So it’s my honor tonight to introduce ourspeakers, Dr. Suzan Carmichael andDoctor Betty Shachar, and their lectureentitled, Taking Care of Yourself andYour Baby: Nutrition and Fitness BeforeandDuring Pregnancy, Research andRecommendations. Dr. Carmichael is an associate professorof pediatrics atStanford University’s School of Medicine. She received her PhD from UC-Berkeley andspent two years at the Centers forDisease Control before joining the Marchof Dimes to do research oncauses of birth defects. Her dissertation was on the pattern ofweight gain during pregnancy andrisk of preterm delivery. Her research has focused largely onnutritional, environmental, social, andgenetic contributors to structural birthdefects andother perinatal outcomes, such as pretermdelivery. Dr. Betty Shachar is an MD OB-GYN fromIsrael. She is a post-doctoral research fellow atthe March ofDimes Prematurity Research Center atStanford. Her main interest of study is risk factorsforpreterm birth, in particular theinter-pregnancy interval. So please join me in welcoming ourspeakers tonight. . >> Thank you all for coming tonight. So, to start out with a brief outline ofwhat we’re going talk about asFelice said, we’re gonna talk about arecommendations, and research. I think mine might be a little heavier on,on recommendations than actual research. But we’re going talk about maternal weightand weight gain. Diet and supplements, andthen I’ll take about those and then Bettywill talk about physical activity. So, before I get started I’ll just giveyoua little bit more background about myself. Felice mentioned my dissertation was onweight gain and preterm delivery. Basically just want to let you know thatmaternal andinfant nutrition has always been a passionof mine. It’s kind of been the one thing that hasbeen constant through mydifferent career steps. So the dissertation fit that. I was a nutritionist for the WIC program. It’s a nutrition education and supplementprogram for low income women. I was a Peace Corps volunteer fora little while in Honduras, doing againmaternal and infant nutrition. And then my other piece of experience isthat I do have two boys. So I’ve been through pregnancy a couple oftimes andI can sort of relate to the changes inyour body, the changes in your weight, andthe crazy changes in your appetite. So first we’ll talk about pre-pregnancyweight andbasically we’re usually talking about bodymass index or BMI and that’s calculated asyour weight in kilograms divided by yourheight in meters squared. And for better orfor worse we’re all familiar with theobesity epidemic I’m sure. And then this, this slide just sort ofgives you a visual of that. I’m trying to figure out where I can pointfrom. So this is basically a heat map from theCDC of prevalence ofobesity by state in 1987 versus 2008. The darker colors are obviously moreprevalent,at higher prevalence of obesity. But it just shows you how striking theepidemic has been and really how recent. It’s only been the last, you know,couple of decades this has really emergedas a big problem. And actually an interesting statistic isthat for the first time, average lifespanis shorter for the first time for currentgenerations than for previous generations. And this is attributable to the obesityepidemic. So why is pre-pregnancy weight important?Well, it is associated with a number ofdifferent adverse maternal andinfant health outcomes. And although I’m going to focus on obesitymore it’s true at both extremes ofthe spectrum of BMI and that underweightwomen and obese women are atincreased risk of different, somewhatdifferent set of adverse outcomes. So things like diabetes, and hypertension,preterm delivery,growth restriction of the baby areassociated with the extremes of BMI. What can we do about it?Preconception care, ideally, is veryimportant tohelp people be as healthy as they can atthe start of pregnancy. Unfortunately, we don’t always do a greatjob of that in our health care system. And also about half of all pregnancies arenot planned. So that’s a very striking figure, but itmakes it kinda hard to dothe preconception care and intervenebefore a woman gets pregnant. So I think the best we can do, you know,we need to be careful about what kind ofinterventions we try to implement duringpregnancy. But basically knowing a woman’spre-pregnancy weight helpsa clinician know what her risks may be andthen monitor her appropriately and giveappropriate advice based on that. And I’m gonna give you a little bit, alittle window into some ofthe research that we’ve done in this areaof obesity and pregnancy outcomes. Okay. So, this is a schematic that just kind ofgives you an idea of how we might thinkabout the research questionof the association of obese, obesity withpregnant, adverse pregnancy outcomes. So, basically, we’re interested in whatare the mechanisms andthe mediators that are responsible forthis