Como citar:
PERFEITO, Rodrigo Silva; ALLEVATO, Leonardo; SILVEIRA, Deivison da Silva. Effects of the practice of Pilates in pregnancy: a literature review. SFM v.7, n.2, 2019.
Effects of the practice of pilates in pregnancy: a literature review
Rodrigo Silva Perfeito; Leonardo Allevato; Deivison da Silva Silveira
Instituto de Pilates, Fisioterapia e Educação: Fisart
Abstract: Pregnancy is one of the most anticipated moments in women's lives.
However, biological and physiological changes cause a lot of discomfort, and
the possibility of the occurrence of various diseases. Exercise may be a good
alternative to bring relief and welfare to these women and Pilates, one of the
fastest-growing modalities of exercise in the world which is currently used not
only in fitness, but also in rehabilitation, injury prevention and health
promotion, is a modality that has been widely recommended as an adjunct in the
treatment of various diseases. Nevertheless, many people step into an exercise
program aiming to have a healthier life without thinking in their ongoing
participation. Thus, pregnant women adhering to an exercise program require
some care and a general health assessment including medical and obstetric risks
have to be considered. To this end, the Pilates instructor should know the
audience and the specific needs of the group in question to check if there are
any contraindications for the exercise and to determine the best frequency,
intensity and amount of exercise to be prescribed. Therefore, this paper aims
to review the effects of the practice of Pilates in pregnant womenduring and
after labor listing its benefits and peculiarities of its prescription.
Keywords: bleeding, exercise, hypertension, Pilates, pre-eclampsia, pregnancy
Keywords: bleeding, exercise, hypertension, Pilates, pre-eclampsia, pregnancy
Resumo: A gravidez é um dos momentos mais esperados na vida das mulheres. No entanto, alterações biológicas e fisiológicas podem causar muito desconforto e a possibilidade de ocorrência de várias doenças. O exercício pode ser uma boa alternativa para trazer alívio e bem-estar para essas mulheres, e o Pilates, uma das modalidades de exercício que mais cresce no mundo, atualmente é utilizada não somente para condicionamento físico, mas também para reabilitação, prevenção de lesões e promoção da saúde, além de amplamente recomendada como adjuvante no tratamento de várias doenças. No entanto, muitas pessoas entram em um programa de exercícios com o objetivo de ter uma vida mais saudável sem pensar em sua participação contínua. Assim, mulheres grávidas que aderem a um programa de exercícios requerem alguns cuidados e uma avaliação geral da saúde, incluindo riscos médicos e obstétricos. Para tanto, o instrutor de Pilates deve conhecer o público e as necessidades específicas do grupo em questão para verificar se há alguma contra-indicação para o exercício e determinar a melhor frequência, intensidade e quantidade de exercício a ser prescrito. Portanto, este trabalho tem como objetivo revisar os efeitos da prática do Pilates em gestantes durante e após o parto, relacionando seus benefícios e peculiaridades de sua prescrição.
Palavras-chave: sangramento,
exercício, hipertensão, Pilates, pré-eclâmpsia, gravidez
INTRODUCTION
One of the fastest-growing modalities of exercise in the world is
Pilates method. If dancers and athletes were originally the prevailing public,
today Pilates has been widely used not only in fitness, but also in
rehabilitation, injury prevention and health promotion, attracting many other social
groups1.
This new way of understanding and practicing the method makes possible
new approaches transcending the classical perception and allowing to understand
Pilates as a polysemic tool before achieving the various goals of the
practitioner and not only as a means to justify itself. Therefore, each day more
pregnant women seek Pilates to get more relief by minimizingthe biological
offsets which occur in this period.
We all know that pregnancy is one of the most anticipated moments in
women's lives. However, biological and physiological changes cause a lot of
discomfort, and the possibility of the occurrence of various diseases 2.
Among these various changes, one of them shows up in locomotor system causing
lumbar hyperlordosis and changes in center of gravity due to the anterior rotation
of the pelvis 2,3,4. In addition to this, about 25% of all women experience
some symptoms of musculoskeletal discomfort that may be, even temporarily,
disabling. One of the most common symptoms is low back pain, which can reach
90% of pregnant women5.
