Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes

Julie Brown; Gilles Ceysens; Michel Boulvain

doi:10.1002/14651858.CD012202.pub2

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Figure 1

Study flow diagram.

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Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Exercise versus control, Outcome 1 Hypertensive disorders of pregnancy (pre‐eclampsia).

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Analysis 1.2

Comparison 1 Exercise versus control, Outcome 2 Caesarean section.

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Analysis 1.3

Comparison 1 Exercise versus control, Outcome 3 Perinatal mortality (stillbirth and neonatal mortality).

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$Comparison 1 Exercise versus control, Outcome 4 Mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy).$

Analysis 1.4

Comparison 1 Exercise versus control, Outcome 4 Mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy).

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Analysis 1.5

Comparison 1 Exercise versus control, Outcome 5 Use of additional pharmacotherapy.

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Analysis 1.6

Comparison 1 Exercise versus control, Outcome 6 Maternal hypoglycaemia.

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Analysis 1.7

Comparison 1 Exercise versus control, Outcome 7 Glycaemic control end of treatment (Mean).

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Analysis 1.8

Comparison 1 Exercise versus control, Outcome 8 Glycaemic control end of treatment (Fasting blood glucose concentration).

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Analysis 1.9

Comparison 1 Exercise versus control, Outcome 9 Glycaemic control end of treatment (Postprandial blood glucose concentration).

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Analysis 1.10

Comparison 1 Exercise versus control, Outcome 10 Glycaemic control end of treatment (HbA1c).

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Analysis 1.11

Comparison 1 Exercise versus control, Outcome 11 Glycaemic control end of treatment (Glucose tolerance test).

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Analysis 1.12

Comparison 1 Exercise versus control, Outcome 12 Weight gain in pregnancy.

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Analysis 1.13

Comparison 1 Exercise versus control, Outcome 13 Weight gain in pregnancy (Excessive).

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Analysis 1.14

Comparison 1 Exercise versus control, Outcome 14 Adherence to the intervention.

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Analysis 1.15

Comparison 1 Exercise versus control, Outcome 15 Induction of labour.

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Analysis 1.16

Comparison 1 Exercise versus control, Outcome 16 Maternal mortality.

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Analysis 1.17

Comparison 1 Exercise versus control, Outcome 17 Views of the intervention (favourable).

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Analysis 1.18

Comparison 1 Exercise versus control, Outcome 18 Postnatal weight retention or return to pre‐pregnancy weight.

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Analysis 1.19

Comparison 1 Exercise versus control, Outcome 19 Stillbirth.

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Analysis 1.20

Comparison 1 Exercise versus control, Outcome 20 Macrosomia.

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Analysis 1.21

Comparison 1 Exercise versus control, Outcome 21 Gestational age at birth.

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Analysis 1.22

Comparison 1 Exercise versus control, Outcome 22 Preterm birth.

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Analysis 1.23

Comparison 1 Exercise versus control, Outcome 23 Five‐minute Apgar < seven.

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Analysis 1.24

Comparison 1 Exercise versus control, Outcome 24 Birthweight.

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Analysis 1.25

Comparison 1 Exercise versus control, Outcome 25 Length (cm) (at birth).

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Analysis 1.26

Comparison 1 Exercise versus control, Outcome 26 Neonatal hypoglycaemia.

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Analysis 1.27

Comparison 1 Exercise versus control, Outcome 27 Respiratory distress syndrome.

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Analysis 1.28

Comparison 1 Exercise versus control, Outcome 28 Neonatal jaundice (hyperbilirubinaemia).

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Analysis 1.29

Comparison 1 Exercise versus control, Outcome 29 Hypocalcaemia.

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Summary of findings for the main comparison. Exercise compared to control for pregnant women with gestational diabetes for improving maternal outcomes

Exercise compared to control for pregnant women with gestational diabetes for improving maternal outcomes
Patient or population: pregnant women with gestational diabetes Setting: USA, Italy, Brazil, Australia Intervention: exercise Comparison: control
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with exercise	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Hypertensive disorders of pregnancy (pre‐eclampsia)	43 per 1000	13 per 1000 (0 to 308)	RR 0.31 (0.01 to 7.09)	48 (2 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Event rates were very low with 0/25 in the exercise group and 1/23 in the control group. No data were reported for pregnancy‐induced hypertension or eclampsia.
Caesarean section	319 per 1000	274 per 1000 (201 to 370)	RR 0.86 (0.63 to 1.16)	316 (5 RCTs)	⊕⊕⊕⊝ MODERATE ¹
Development of type 2 diabetes ‐ not measured	‐	‐	‐	‐	‐	This outcome was not measured in any of the included studies in this review.
Perineal trauma/tearing ‐ not measured	‐	‐	‐	‐	‐	This outcome was not measured in any of the included studies in this review.
Postnatal weight retention or return to pre‐pregnancy weight (maternal BMI (follow‐up) kg/m²)	The mean maternal BMI (follow‐up) kg/m2 was 0	MD 0.11 higher (1.04 lower to 1.26 higher)	‐	254 (3 RCTs)	⊕⊕⊕⊕ HIGH
Postnatal depression ‐ not measured	‐	‐	‐	‐	‐	This outcome was not measured in any of the included studies in this review.
Induction of labour	400 per 1000	552 per 1000 (284 to 1,000)	RR 1.38 (0.71 to 2.68)	40 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 3}	Event rates and sample size were low 11/20 in exercise group and 8/20 in control group.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Lack of clarity for most items related to risk of bias ‐ downgraded one level. ² Wide confidence intervals crossing the line of no effect and low event rates with a small sample size are suggestive of imprecision ‐ downgraded one level. ³ Imprecision ‐ low event rates and small sample size ‐ downgraded one level.