association. And, as well, we’re really interested inwhat kind ofprotective factors may allow us to sort ofintervene orstop this progression to an adverseoutcome among obese women. Some of the common mechanisms that we’rethinking about and working on andtrying to understand that may beresponsible for these associations forexample, of obesity with preterm deliveryare inflammation and infectionbecause those are both higher and a bitdifferent in obese versus non obese women. Some of the most commonly cited mediatorswould be the higher prevalence ofdiabetes and hypertension in obese womenperhaps being responsible. And then some of the protective factorsthat can protect againstthe negative effects are that we study ournutrition and exercise. So, I’m gonna give you a few examples ofhow we’ve tried to really understand thisassociation of obesity with in particular,neural tube defects. Neural tube, because most of our,a lot of our research has been on, onstructural birth defects. So, neural tube defects are when theneural tube does not close properly. And it may be at the top of the spine orthe lower part of the spine. A couple of the most commonly, ormost familiar outcomes, neural tubedefects, are spina bifida and anencephaly. So we know that neural tube defects areabout twice aslikely among women who are obese as womenwho aren’t obese. But still keep in perspective that eventhough it’s a two-fold increased risk,these are still relatively rare. They affect less than 1 per 1,000deliveries. But still we wanna understand how toprevent themeven when they aren’t when they’re thatrare. So if we think about obesity, it’s apretty broad category. And one thing that we’ve tried to thinkabout, well, what is it about obesity,not all, sometimes people refer to healthyobesity versus unhealthy obesity. And or maybe there’s a spectrum of sort ofthe unhealthiness of obesity depending onwhat else is going on. So abdominal obesity is so this is sort ofthe, the apple shape if you will. Where the weight tends to be gained in thewaist andthen the alternative is sort of the, ifyou will, the pear shape, orpeople who tend to gain weight in theirhips and the abdominal type isassociated with worse endocrine milieu,including worse glycemic control, which isimportant to pregnancy outcomes. So, what we did is in one of our studiesof neural tube defects,is we looked at the association of obesitywith neural tube defects overallin our study, and here you see the 1. 3 isthe overall association,and when we’re doing these studies weeither do odds ratios or risk ratios. But basically one means, when you comparethe two groups, the ratio is one,there’s no association. And then on the y-axis will be, sort of,the fold increase ordecrease in risk for your, your twogroups. So here when we looked overall we saw aslight increased risk of neural tubedefects among women who were obese versusnot obese, but then we asked women,we usually do telephone surveys for a lotof our birth defect studies. We asked women about when you gain weightdo you tend togain it in your waist or your hips. So trying to get at that pear versus applephenotype and we found that womenwho were obese and tended to be more theabdominal type of obesity there,that’s where we were, that’s what wasdriving the increased risk is those women. Whereas, the women who tended to have theother body type the obesity was notassociated with the increased risk. And that sort of fit with our hypothesisof thinking that maybe that the worstglycemic control is associated with, isdriving the increased risk for NTDs. And then in thinking about thisin a similar way rather than type ofobesity, we thought about well what other,what factors may, are the,is the association of different other riskfactors with neural tube defects similar,operating similarly in women who are obeseversus not obese. And again, that helps us really understandwhat’s driving that association. So one thing we know, is that nutritionand particularly folic acid is reallyimportant to neural tube defects andintake of certain nutrients andfolic acid in particular, or folates isknown to be protective. So, if you see in my slides if you see anodds ratio orrelative risk that’s less than one, thatmeans reduced risks. So, here, for example, there are twostudies that I’m illustrating. And this one was conducted by ourcolleague, Martha Werler. And what she did was,she looked at well, is folate intake abovethis amount versus less than that?Is it’s association, or it’s protectiveeffects against neural tube defects,is that similar among women who are higherweight and lower weight. In their study, they cut it at notobesity, butrather 70 kilograms pre-pregnancy weight,about 150 pounds. And what they found was that Folate, theusual oops. The usual protective effects that we seewere observed forthe women who were lower weight, but notfor the women who were higher