1. Exercise in Gestational diabetes Dr. Asieh Sadat Baniaghil

2. Definition Gestational diabetes is diabetes mellitus that develops in women for the first time during pregnancy (ACOG, 2015). Some women found to have gestational diabetes actually may have had mild diabetes before pregnancy that was not diagnosed (ACOG, 2013).

3. Short & long-term effects of gestational diabetes When glucose levels are too high, health problems can occur, which can negatively affect the pregnancy and the health of the baby (ACOG, 2015). mother neonate Macrosomia possible cesarean birth High blood pressure and preeclampsia diabetes in the future Jaundice Hypoglycemia diabetes in the future respiratory distress syndrome (NIH) (ACOG, 2013)

4. An estimated 6 to 7% of pregnancies are complicated by diabetes, and approximately 90% of these cases are women with gestational diabetes (ACOG, 2015).

5. وزارت بهداشت و درمان و آموزش پزشکی،

6. ADA, 2016

7. وزارت بهداشت و درمان

8. 5 Tips for Women with Gestational Diabetes (CDC, 2015) Eat Healthy Foods Exercise Regularly Monitor Blood Sugar Often Take Insulin, If Needed Get Tested for Diabetes after Pregnancy

9. Exercise Guideline (by Cochrane) Insufficient information available to recommend or advise against diabetic pregnant women enrolling on exercise programs. Four small trials involving 114 pregnant women evaluated this intervention. None included pregnant women with type 1 or type 2 diabetes.

10. Exercise Guideline (by Cochrane) The programs generally consisted in exercising three times a week for 20 to 45 minutes. We found no significant difference between exercise and the other regimen in all the outcomes evaluated. There is insufficient evidence to recommend, or advise against, diabetic pregnant women enrolling in exercise programs. Further trials, with larger sample size, are needed.

12. EXERCISE GUIDELINES (WJD/ World J Diabetes, 2015)

13. IMPORTANCE In regards to evidence specific to GDM treatment, exercise has been shown to be an effective tool in glucose control which may prevent, reduce or delay the need for insulin.

14. (WJD)

15. absolute contraindications of exercise (WJD) The absolute contraindications as recommended by ACOG are medical conditions which may be exacerbated by engaging in exercise. It is important that to educate patients that these conditions are not caused by exercise and until the condition is stabilized, they should not engage in exercise.

16. relative contraindications of exercise (WJD) Clinical knowledge and expertise must be applied when assessing each individual situation in regards to exercising with relative contraindications.

17. FITT in exercise (WJD) - frequency - intensity - time/duration - type

18. Type (WJD) Safety during pregnancy is paramount and studies have shown a variety of exercises ranging from low exerting forces such as Yoga to higher exerting forces such as aerobic classes and jogging can be safe for both mother and fetus. In addition to aerobic exercise, resistance strength training (i.e., weightlifting) and flexibility exercise are also beneficial and safe for gestational women and fetus.

19. Type (WJD) The ACOG reports hydrotherapy exercise to be considered safe during pregnancy with the potential to improve positive outcomes and pregnancy management.

20. CDC,2015 Get at least 30 minutes of moderate-intensity physical activity at least five days a week. This could be brisk walking, swimming, or actively playing with children

21. (NIH) The National Institute of Diabetes and Digestive and Kidney Diseases brisk walking, swimming, dancing, or low- impact aerobics (NIH).

22. Type (WJD) it is advised that some forms of exercise should not be practiced during pregnancy, including the following: recreational sports with increased risk of forceful contact or falling (i.e., basketball, rugby, horseback riding and gymnastics) exercising in a supine position after the first trimester (may obstruct inferior vena cava flow) motionless standing and scuba diving (risk of fetal decompression sickness)

23. type (NIH) Avoid activities in which you can get hit in the abdomen, such as basketball or soccer. Avoid activities that may cause you to fall, such as horseback riding or downhill skiing. Do not exercise on your back after the first trimester. This kind of physical activity can put too much pressure on an important vein and limit blood flow to your baby.