Within psychological and social aspects, physical exercise can help fight
prenatal depression, which despite being well studied, can affect both the
mother and the fetus, and reach about 10% of pregnant women. This condition
also leads to poor adherence to prenatal visits, which has been strongly
associated with neonatal mortality6, 7.
Weight gain is also a worrying factor in pregnant women, since it is
quite common in this period and reaches about 46% of them. Pregnant women who
exercise tend to gain less weight than pregnant women who do not exercise,
thereby reducing risks both to their health and fetal health. Pregnant women
who are overweight tend to do more cesareans, develop preeclampsia and obesity
postpartum8.
Pilates can be considered an important tool in this period, because the
exercise has been recommended as an adjunct in the treatment of various
diseases4. Nevertheless, many people step into an exercise program aiming
to have a healthier life without thinking in their ongoing participation.
Thus, pregnant women adhering to an exercise program require some care
and a general health assessment including medical and obstetric risks have to
be considered. To this end, the Pilates instructor should know the audience and
the specific needs of the group in question.
In addition, some partial contraindications such as severe anemia,
hypertension or uncontrolled diabetes, morbid obesity, among others, or yet
total contraindications such as pre-eclampsia, bleeding in the first trimester
of pregnancy, risk of premature birth, among others, should be observed9.
Physical exercises may be beneficial during pregnancy and postpartum,
and although pregnancy is a time for changing lifestyle, some care that should be
taken within the first months of pregnancy may discourage the practice of a
number of activities. This is another point that should be planned and
reflected by Pilates instructor.
In general, there are many ways that physical exercise can benefit pregnant
women and for this reason we must be prepared to meet the public. Studies also
show that pregnant women who exercise until the last day of pregnancy, besides
having fewer complications in labor, give birth to healthier children. These
results endure over the years, because these children tend to have better
school performance and develop fewer diseases5.
Thus, the aim of this review is to suggest Pilates as a form of exercise
that will stimulate positive biological adaptations in women during pregnancy,
minimizing their discomfort and providing a better perspective in life.
PILATES METHOD
Pilates method was created by Joseph Hubertus Pilates (1883-1967) born
in Germany in 1883. During his childhood he suffered with health problems
resulting from rickets, asthma and rheumatic fever1.
Trying to overcome his biological weaknesses he began his studies on the
anatomy of the human body, especially in relation to posture and respiratory
diseases. His aim was self-treatment. That is, he was looking for a stronger, more
efficient, and healthier body. It all started when the family doctor gave him
an ancient and discarded book of Anatomy. Joseph memorized all parts of the
body and moved them to root the theoretical and the practical knowledge1,4,12.
Despite his complicated childhood, Joseph became a relatively healthy teenager.
In 1912, after the outbreak of World War II he was cloistered on the
battlefield in Lancaster in England. At this time, the world had suffered a
great flu epidemic that killed thousands of people, aggravated by unsanitary
conditions. At this time, Joseph was already testing the creation of Pilates
encouraging other prisoners to exercise13,14. After some time, he
was transferred to another battlefield in which he was intended for a nurse. At
that point, he adapted strings from car carburetors and hospital beds to set overload
on exercises for bedridden soldiers, and thus new evidence of the method we now
call Pilates arose by that time 1,15.
After the war, he returned to Germany and unhappy with some political
issues, he decided to abandon his homeland. Thus, in 1926 he makes his second
and final trip to New York, the first of which had been on vacation. This time,
he met his last wife who was called Clara 4.
After reaching the American city, Joseph and Clara were invited to manage
a boxing gym where Joseph created several devices, a methodology and self principles
for the Pilates method. These principles are known as Contrology,
concentration, proper breathing, recognition of the body or proprioception,
precision, fluidity and power house10,16.
