study in potential confounding variables such as habitual Haematological variables are shown in table 1. The pattern of
physical activity and occupational activities,17 smoking habits, haematological adaptations was similar in both groups, reflecting
alcohol intake and previous parity.12 There is no worldwide the typical pattern observed in supplemented gravida, ie, a steady
consensus regarding iron prophylaxis during gestation, although fall in haemoglobin concentrations over the second trimester due
the European Comissions report recommends that daily iron to haemodilution and a rise later in gestation due to haemocon-
supplements (with no dose specification) are given in the latter centration.5 Except mainly for a slightly higher haemoglobin and
half of pregnancy.18 In Spain, there are no official guidelines, but iron concentration in the intervention group at baseline, we
iron supplementation (5070 mg) is commonly administered by observed no major between-group differences (either in absolute
obstetricians from the first maternal visit. Accordingly, all the values or in over time relative changes).
participants were told to ingest a tablet containing 60 mg
ferrous iron daily (at bedtime) from the first maternal visit to
the end of gestation. All participants took folic acid (4 mg)
during the first trimester.
We determined haematological variables and iron (see table 1)
in the first maternal visit (baseline) and at the beginning of the
second and third trimesters with Advia 2120 (Bayer Health
Care, Tarrytown, New York, USA) and Hitachi 717 analysers
(Roche Diagnostics, Barcelona, Spain). We compared the
aforementioned variables with repeated-measures analysis of
variance. The Tukey test was used post hoc. The frequency of
maternal anaemia in the two groups was compared with the x2
test. We conducted all analyses using the intent-to-treat
principle. All statistical analyses were performed using SPSS,
with the significance level at less than 0.05.
A total of 72 (training) and 70 (control group) gravida were
included in the analysis. There were no protocol deviations from
study as planned.
The frequency of participants with maternal anaemia in the Figure 1 Frequency of prepartum maternal anaemia in the control and
two groups did not differ at baseline (x2 = 2.058, p = 0.151), intervention group at different time points.

Br J Sports Med 2009;43:954956. doi:10.1136/bjsm.2008.055764 955

 Short report
What is already known on this topic
In healthy gravida, regular exercise does not affect main
gestational outcomes, eg, gestational age or Apgar scores.
Recent guidelines by the American College of Obstetricians and
Gynaecologists do in fact promote regular exercise during
pregnancy for its overall health benefits, including a decreased
risk of hypertension and gestational diabetes.
What this study adds
Regular, light-intensity resistance exercise performed during the
second half of pregnancy does not increase the risk of maternal
anaemia nor does it alter haematological variables.
The novel topic we addressed here is of medical relevance
given the potential medical complications and the deterioration
of quality of life associated with maternal anaemia.6 Although
pregnancy is a physiological, naturally occurring process, it is
also unique in that most body control systems are transiently
modified in an attempt to maintain both maternal and fetal
homeostasis.11 Regular exercise could thus be a cause of concern
as it could potentially challenge the homeostasis of the
maternalfetal unit by inducing changes in visceral blood flow,
body temperature, shear stress or iron and erythrocyte turn-
over.7 2022 The present findings, however, together with other
recently published outcomes from the same RCT12 support the
notion that regular exercise is a safe option for pregnant,
healthy gravida. Whether exercise may impair iron metabolism
in non-supplemented women, as can be the case in developing
countries, remains to be elucidated. However, it is biologically
plausible that exercise of light intensity, as that performed in
the present study, does not increase the risk of prepartum
maternal anaemia.
Competing interests: None.
Ethics approval: The research protocol was reviewed and approved by the ethics
committee of the Hospital Severo Ochoa, Medrid, Spain and followed the ethical
guidelines of the Declaration of Helsinki.
Patient consent: Obtained.
956
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Br J Sports Med 2009;43:954956. doi:10.1136/bjsm.2008.055764