Summary of findings for the main comparison. Exercise compared to control for pregnant women with gestational diabetes for improving maternal outcomes

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Summary of findings 2. Exercise compared to control for pregnant women with gestational diabetes for improving fetal outcomes

Exercise compared to control for pregnant women with gestational diabetes for improving maternal and fetal outcomes
Patient or population: pregnant women with gestational diabetes Setting: USA, Italy Intervention: exercise Comparison: control
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with exercise	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Large‐for‐gestational age ‐ not reported	‐	‐	‐	‐	‐	None of the included studies in this review reported data for this outcome.
Perinatal mortality (stillbirth and neonatal mortality)	0 per 1000	0 per 1000 (0 to 0)	not estimable	19 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 2}	There were no events in either the exercise or the control group and the sample size in only 19 infants.
Mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy)	65 per 1000	36 per 1000 (8 to 169)	RR 0.56 (0.12 to 2.61)	169 (2 RCTs)	⊕⊕⊕⊝ MODERATE ³	Event rates and sample size were low with 2/61 in the exercise group and 7/108 in the control group.
Neonatal hypoglycaemia	59 per 1000	118 per 1000 (12 to 1,000)	RR 2.00 (0.20 to 20.04)	34 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 3}	Event rates and sample size were low with 2/17 in the exercise group and 1/17 in the control group.
Adiposity ‐ not reported	‐	‐	‐	‐	‐	None of the included studies in this review reported data for this outcome at any life stage.
Diabetes (type 1, type 2) ‐ not reported	‐	‐	‐	‐	‐	None of the included studies in this review reported data for this outcome at any life stage.
Neurosensory disability	‐	‐	‐	‐	‐	None of the included studies in this review reported data for this outcome.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ There is a lack of clarity for most items associated with risk of bias ‐ downgraded one level. ² Imprecision ‐ There are no events in either group and the sample size is only 19 infants ‐ downgraded one level. ³ Imprecision ‐ wide confidence intervals and low event rates ‐ downgraded one level.

Summary of findings 2. Exercise compared to control for pregnant women with gestational diabetes for improving fetal outcomes

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Comparison 1. Exercise versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hypertensive disorders of pregnancy (pre‐eclampsia) Show forest plot	2	48	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.01, 7.09]

2 Caesarean section Show forest plot	5	316	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.63, 1.16]

3 Perinatal mortality (stillbirth and neonatal mortality) Show forest plot	1	19	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy) Show forest plot	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.12, 2.61]

5 Use of additional pharmacotherapy Show forest plot	7	413	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.54, 1.08]

6 Maternal hypoglycaemia Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

7 Glycaemic control end of treatment (Mean) Show forest plot	1	34	Mean Difference (IV, Fixed, 95% CI)	0.28 [0.04, 0.52]

8 Glycaemic control end of treatment (Fasting blood glucose concentration) Show forest plot	4	363	Std. Mean Difference (IV, Random, 95% CI)	‐0.59 [‐1.07, ‐0.11]

9 Glycaemic control end of treatment (Postprandial blood glucose concentration) Show forest plot	3	344	Std. Mean Difference (IV, Random, 95% CI)	‐0.85 [‐1.15, ‐0.55]

10 Glycaemic control end of treatment (HbA1c) Show forest plot	2	320	Mean Difference (IV, Fixed, 95% CI)	‐0.43 [‐0.51, ‐0.35]

11 Glycaemic control end of treatment (Glucose tolerance test) Show forest plot	1	19	Mean Difference (IV, Fixed, 95% CI)	‐81.6 [‐96.03, ‐67.17]

12 Weight gain in pregnancy Show forest plot	2	104	Mean Difference (IV, Fixed, 95% CI)	‐0.34 [‐1.25, 0.58]

13 Weight gain in pregnancy (Excessive) Show forest plot	1	79	Risk Ratio (M‐H, Fixed, 95% CI)	0.9 [0.47, 1.72]

14 Adherence to the intervention Show forest plot	1	19	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.83, 1.21]

15 Induction of labour Show forest plot	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	1.38 [0.71, 2.68]

16 Maternal mortality Show forest plot	2	48	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

17 Views of the intervention (favourable) Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

18 Postnatal weight retention or return to pre‐pregnancy weight Show forest plot	3	254	Mean Difference (IV, Fixed, 95% CI)	0.11 [‐1.04, 1.26]

18.1 Maternal BMI (follow‐up) kg/m2	3	254	Mean Difference (IV, Fixed, 95% CI)	0.11 [‐1.04, 1.26]
19 Stillbirth Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

20 Macrosomia Show forest plot	5	296	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.35, 1.35]

21 Gestational age at birth Show forest plot	4	167	Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.40, 0.38]

22 Preterm birth Show forest plot	5	302	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.39, 2.36]

23 Five‐minute Apgar < seven Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.65]

24 Birthweight Show forest plot	6	192	Mean Difference (IV, Fixed, 95% CI)	‐61.50 [‐195.21, 72.20]

25 Length (cm) (at birth) Show forest plot	1	34	Mean Difference (IV, Fixed, 95% CI)	‐1.70 [‐3.41, 0.01]

26 Neonatal hypoglycaemia Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.20, 20.04]

27 Respiratory distress syndrome Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

28 Neonatal jaundice (hyperbilirubinaemia) Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.65]

29 Hypocalcaemia Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Exercise versus control

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