Even though influenced by a number of other activities such as ballet,
meditation techniques, weight training and yoga, Pilates method brought an
essence coming specifically from its creator. The original name of the method was
Contrology, it turned to be called Pilates only after Joseph’s death in 1967 10,11,17.
Finally, the method can be understood as a kind of systematized training,
which enables the maintenance or increase in flexibility, posture,
cardiorespiratory fitness and valences of strength training such as hypertrophy,
power, endurance and muscle strength. It also uses specific principles and
instruments with the objective of stimulating social, biological and
psychological adjustments in favor of treatment, physical conditioning, injury/disease
prevention and health promotion in general 1,4.
MAIN BIOLOGICAL CHANGES DURING PREGNANCY
During pregnancy, a woman's body undergoes many biological changes.
Besides the uterine and fetal growth, important changes in locomotor,
cardiorespiratory system, metabolism and body composition and aesthetics occur18.
In addition to this, pregnancy is characterized by several physiological,
biochemical and endocrine adjustments targeted to promote a favorable
environment for the development of the fetus19.
Starting the discussion by body composition, it is known that the
pregnant woman undergoes some changes in this field, the main one concerning weight
gain by increasing fat and lean mass. The gain of fat mass occurs by increasing
the intake of some nutrients4, while the increase in lean body mass
is due to the large amount of energy demand required for the development of the
fetus, altering metabolism and homeostatic mechanisms20.
Considerable changes in secretion and insulin sensitivity also occur, as
the resistance to it progressively increases and with greater intensity around
the 24th week of pregnancy, allowing a greater supply of glucose to the fetus
coupled with the increase in blood glucose21. Due to these factors,
it is necessary and suggestive an adequate follow-up of a professional to
prevent excessive gestational weight gain, which may cause a framework for
gestational obesity, which in turn could impact in numerous acute and chronic
complications. Studies also report that the gain of fat mass may last up to 3
years after pregnancy22.
Regarding the distribution of weight gain during pregnancy, during the
first and second quarters, fat gain, increased plasma and abdominal volume are
predominant factors for weight gain, while from the third quarter on weight gain
is related to fetal growth and increased amniotic fluid23.
Thinking of the locomotor system, the main changes concern the increased
abdominal girth due to the growth of the uterus, causing the protruding
abdomen, diastasis of the rectus abdominis, modified center of gravity and
increased lumbar lordosis. In addition, there are changes in the alignment of
the pelvis due to the relaxation in cartilage that form the pubic symphysis and
ligament laxity due to the secretion of hormones such as relaxin, widening the
pelvic cavity for future passage of the fetus. There is also a weakening of the
pelvic floor muscles due to increased intra-abdominal size and weight gain in
this region4,24,25.
Due to uterine expansion and adoption of compensatory postures, the
spine undergoes exacerbated efforts, emphasizing its physiological curvatures
and causing pains mainly in the cervical and lumbar regions 26, 27.
The stretching of the abdominal muscles as a result of increased
intra-abdominal volume and contraction of the paraspinal musculature are
important characteristics that explain the loss of abdominal strength, neck
pain and back pain28.
In addition to what has already been discussed, we can report that the
spine is the body part that suffers most changes during pregnancy, accentuating
its curves and causing overloads due to weight gain, breast, uterine and
abdominal growth, pelvic anteversion, hip lateral rotation, fluid retention and
ligament laxity due to an increased production of the hormone relaxin29.
Due to greater mechanical stress and overload, there is an increased fatigue of
the muscles of the spine, and scientific literature points at it as an
indicator for the increased prevalence of lumbar pain30.
The practice of specific exercises for pregnant women significantly contributes
to the decrease in the number of low back pain when compared to pregnant women
who do not perform physical exercise31. Activities such as Pilates
method provide significant improvements with respect to posture, reduction in
back pain, improved breathing, and feeling physically and mentally well-being32,
as we shall see in greater depth in future reflections.
Due to increased metabolic changes during pregnancy, there is a larger
work of certain glands and hence the dosage of some endogenous hormones.
Maximizing of the production of estrogen and progesterone would be an example.
