British Journal of Sports Medicine
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BACKGROUND Guidelines on physical activity or exercise and pregnancy encourage pregnant women to continue or adopt an active lifestyle during and following pregnancy.1-3 Two systematic reviews of pregnancy-related guidelines on physical activity found similarities between recommendations from different countries, but noted that the guidelines differed in focus.4 5 The guidelines provided variable guidance on prenatal exercise, or on how pregnant women might approach continuing or adopting sport activities.6 However, most guidelines did not include important topics such as prevalence and known risk factors for common pregnancy-related diseases and complaints, and the role of exercise in preventing and treating them. Importantly, the focus of most previous guidelines has been on healthy pregnant women in the general population, in whom there is almost always a decline in physical activity during pregnancy.7 8 Indeed, a high proportion of pregnant women follow neither physical activity nor exercise guidelines, 9 putting them at increased risk of obesity, gestational diabetes mellitus (GDM), and other pregnancy-related diseases and complaints.1 On the other hand, there are enthusiastic exercisers and elite athletes who often meet and exceed general exercise recommendations for pregnant women, but there are no exercise guidelines specifically for these women. Important questions for such women are unanswered in current guidelines: Which activities, exercises and sports can they perform, for how long and at what intensity, without risking their own health and the health of the fetus? How soon can they return to highintensity training and competition after childbirth? The IOC and most National Sports Federations encourage women to participate in all Olympic sport disciplines. The IOC promotes high-level performance, and it is also strongly committed to promoting lifelong health among athletes10-not just during their competitive sporting careers. With an increasing number of elite female athletes competing well into their thirties, many may wish to become pregnant, and some also want to continue to compete after childbirth. With this background, the IOC assembled an international expert committee to review the literature on physical activity and exercise (1) during pregnancy and (2) after childbirth, using rigorous systematic review and search criteria.11 For efficiency, where sex is not specified, the reader should assume that this manuscript about pregnancy and childbirth refers to females (ie, 'the elite athlete who wishes to train at altitude' is used in preference to 'the elite female athlete...'). AIMS The September 2015 IOC meeting of 16 experts in Lausanne had three aims. They were to: 1. Summarise common conditions, illnesses and complaints that may interfere with strenuous exercise and competition, during pregnancy and after childbirth; 2. Provide recommendations for exercise training during pregnancy and after childbirth, for highlevel regular exercisers and elite athletes; and 3. Identify major gaps in the literature that limit the confidence with which recommendations can be made. METHODS For each section of the document, a search strategy was performed using search terms such as 'pregnancy' OR 'pregnant' OR 'postpartum' AND 'exercise' OR 'physical activity' OR'leisure activity' OR'leisure' OR 'recreation' OR 'recreational activity' or 'physical fitness' OR 'occupational activity' AND terms related to the condition under study (eg, 'gestational diabetes'). Available databases were searched, with an emphasis on PubMed, EMBASE, Cochrane, PEDro, Web of Science and SPORTDiscus. In addition, existing guidelines with reference lists were scanned. The review of each topic followed the general order: prevalence of the condition in the general pregnant or postpartum population, prevalence in high-level exercisers or elite athletes, risk factors in the general population and in relation to exercise and sport, and effect of preventive and treatment interventions. Level of evidence and grade of recommendations are according to the Cochrane handbook (table 1) for prevention and treatment interventions only. Each member of the working group was assigned to be the lead author of one or more topics and 1-3 others were assigned to review each topic. A first full consensus draft was reviewed before and during the 3-day IOC meeting (27-29 September 2015), and a new version of each topic was submitted to the meeting chairs (KB and KMK) shortly after the meeting. Each topic leader made amendments before sending a new version for comments to the working group.