weight. So it seemed to be helping in the womenwho had the normal weight, butnot the women who were higher weight. And then another study that we did waslooking at more holisticallyat nutrition and that we, I’ll talk moreabout diet quality in a little while, butbasically it’s like an overall sort ofscore of the quality of your diet. And what we found was that among womenwith normal BMI there wasa protective association. So, diet quality, higher diet quality wasassociated with lower risks. But among obese women, it wasn’t. So basically the take home message fromthese studies was that, well,maybe, it may be that the ideology ofwhat’s causing NTDs among obese women maybe a little bit different thanwhat we’ve seen in the general populationwith regard to nutrition and folic acid. So basically these kinds of studies I’mgiving you are an example kind oflike we’ll know an association and try togo the next step and try to understand it. In research your steps are often, theyfeel like baby steps, butit’s just kind of the nature of trying tomake progress. It’s usually not a magic bullet, buteach step hopefully gets us a littlecloser to understanding associations. So here’s another one of those sort ofinteraction slides. So this one sort of is, is demonstrating,well,what about if a woman has obesity anddiabetes?Are those the women who are driving therisk, again, with this sort of hypothesisabout is it glycemic control that may bedriving this ends increased risk. And so this study was conducted by ourcolleague Adolfo Correa when hewas at CDC. And basically the reference group,the comparison group, was the women thatwe expected to be best off which waswomen who did not have diabetes and theyhad normal BMI. And so we found out that women who had nodiabetes butwere obese, they weren’t at increasedrisk. And remember we usually are seeing,overall in the population, an increasedrisk there. But if we excluded the women withdiabetes, they weren’t at increased risk. Women who’d had gestational diabetes andnormal BMI again weren’t really atincreased risk. But then if you had gestational diabetesand obese the risk starts to pop up. If you have pregestational diabetes andnormal BMI it’s again higher andthe worst is if you have thepregestational diabetes and obesity. So, again, it’s kind of showing, well, ifwe kind of dig in a little bit deeper,is it everyone who’s obese or should we beparticularly concerned abouttaking care of women who have multiplerisk factors?So, now, I’m going to move on to my secondtopic which isweight gain during pregnancy. And this slide just gives you a generalfeel for what the pattern,the average pattern of gain looks like. Basically in the first trimester and thisis on average,in the first trimester gain tends to bepretty minimal, I mean some women gain,some women lose weight, but on averageit’s pretty flat. And then after that, it tends to be ratherlinear if you, again, this is averaging. Everybody knows that that’s not theirparticular case,just like we know that we know that wedon’t have 1. 3 children. But that gives you a feel for the patternof gain and how it looks. And, then this slide just tells you alittle bit more about what all thatgain is going towards. So, I don’t know if all of you are alreadyfamiliar with all of this, butbasically half of it’s going to the baby. Half of it’s going to mom. And all the things that, that you’rebuilding. And again, the average increase incalories that are really needed,thought to be needed to build all of thisin first trimester, it’s about null. And then in the second andthird trimesters, it’s about 350 to 500extra calories per day. But what I want to really impart is thatall of these are averages andwe know that we’re all over the board inwhat really happens. And just because one isn’t on the averagedoesn’t mean that they’re not going tohave a good outcome. Also it’s really amazing how muchadaptability there is in the human body,especially during pregnancy. For example there were some studies likeover 50 years ago that really weretrying to figure out what were themetabolic requirements of pregnancy. And it was found that women who wereundernourished actually hada lower actual, you know, incrementalenergy intake need than women whowere normal weight or perhaps overweight. And, part of the explanation for that isbecause of the adaptability. Somehow, your body kind of, in a lot ofways, knows what it needs, andhas a really wide range of ability toadapt and to change, you know,how well, how efficiently it’s using whatyou’re, what you’re taking in. So, just want to point that out to put allof this, these averages in context andjust really appreciate how much your bodyreally does adapt andkind of know, it knows what to do a lot ofthe time. So are all of you familiar with theInstitute ofMedicine’s weight gain recommendationsduring pregnancy or not?Anybody familiar with