These hormones are responsible for changing the size of the breasts, inducing
the production of breast milk, increasing uterine walls, modifying female
sexual characteristics, among others 4.
In contrast, an increased release of the progesterone hormone negatively
affects muscle tone, especially reducing contractility and control of the
sphincter muscle, which together with increased uterine pressure on the bladder
reduces the ability of the restraint of urine, corroborating the increase of
urinary incontinence episodes25.
There are also unstable mood swings that can be stimulated by changes in
the nervous and hormonal systems18. In sum, physiological changes
can occur in the skin, as the appearance of pimples, stretch marks,
pigmentation, besides the abnormal growth of hair and nails33.
Thinking of the cardiorespiratory system, the increased secretion of
progesterone stimulates the respiratory center to increase breathing amplitude,
causing a 50% increase in lung ventilation34. Studies show that
about 75% of pregnant women experience dyspnea as a result of hyperventilation.
These changes result in a decrease in functional residual capacity, a factor
that can increase hypoxemia caused by acute asthma, manifestedby the premature
airway closure, causing pregnancy complications 34,35.
Changes and sleep disturbances can also occur with some frequency36.
There are several studies that link snoring during sleep and excessive
sleepiness during the day with pregnancy. These symptoms tend to increase in
parallel with the advancement of pregnancy37. Hemodynamic changes
such as increased cardiac output and increased retention of sodium and water
are also observed during this period38,39.
In addition to these changes, which are most common in the period in
question, other ones may occur stimulated by lifestyle and work. These and all
other changes detected during an assessment prior to the beginning of Pilates sessions
should be taken into account when prescribing exercises.
PRESCRIPTION OF EXERCISES, SUGGESTIONS AND CONTRAINDICATIONS
We have vast literature that emphasizes the practice of Pilates and
other exercise modalities as something that could help minimizing biological
complications that occur during pregnancy, besides the improvement of the
indices related to miscarriage and preterm delivery41,42. In spite
of having sufficient data to defend the point of view that the practice of
systematic exercise produces beneficial effects in humans, we need to
understand,in a qualitatively and quantitatively perspective, to what variables
of the exercises these numerous studiesare referring to.
We affirm this, as one of the greatest difficulties that the Pilates
instructor faces when you have a pregnant student is precisely the proper
exercise prescription as its intensity, duration and weekly frequency.
For so long apregnant woman was understood as a weak individual and
lacking only physical activities that would put her in movement without any
incentive to increase biological adaptations. As exemplified in some studies, the
practice of physical activity, as it is for Pilates, could not exceed a heart
rate (HR) of 140 bpm and a 15-minute duration43,44.
However, more recent studies demonstrate that although it is still a
controversial subject and respecting the specific needs of pregnancy, the
pregnant woman can also practice long-term exercises on a daily basiswith
intensities ranging from moderate to high4,44.
The average intensity of exercise suggested in most studies is quite below
the capacity of the pregnant woman. This score ranges from 60 to 70% of their
aerobic capacity or 120-140 bpm for other sports. Other means would be 55% of
HRmax or 50% of VO2max [19, 45]. Besides HR, oxygen
consumption and aerobic capacity, there is still the possibility of using the subjectivity
of the woman’s own perception or scales like Borg’s Perceived Exertion, since
fatigue in certain regions, such as the legs, will affect the performance in several
exercises4. In summary, the most consistent recommendation in the
literature is the realization of exercises of mild to moderate intensity.
However, we must bear in mind that this measure is only to ensure the safety of
pregnant women, as for a woman athlete, for example, training could be performed
at a higher intensity without causing any inconvenience to the mother or the fetus.
As regards the duration of the exercise it is possible to find in
literature suggestionsof an average of 30 minutes daily and 150 minutes weekly sessions9,44,46.
Once again it has to be taken into consideration that these are parameters seeking
the practitioner security, but longer durations than those highlighted in
literature are quite feasible and the Pilates instructor himself is the most important
agent to establish which will be the best duration of the exercise after a well
done assessment.
