A 38-year-old woman, gravida 4 para 3, at 8 weeks gestation comes to the office to establish prenatal care. She has had no bleeding or cramping. The patient was diagnosed 6 months ago with type 2 diabetes mellitus and started a daily exercise routine with a stationary bicycle. Her diabetes has been well controlled, and her most recent hemoglobin A1c was 6.8%. Her first pregnancy was a cesarean delivery at term gestation for breech presentation. The patient then had 2 painless, second-trimester deliveries consistent with cervical insufficiency. Vital signs are normal. BMI is 29 kg/m². On pelvic examination, the cervix is closed and there is no vaginal bleeding. Transvaginal ultrasound shows an 8-week intrauterine gestation with positive heart tones. The patient asks if she can continue her current exercise program. Which of the following is this patient's contraindication to exercise in pregnancy?

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Explanation: 11ec25c8_da77_e4db_bc81_a57eb690157e_MD0003_00 Exercise during pregnancy is associated with a decreased risk of gestational diabetes mellitus, preeclampsia, and cesarean delivery. Therefore, low-risk patients who exercised regularly prior to pregnancy are encouraged to continue moderate-intensity exercise during pregnancy. Advanced maternal age and prior cesarean delivery are not contraindications to exercise (Choices A and E). However, exercise during pregnancy may exacerbate some obstetric conditions; therefore, it is contraindicated in certain at-risk patient populations. Exercise should be avoided in patients with the following features: At risk for preterm delivery due tocervical insufficiencypreterm labor during current pregnancypreterm premature rupture of membranes At risk for antepartum bleeding due toplacenta previapersistent second- or third-trimester bleeding With underlying conditions that could be exacerbated by exercise, such assevere anemiahypertensive disorders of pregnancy (eg, preeclampsia)restrictive lung diseasesevere heart disease Cervical insufficiency-a cervical structural weakness associated with painless, second-trimester pregnancy loss-is managed with cerclage placement. A cerclage is a suture placed around the cervix to reinforce it and help prevent preterm delivery. Patients with cervical insufficiency and a cerclage should avoid exercise during pregnancy to minimize the risk of preterm delivery. cerclage (Choices B and D) Type 2 diabetes mellitus and increased BMI are associated with an increased risk of preeclampsia, fetal macrosomia, and labor dystocia. Regular exercise, along with prevention of excessive gestational weight gain, can reduce these risks. (Choice F) Pregnant patients should avoid exercises that increase the risk of abdominal trauma and maternal injury (eg, contact sports, downhill skiing). Hot yoga is also not recommended due to the risks of hyperthermia (eg, fetal neural tube defects). Most other types of exercise, including stationary cycling, are safe in pregnancy. Educational objective: Moderate-intensity exercise is recommended for most pregnant women. However, exercise is contraindicated in patients who are at risk for preterm delivery (eg, cervical insufficiency), have antepartum bleeding, or have an underlying medical condition that could be exacerbated by exercise. References: ACOG Committee opinion no. 650: physical activity and exercise during pregnancy and the postpartum period. (http://www.ncbi.nlm.nih.gov/pubmed/26595585) Exercise in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/28886825) Hot yoga and pregnancy: fitness and hyperthermia. (http://www.ncbi.nlm.nih.gov/pubmed/24452558)

A 38-Year-Old Woman, Gravida 4 Para 3, at 8 Weeks