them?Yes, no?It’s a safe way to raise your hand. Okay, so, that’s interesting,cause I’m notsure how much people already know, or whatkind of advice, you know, you’re given. So, basically the Institute of Medicinecame out with recommendations forweight gain. It had a thick report from 2009. The first report was in 1990. That’s when, it’s the 1990, 93 to 96 whenI was doing my dissertation work. My adviser had been on the originalcommittee and we were trying to follow-upand fill in some of the gaps in researchthat they found in doing that report. But, basically a lot of research, a lot ofconsensus work went in,has gone into these recommendations. And they’re basically, they’re different,by BMI category. They’re ranges. And one of the new things they did in the09 report was to provide, excuse me,a rate of gain, as well as just a total. And, basically, during the firsttrimester, it’s recommended, you know,negligible weight gain, as if we cancontrol it. But basically this shows the short ofaverage weekly gain that is, issort of expected to reach this, this totalgain for a term, a full-term pregnancy. They also added recommendations for twinsin the recent report andrefined the recommendation for obesewomen. And again, these are, you know,recommendations. Most women, I don’t know if it’s mostexactly,but a lot of women don’t gain within therecommendation andthey tend towards gaining more than therecommendation. But again, it’s just, it’s a, it’s arecommendation, it’s a gauge. And it’s, it’s important because,to monitor weight gain during pregnancybecause it provides clues. It’s like, it’s not the end all, be all onits own, but I think in the context of,you know what else is going on with awoman it can provide clues to whether,everything else is going well or not. On some people, especially when I wasdoing my doctoral work, there was a lot ofdebate about whether we should evenmeasure weight gain during pregnancy. I mean, I can’t imagine prenatal care withactually er, er,pregnant women never actually stepping ona scale. But it’s debated I guess partly because ofit’s sensitivity. But it’s never been intended that it wouldbe just considered in isolation,what your weight gain is. It’s more of, it’s part of the wholepicture of what’s going on. So what can we do about weight gain?Again, I don’t think it’s something thatwe need to harshly control oranything, it basically is good to monitorandthen give appropriate advice as one seeshow it’s going. I’m not going to talk about research onthis particular topic because Ifeel like well I don’t a whole lot of timeto talk, andalso a lot of research really went intocoming up with those recommendations,so suffice it to say that research is whatled to those. And then the last topic I’m gonna talkabout is nutrient intake and nutritionduring pregnancy as it relates to food andnutrients rather than body mass index. So, again, this picture shows you all,to build all of these things naturally weactually need, we need an increase inenergy but we also need an increase in alot of different nutrients as well. So then the question is, how do you getthat andwhat you should do during pregnancy andthis was just a quick Amazon you know –no, I’m sorry not Amazon, Google on booksthat might be on Amazon. On, you know, you put in nutrition duringpregnancy advice andyou get like the, I, I don’t even knowwhat all these are butit’s, you could spend your whole pregnancytrying to read up on it. So my advice is to basically, the PublicHealth Service andother organizations recommend to take amultivitamin mineral supplement whenyou’re planning pregnancy and duringpregnancy. And as far as dietary recommendations,anybody can, you know, look on the web andsee what it says, see what, you know,different people are saying, but mygeneral advice is to keep it simple. And if, if you’re reading things that arestressing you out,because they get so detailed or whatever,then, then try something else. Try another set of recommendations. And really the recommendations for ahealthy diet you know,when you’re not pregnant are very similarto when you are pregnant. And so in that vein I’ve included a coupleof books here. I really like the Eat, Drink, and BeHealthy by Walter Willett at Harvard. He’s very practical. And that just really spoke to me. It was very readable. It’s not trendy. And then I haven’t actually read MichaelPollen’s recent food rules. But I have read other books by him, he’sat Berkley, and he gives again,it’s not like eat this particular nutrientbut more general advice abouthow to eat and how to sort of select whatyou’re eating in general. And so those tend to be the kinds ofadvice that I think are the most helpful,the most holistic, the most perhaps easierto follow andnot get obsessed about hopefully. But just to share with you a few of thefood rules from,from Michael Pollan to give you a feel ifyou haven’t read him