As for the weekly frequency, which is also a consensus in literature, it
is suggestedto conduct activities 3 to 4 days per week in non-athletic women
and with greater frequency and intensity in female athletes4,42,44,47.
Again, these suggestions should be evaluated and, respecting the principle of
biological individuality, modified according to each practitioner.
The most recommended exercises, beyond Pilates itself, are swimming,
hiking, yoga, among others that can be adapted to not cause an intense and
disproportionate effort to the physical condition of the woman41.
Exercises less suitable are those which can cause some impact or
physical contact in the abdominal region. Some examples are football, horse
riding, diving, basketball and handball 4,44,48.
Besides, there are some relative and absolute contraindications as for the
participation of pregnant women in an exercise program. Relative contraindications
state that pregnant women may take part in an exercise program as long as the
Pilates instructor is aware of some conditions he should take into
consideration such as anemia, obesity, heart and thyroid disorders,
hypertension, diabetes, and other similar ones. When the practitioner has any
absolute contraindication, exercise should be avoided until the cause of the
problem is normalized. Some of them are severe or uncontrolled heart and lung
diseases, such as heart failure and recent pulmonary embolism, uterine
bleeding, acute infectious diseases, or similar ones19,49.
Incorrectly prescribed exercises in Pilates can cause complications such
as bleeding, dizziness, prolonged dyspnea, pains and abnormal movement of the
fetus. In these or similar situations, the practice of exercise should cease
and the pregnant woman be referred to a physician.
The moderate and high intensity exercise should be avoided in places of
very high temperature, since the thermoregulation of the pregnant woman is not so
efficient and hydration is an important feature to be taken into consideration42.
At the most, after conducting a pre-exercise assessment, the Pilates instructor
will be prepared to prescribe exercises with intensity, duration and frequency consistent
with the needs of pregnant women.
KEY BENEFITS OF PILATES PRACTICE
Since its creation, the Pilates method has been used both in rehabilitation
and for fitness, aesthetics and health promotion50. These exercises may
be challenging even for trained individuals and athletes51. Thus, it’s
a method able to meet the most varied profiles, providing many benefits on the
varied needs of the practitioner, including pregnant women4.
Sedentary pregnant women, the most common public in Pilates,when compared
with athletes, show a great fitness deficit, increasing the risk of certain
diseases during and after pregnancy. This finding confirms the importance of
exercise through the gestational period, and Pilates is one of the most
suitable methods indicated by health professionals52.
Many are the benefits of exercising during pregnancy. One of the biggest
complaints during pregnancy is constant nausea and vomiting. About 80% of women
feel both symptoms from the first trimester4,53. A recent study
showed that exercise, such as Pilates, significantly decreases nausea in the
first quarter and vomiting in the second trimester of pregnancy53.
It may seem a simple benefit, but it is a strong indicator of improved quality
of life during this period.
Another benefit of the practice of Pilates is related to the treatment
of back pain, which is one of the most debilitating symptoms of pregnancy.
Studies show that 61% to 88% of women experience back pain during pregnancy,
ranging from mild discomfort to severe pain54,55. Pilates has been
often used in the prevention and treatment of this type of pain56,57,
as one of the foundations of the method is the core (or Power House) stabilization
and strengthening. Exercises that promote trunk stabilization associated with
the stretching of the hamstrings have been portrayed with significant positive
results in relieving this symptom58.
Another condition that affects up to 14% of the female population during
pregnancy is Gestational Diabetes Mellitus (GDM)59. Factors such as
obesity and family history potentiate the risk of developing GDM, affecting not
only the health of women, but also the fetus. Metabolic complications may also
cause possible birth complications, macrosomia, pre-eclampsia and bleeding, and
the risk of developing type 2 diabetes after pregnancy 60. In
addition to these endogenous factors, exogenous ones, such as sedentary
lifestyles, further increase the risk of developing this disease 61.
This occurs because during pregnancy women tend to decrease or stop the
practice of physical exercises62. About 23% of women who exercised
before pregnancy, stop exercising when they enter this new phase of life 63,64.