24. Type (WJD) Warm up’s of between 5-10 min at a low to moderate intensity using aerobic activities can increase body temperature and reduce post- exercise muscle soreness and stiffness. Warm ups are an important stage in exercise, as physiological systems gradually adjust to meet the bioenergetics and biomechanical demands of the working component of the exercise session.

25. Type (WJD) Performing a post exercise cool down is recommended if vigorous exercise is performed to reduce the risk of a vasovagal response which may lead to syncope. Stretching and flexibility training is distinct from the warm up or cool down phase and can be performed after either.

26. Frequency and duration (WJD) ACOG advises against exercising for more than 45 min continually because of a risk of increased fetal temperature. Although significant research has not yet been conducted on humans, animal studies have shown that an increase in core temperature by as little as 1.5 ℃ during embryogenesis (in early stages of pregnancy) may result in major congenital malformations.

27. Frequency and duration (WJD) there exercise should be conducted with no more than 2 consecutive days between aerobic exercise sessions. This is due to the transient improvement of insulin action and passive glucose uptake after exercise for up to 48 h.

28. Intensity (WJD) Therefore in accordance to other general pregnancy exercising guidelines, a recommended intensity of a moderate level is suggested.

29. For women who were previously sedentary before pregnancy, it is advised that they consult their medical practitioner who may asses their suitability to exercise.

30. Frequency and duration (WJD) For women who were previously sedentary it may be more convenient for them to start an exercise program in the second trimester, after which most of the initial discomforts of morning sickness, nausea and fatigue have settled down. as previously discussed, exercise in early pregnancy can reduce the risk of GDM, therefore sooner the woman can comfortably exercise the better.

31. Frequency and duration (WJD) Women with little physical activity history should begin with 15 min of continuous aerobic exercise three times a week with a graded increase to 30 min at least four times a week.

32. Precautions (WJD) if any of the following warning signs occur, it is advised that exercise should be terminated: -vaginal bleeding -Dizziness -Headache -chest pain -muscle weakness -preterm labor -decreased fetal movement -amniotic fluid leakage -calf pain OR Swelling AND dyspnea without exertion

33. Precautions (WJD) It is suggested that continual self monitoring of blood glucose levels with physician consultation should be encouraged. Furthermore, if at pre-exercise the blood glucose level is ≤ 4.0 mmol/L this should be considered low and exercise should not begin till administration of some long and short acting glucose in food or drink.

34. Precautions (WJD) In order to take advantage of the hyperglycemic effect of food, it may be advantageous to exercise an hour after a meal. It also may be important to consider taking insulin medication well before exercise to further reduce the risk of hypoglycemia.

35. دیابت بارداری، دکتر بنی عقیل و همکاران، 1392

37. دیابت بارداری، بنی عقیل و همکاران، 1392

38. دیابت بارداری، دکتر بنی عقیل و همکاران، 1392

39. -75 ﺩﺭﺻﺪ ﺿﺮﺑﺎﻥ ﻗﻠﺐ بیشینه / 55 تا 75 درصد HR MAX -70 تا 75 درصد يک تکرار بيشينه / 70% ﺣﺪاﻛﺜﺮ ﻇﺮﻓﻴﺖ ورزﺷﻲ / 70 درصد ﻳﻚ ﺗﻜﺮﺍﺭ ﺑﻴﺸﻴﻨﻪ IRM

40. انیستیتو تغذیه - وقتی با شدت متوسط ورزش میکنید، ورزش برای شما قابل انجام است اما احساس میکنید که این ورزش کمی برای شما سخت است. - وقتی این علائم را دارید بدانید که شدت ورزش شما متوسط است : - تندتر از معمول نفس میکشید. - کمی تعریق دارید. - مقداری کشش در عضلات احساس میکنید. - در ورزش با شدت متوسط شما میتوانید جملات کوتاه را بگویید اما نمیتوانید جملات بلند و دنباله دار را بگوئید. یا آواز بخوانید ! - وقتی که با آخرین توان ورزش میکنید ضربان قلب شما در حداکثر میزان خود قرار دارد. این میزان را بشمارید. اگر شما یک فرد بالغ و سالم هستید، شدت ورزش شما باید تا حدی باشد که ضربان قلبتان بین 60 تا 85 درصد حداکثر ضربان قلب شما باشد.