before. Because I think they’re true but they’realso somewhat amusing. So eat only foods that will eventuallyrot. So that might exclude some of theHalloween candy that we all just got. If it came from a plant, eat it. If it was made in a plant, don’t. And again, it would be hard to follow thisstrictly, but I think you get the idea. Eat the rainbow, which does not meanSkittles. Eat all the junk food you want as long asyou cook it yourself. Isn’t that freeing?Eat more like the French, or the Japanese,or the Italians, or the Greeks, which,I think, means don’t eat like us in theU. S. and break the rules once in a while. you know, to enjoy food and don’t feellike you’re married to the rules. Eating should be enjoyable. It’s something we all do together. It represents community. There’s so much more to it than just anutrient. He also says you know, if the ingredientlist is something thata third grader can’t pronounce, then tryto avoid it. But, anyway. I like, I like his stuff. So as far as a little bit into theresearch we’ve done on nutrition andagain, I’ll use neural tube defects as anexample. So here it says there’s been a reductionin neural tube defects afterfortification in 1998. And do you guys know what nutrient I’mtalking about?Anybody?So, folic aid. So, basically there was a lot of researchthat was done showing that folic acid,which is a B vitamin comes from the wordfoliage. Basically a lot of research was doneshowing that it was protective againstneural tube defects and that led in 1998tomandated folic acid fortification of thefood supply, and that’s primarily grains. It’s all the things that were alreadyfortified with things with thiamine,riboflavin, iron, and niacin. So now it’s also folic acid. I’ve always thought it fascinating thatmost people don’t even, there was somuch debate in the scientific community,but the general public doesn’t evenrealize there was a nutrient added to thefood supply at that point. But basically it’s a huge, it’s beenlauded as one of the mostimportant public health successes in thelast couple of decades because it reallyhas substantially reduced the prevalenceof neural tube defects, which is great. One of the main challenges, though, thatwe face in doing research on nutrition,is that naturally, nutrients co-occur. So it’s, they co-occur in a vitaminsupplement,they co-occur in anything that we eat. And so that just makes it harder from aresearch perspective to actually isolatethe effects of a particular nutrient. Or even a particular food for that matter. So one of the things that we’ve done,we’ve done lots of single nutrientresearch, but one of the things we’ve donerecently is take a step back andtry to come at it from a differentdirection and study diet quality,which is more, I mentioned it recently inthe context of one of the slides. But it’s been more a holistic approach. Basically it’s an overall score based ondifferent food groups andnutrients that you’ve eaten and thisapproach hasbeen used a lot in more chronic diseaseslike cardiovascular disease andthen the cancer research world, adultmortality, and it’s been so,shown to be, if you have a better overalldiet quality, you have better outcomes. All, all different types of outcomes. But it really hasn’t been done in thefield of birth defects orreally not so much in reproductiveoutcomes in general. So, the idea is, if you look at dietquality, if your diet quality is better,does that effect outweigh the effect ofany particular nutrient. So because in our bodies, I mean, as wemetabolize these things, as we use them,nutrients depend on each other. There are, you know you look at the folicacid orfolate cycle and it has B12 in it, it hascholine in it, it has B6 in it. All these things sort of, they all worktogether. So, from this perspective that’s kind ofwhat drove thinking about diet qualityrather than just single nutrients. So, one of our recent studies was on birthdefects anddiet quality index and basically, the dietquality index was basedon USDA food pyramid, if any of you arefamiliar with that. Basic food dietary food guidelines withsome modifications to make itmore applicable to pregnancy. Recently the food pyramid has beenreplaced by the my plate cartoon. But basically we saw that Diet QualityIndex wasprotective against neural tube defects anda couple of other birth defects. And that was independent of, it didn’tmatter how much folate orfolic acid the woman took or whether shetook multi-vitamins or not. There was an independent effect of dietquality. So basically the message is that it’s goodto take a supplement. It’s also good to try to have a generallygood diet, sowhat you eat is still important. Just a couple more slides again to kind ofin that vein of thinking aboutinteractions and if we have, maybe we haveone thing that puts us at increased risk,but is there something else we can do tolower our risk. So we’ve done a