The daily practice of Pilates or other exercise modality has been
advocated because it assists in improving insulin resistance and, consequently,
minimizing the GMD. As already said, Pilates is an interesting tool because it can
be adapted to many different purposes and profiles of practitioners 65.
For different types of purposes, including for the GMD, the American
College of Obstetricians and Gynecologists recommends a minimum of 30 minutes
of moderate exercise being performed daily 64.
Another continuing problem that affects the health and quality of life
of women is urinary incontinence, as it is considered a risk factor especially
during pregnancy and childbirth66. As saw earlier, it is related to
pelvic disorders, overactive bladder syndrome and pelvic organs prolapse. A prevalence
of 24% of the female population is affected by this disorder 4.
Studies show a strong association between pelvic disorders and risk factor in
vaginal delivery 67,68.
Pilates would help to minimize these discomforts as its methodology is based
on stabilization of the center of force (Core) or Power House, as it is called
in Pilates, which consists of the contraction of the transversus abdominis
muscles, multifidus and pelvic floor (perineum) responsible for static and
dynamic body stabilization. During execution of the exercises, the method
requires the central balancing of the body by activating the Power House,
associated with the control of breathing 69.
In addition, exercises that specifically train the pelvic floor muscles
are used as treatment for urinary incontinence70. Thus, Pilates is
shown to be a favorable method for the prevention and treatment of this
disorder if we take into consideration that its principles of controlling and
stabilizing the central part of the body also strengthen the pelvic floor
musculature.
Another benefit would be the reduction of symptomatic dyspnea throughout
the pregnancy due to the specific diaphragmatic breathing training in Pilates
and stimulation of concentration during the exercises and tasks of daily life,
favoring the perception of well-being before and during labor4.
In summary, there are various benefits of practicing Pilates for
promoting women's health during e after pregnancy.
CONCLUSION
Based on the literature reviewed, Pilates can be suggested as a
favorable modality of exercise to be practiced during pregnancy, because of its
benefits for the prevention and treatment of various diseases that can affect
women in this period.
Surveys used in this article point to many benefits achieved by regular
exercise during pregnancy, except in specific cases where health professionals
evaluate and consider their practice unfeasible.
In other words, when Pilates is prescribed appropriately, it has been
proving to be a powerful tool for health promotion, prevention and treatment of
diseases that may affect women during pregnancy.
In last words, we believe it is important to warn that the Pilates
method is just a tool for professional intervention. When properly engineered, it
might be critical to the well being of the practitioner, however, if it is prescribed
in a bad way, it might be a source of injuries and aggravation in pre-installed
pathologies. Thus, it is not the Pilates method that assists in the promotion
of women's health in pregnancy, but the instructor properly using the method.
We also emphasize the need for more papers that specifically address the
Pilates method on the above subject, once the specific ones are very scarce.
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44. American College of Nurse-Midwives. Exercise in Pregnancy. Journal of Midwifery & Women’s Health. 2014, doi: 10.1111/jmwh.12218.
45. American College of Obstetricians and Gynecologists. Exercise during pregnancy and the postnatal period. Washington. DC: American CollegeofObstetriciansandGynecologists, 1985.
46. Weinert LS, Silveiro SP, Oppermann ML, Salazar CC, Simionato BM, SiebeneichlerA, ET al. Diabetes gestacional: um algoritmo de tratamento multidisciplinar. ArqBrasEndocrinolMetabol. 2011;55(7):435-45.
47. Seneviratne SN, Parry GK, McCowan LM, Ekeroma A, Jiang Y, Gusso S, Peres G, Rodrigues RO, Craigie S, Cutfield WS, Hofman PL. Antenatal exercise in overweight and obese women and its effects on offspring and maternal health: design and rationale of the IMPROVE (Improving Maternal and Progeny Obesity Via Exercise) randomised controlled trial.BMC Pregnancy Childbirth. 2014;14:148.
48. Davies GA, Wolfe LA, Mottola MF, et al: Exercise in pregnancy and the postpartum period. J ObstetGynaecolCan 2003; 25, 516-29.