lot of work on stress andpregnancy outcomes. And so one we did in particular, againNTDs is an example, is we looked atwhether the association of stress withNTDs was similar regardless ofwhether a woman took a multivitamin ornot, during very early pregnancy. So neural tube defects happen in the firstfew weeks of pregnancy before most womeneven know that they’re pregnant, even ifthey’re planning a pregnancy. And so what we saw was, that for women whodid not take vitamins,if they had increased stress they had anincreased risk. But among women who did take vitamins theincreased risk was much lower. So, hopefully, you know, maybe that meansagain, we can’t really take cause fromthis so it’s association and so forth, andit’s one study. But it suggests that perhaps it’s possiblethatnutrition can protect against thesenegative, other negative risk factors. And then one more, this is my lastresearch slide. Again, in the context of these multiple,thinking about multiple risk factors. So here we looked at well, actually, thiswas not our work. This was an Adolfo Corea, again from CDC,but using data from the National BirthDefects Prevention study whichwe’ve been part of for many years in ourgroup. And basically this was heart defects andNTDs and clefts. And the reference group was women who didnot have diabetes or take vitamins. No, no, I’m sorry, the reference group waswomen who did not have diabetes andthey did take vitamins. So that’s kind of what we’re thinking ofas our lowest risk group. And women who, so this is the light bluegroup here. Women who just. . . these first two bars here are women whohad either one or the other. So this is the women that had no diabetesbut they didn’t take vitamins. This is the risk for women who haddiabetes anddid take vitamins, so they had one of thetwo risk factors. But as you see, it’s starkly, much moreincreased risk for women who had both. So hopefully this is, again, saying ifyou, if you take vitamins maybe itcan help protect against the increasedrisk associated with diabetes. And some animal work has been reallyinteresting, showing that one ofthe mechanisms by which diabetes may becausing birth defects,this was from animal models but it, it maybe oxidative stress may be the mechanism. So that kind of ties in, that makes sensethat if you’re taking a vitamin you’regetting higher doses of a lot of differentantioxidants. It could be protective for that reason. So my last slide is basically as far asall the advice and so forth avoid,try to avoid feeling this way and anythingthat’s making you feel that way duringpregnancy or otherwise when it comes toall the dietary advice especially. I advocate for the simpler the better, themore general the better, keep it simpleand that’s basically where I’ll concludeand hand it over to Betty. >> So hello again and thank you for havingme here. I’m Betty Shachar and I’ll try to keep ita little bit more simple I think about andshorter physical activity in pregnancy. Happy to answer any question in the, atthe end. Did it move?Hm. Why is it that small?Okay, I’ll try to use my computer insteadof this. So the, my goal in this presentation isactually to answer the common questions ofevery woman. Should I do any exercise during pregnancy?What kind of activity am I allowed to do?Should I avoid some kind of activity?And what should I be aware of whileexercising. I’ll start with some, background. The first US guidelines forphysical activity during pregnancy were in1985 and they were very conservative. There wasn’t much data about physicalactivity during pregnancy at that time. They didn’t, they suggested to limitvigorous activity to more than,more, no more than 15 minutes andnot to let maternal heart rate exceed 140beats per minute. Also, obese women were recommended not todo any physical activity during pregnancyor women who didn’t do any physicalactivity before pregnancy were alsorecommended not to begin activity,physical activity during pregnancy. So, what have actually changed since then?The decades of research that hasestablished a variety ofhealth benefits of physical activity,activity forvirtually everyone, regardless of age,gender, or physical capabilities. And the landmark was the Physical ActivityGuidelines for Americans in2008 which has a specific role forthe physical activity, during pregnancyand the postpartum period. So what are the benefits of physicalactivity during pregnancy?We all know then what is the generalbenefits of a healthy heart,mind and body. And what Susan explained much of they’reless likely to gain weight andwe all know now about the adverse outcomeof pregnancy associated with obesity. It’s also suggested to reduce stress, andstress by himself is a risk factor foradverse pregnancy outcome, in particular,preterm birth. So there’s also a lot of data aboutphysical activity andspecific birth outcomes. For example preterm birth. There is