49. Bennell K. The female athlete. In: Brukner P, Khan K: Clinical sports medicine, 2. ed, Austrália, McGraw-Hill, 2001. p. 674-99.
50. Anderson B, Spector A. Introduction to Pilates-based rehabilitation. OrthopPhysTherClin N Am. 2000;9:3.
51. Siler B. The Pilates Body. New York: Broadway Books, 2000.
52. Haas JS, Jackson RA, Fuentes-Afflick E, et al: Changes in the health status of women during and after pregnancy. Gen Intern Med2005, 20:45-51.
53. Lacasse A, Rey E, Ferreira E, Morin C, Berard A. Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity. BMC pregnancy and childbirth. 2009;9:26.
54. Olsson C, Nilsson-Wikmar L. Health-related quality of life and physical ability among pregnant women with and without back pain in late pregnancy. ActaObstetGynecol Scand. 2004;83(4):351–357.
55. Kristiansson P. Interventional spine an algorithmic approach. In: Slipman CW, Simeone FA, Mayer TG, editor. Epidemiology of backpain in pregnancy. Elsevier: Philadelphia: Saunders; 2008. pp. 1307–1310.
56. La Touche R, Escalante K, Linares MT. Treating non-specific chronic low back pain through the Pilates Method. J BodywMovTher. 2008;12:364–370.
57. Ozer Kaya D, Duzgun I, Baltaci G, Karacan S, Colakoglu F. Effects of calisthenics and pilates exercises on coordination and proprioception in adult women: a randomized controlled trial. J Sport Rehabil. 2012;21:235–243.
58. Kilber W, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189–198.
59. Cheung NW. The management of gestational diabetes. Vasc Health RiskManag. 2009;5:153–164.
60. Dempsey JC, Butler CL, Sorensen TK, Lee IM, Thompson ML, Miller RS, Frederick IO, Williams MA. A case–control study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Res ClinPract. 2004;66:203-215.
61. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1423–1434.
62. Fell DB, Joseph KS, Armson BA, Dodds L. The Impact of Pregnancy on Physical Activity Level, Matern Child Health J. 2008, 13, 597-06.
63. Ning Y, Williams MA, Dempsey JC, Sorensen TK, Frederick IO, Luthy DA. Correlates of recreational physical activity in early pregnancy. J Matern Fetal Neonatal Med. 2003; 13 :385–393.
64. American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2013 Aug. 11 p. (ACOG practice bulletin; no. 137).
65. Clapp JF, III, Rokey R, Treadway JL, Carpenter MW, Artal RM, Warrnes C. Exercise in pregnancy. Med Sci Sports Exerc. 1992; 24 :S294–S300.
66. Mørkved S, Bø K, Schei B, et al. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single-blind randomized controlled trial. ObstetGynecol. 2003; 101:313–9.
67. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br.J.Obstet.Gynaecol. , 2000; 107:1460-1470.
68. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic floor disorders 5–10 years after vaginal or cesarean childbirth. Obstet.Gynecol. de 2011; 118 . :777-784.
69. Silva ACLG, Mannrich G. Pilates na reabilitação: uma revisão sistemática. Fisioter Mov. 2009;22(3):449-55.
70. Kegel AH. The nonsurgical treatment of genital relaxation; use of the perineometer as an aid restoring anatomic and functional structure. Annalsof Western Medicine andSurgery. 1948;2:213–216.
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44. American College of Nurse-Midwives. Exercise in Pregnancy. Journal of Midwifery & Women’s Health. 2014, doi: 10.1111/jmwh.12218.
45. American College of Obstetricians and Gynecologists. Exercise during pregnancy and the postnatal period. Washington. DC: American CollegeofObstetriciansandGynecologists, 1985.
46. Weinert LS, Silveiro SP, Oppermann ML, Salazar CC, Simionato BM, SiebeneichlerA, ET al. Diabetes gestacional: um algoritmo de tratamento multidisciplinar. ArqBrasEndocrinolMetabol. 2011;55(7):435-45.
47. Seneviratne SN, Parry GK, McCowan LM, Ekeroma A, Jiang Y, Gusso S, Peres G, Rodrigues RO, Craigie S, Cutfield WS, Hofman PL. Antenatal exercise in overweight and obese women and its effects on offspring and maternal health: design and rationale of the IMPROVE (Improving Maternal and Progeny Obesity Via Exercise) randomised controlled trial.BMC Pregnancy Childbirth. 2014;14:148.
48. Davies GA, Wolfe LA, Mottola MF, et al: Exercise in pregnancy and the postpartum period. J ObstetGynaecolCan 2003; 25, 516-29.
49. Bennell K. The female athlete. In: Brukner P, Khan K: Clinical sports medicine, 2. ed, Austrália, McGraw-Hill, 2001. p. 674-99.
50. Anderson B, Spector A. Introduction to Pilates-based rehabilitation. OrthopPhysTherClin N Am. 2000;9:3.
51. Siler B. The Pilates Body. New York: Broadway Books, 2000.
52. Haas JS, Jackson RA, Fuentes-Afflick E, et al: Changes in the health status of women during and after pregnancy. Gen Intern Med2005, 20:45-51.
53. Lacasse A, Rey E, Ferreira E, Morin C, Berard A. Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity. BMC pregnancy and childbirth. 2009;9:26.
54. Olsson C, Nilsson-Wikmar L. Health-related quality of life and physical ability among pregnant women with and without back pain in late pregnancy. ActaObstetGynecol Scand. 2004;83(4):351–357.
55. Kristiansson P. Interventional spine an algorithmic approach. In: Slipman CW, Simeone FA, Mayer TG, editor. Epidemiology of backpain in pregnancy. Elsevier: Philadelphia: Saunders; 2008. pp. 1307–1310.
56. La Touche R, Escalante K, Linares MT. Treating non-specific chronic low back pain through the Pilates Method. J BodywMovTher. 2008;12:364–370.
57. Ozer Kaya D, Duzgun I, Baltaci G, Karacan S, Colakoglu F. Effects of calisthenics and pilates exercises on coordination and proprioception in adult women: a randomized controlled trial. J Sport Rehabil. 2012;21:235–243.
58. Kilber W, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189–198.
59. Cheung NW. The management of gestational diabetes. Vasc Health RiskManag. 2009;5:153–164.
60. Dempsey JC, Butler CL, Sorensen TK, Lee IM, Thompson ML, Miller RS, Frederick IO, Williams MA. A case–control study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes Res ClinPract. 2004;66:203-215.
61. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1423–1434.
62. Fell DB, Joseph KS, Armson BA, Dodds L. The Impact of Pregnancy on Physical Activity Level, Matern Child Health J. 2008, 13, 597-06.
63. Ning Y, Williams MA, Dempsey JC, Sorensen TK, Frederick IO, Luthy DA. Correlates of recreational physical activity in early pregnancy. J Matern Fetal Neonatal Med. 2003; 13 :385–393.
64. American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2013 Aug. 11 p. (ACOG practice bulletin; no. 137).
65. Clapp JF, III, Rokey R, Treadway JL, Carpenter MW, Artal RM, Warrnes C. Exercise in pregnancy. Med Sci Sports Exerc. 1992; 24 :S294–S300.
66. Mørkved S, Bø K, Schei B, et al. Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single-blind randomized controlled trial. ObstetGynecol. 2003; 101:313–9.
67. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br.J.Obstet.Gynaecol. , 2000; 107:1460-1470.
68. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic floor disorders 5–10 years after vaginal or cesarean childbirth. Obstet.Gynecol. de 2011; 118 . :777-784.
69. Silva ACLG, Mannrich G. Pilates na reabilitação: uma revisão sistemática. Fisioter Mov. 2009;22(3):449-55.
70. Kegel AH. The nonsurgical treatment of genital relaxation; use of the perineometer as an aid restoring anatomic and functional structure. Annalsof Western Medicine andSurgery. 1948;2:213–216.