converging evidence that’ssuggesting physical activity may actuallyreduce the risk of preterm birth but Imust stop here and say Women who feelcontractions or any other signs of pretermbirth or had previous preterm birth inthe past should not continue to do anyphysical activity during pregnancy. so this is important, even though as youcan see it,it has been related to reduced risk forpreterm birth. What about preeclampsia or hypertensionduring pregnancy?So again there is a bulk of evidence thatsuggests thatphysical activity during pregnancy mayreduce the risk of preeclampsia. But there is another recent Danish studythathave shown that women who reported extraphysical activity ofmore than seven hours per week actuallyhad a higher risk of preeclampsia. So it is still should be decided in theliterature and future studies might,might help us understand the relationshipbetween physical activity andthe risk for preeclampsia. What about gestational diabetes?This is more. . . there is agreement that physical activityduring pregnancy has been shown tobe effective in the treatment ofgestational diabetes. And most studies indicate that exercise isa safe andreasonably effective therapy ingestational diabetes. What about the effects of the baby?So, early studies were, they wereconcerned about fetal distress. People in the literature have showed thatmaternal exercise may contribute to fetaldistress. But actually what we are sure now thatphysical exercise isnot related to fetal stress. And also not related to, about birthweight. Early studies again showed decrease inmean birth weight andincrease risk of low birth weight. Recent reports show that there is norelationship between physicalactivity during pregnancy and mean birthweight. As with preterm birth, women that are,there is a suspicion that their baby mightnot grow well, forexample, there is a suspect IUGR,intrauterine growth retardation,are recommended not to do any physicalexercise. So what are the current guidelines?Healthy women, who are not alrerady inhighly active ordoing vigorous intensive activity, shouldget at least two anda half hours of moderate intensity aerobicactivity per week. And the recommendation is for at least 30minutes every day. So what kinds of activities can you do?There are forms of safe exercise includingwalking,swimming, cycling, aerobics and evenrunning. Activities to avoid —you should better notdo much exercise on your back. Avoid heavy lifting, and standing aroundfor too long. Holding your breath when working out. Any exercise that can compromise yourbalance, there is change in balance duringpregnancy so please, the recommendationsare to avoid this kind of thing. Avoid jumping and most of the sports team,that basketball, volleyball,things that might cause trauma orfall are best, are best to avoid duringpregnancy. Better to avoid. What should you be aware of?Please start slowly. It has been some time,especially if it has been some time sinceyou have exercised. Consume extra daily calories in accordingwith the amount ofcalories you think you have exercised. Avoid overheating by hydrate, by stayingout of the sun. And these are the recommendations for mostof the women. It’s important to understand that not allwomen should exercise. There are women with specific heartproblems, lung disease. As I said, signs of preterm labor orprevious preterm delivery,an incompetent cervix, women with multiplepregnancy, with vaginal bleeding,with ruptured membranes or placenta previawhich is when the placenta is exterior,it’s on the cervix, should not, should notexercise during pregnancy. And these are just the summary of thewarning signs, when to stop,when to stop exercising. If there’s vaginal bleeding, if you feeldizziness or feeling faint. Increased shortness of breath. Any kind of headache, headache. Muscle weakness,uterine contractions, any signs of pretermdelivery as I mentioned before. Decreased fetal movements and chest pain. If you have any of these please stop andturn to your health provider. After delivery. . . So a lot of time there’s the question,when exactly I can start going back toexercise after delivery. So it’s different among different women,butin general we know that the, whenever youfeel ready, it’s okay. There’s no association between a rapidgoing back to physicalactivity after delivery, and any kind of aadverse outcome. So it’s better to a gradual return tophysical activity,but when you feel ready, and it’s alwaysgood to ask your health provider. It’s okay for you to go back to your usualphysical activity. In conclusion, research indicates thatpregnant women should beencouraged to be physically active duringpregnancy. And there, if there are, of course, nocontraindication. And such participation is not harmful andin fact,may be of great benefit of the motherduring pregnancy and after pregnancy. Thank you and if you have any questionsplease.