Sports Medicine

, Volume 7, Issue 6, pp 357–375 | Cite as

Aerobic Exercise During Pregnancy

Special Considerations
  • Stanley P. Sady
  • Marshall W. Carpenter
Review Article

Summary

Alterations in maternal physiology during pregnancy affect the physiological response to aerobic exercise. Maternal resting oxygen consumption (V̇O2) and cardiac output (Q̇) increase during pregnancy. Heart rate (HR) becomes progressively elevated throughout gestation, whereas stroke volume (SV) increases until the third trimester and then declines until term, probably because of diminished venous return. Plasma volume increases earlier and to a greater magnitude than red cell volume, resulting in the ‘haemodilutional anaemia’ of pregnancy and a decline in the oxygen-carrying capacity. Ventilation is greater during pregnancy because of elevated tidal volume and unchanged rate of breathing.

The acute and chronic (training) responses to aerobic exercise during pregnancy have not been thoroughly investigated. Specifically, the effect of gestational age, maternal activity status, and type, duration and intensity of exercise on maternal cardiovascular response have only recently begun to be explored.

During pregnancy cardiac output during submaximal exertion increases above values in non-pregnant women, except perhaps late in gestation. Both heart rate and stroke volume contribute to the elevated cardiac output. Changes in submaximal exercise V̇O2 during pregnancy are dependent on the mode of exercise. At the same workload, V̇O2 increases during weight-bearing exercise, but usually does not differ from postpartum values during weight-supported exercise. One study found no change in V̇02max during pregnancy compared to postpartum values. Some recent evidence indicates that the cardiac output vs V̇O2 relationship for pregnant women is within the range of average values reported for non-pregnant individuals. Exercise arterial-venous oxygen difference is lower during pregnancy, suggesting that the higher cardiac output is distributed to non-exercising vascular beds. The data are limited but suggest that the perfusion of exercising muscle is unchanged during pregnancy and that the major haemodynamic change is an augmented cardiac output so that blood flow to the uterus and fetus is not compromised.

Only one study has measured blood flow during exercise in pregnant women. The reported 25% decrease in uterine blood flow during supine cycle exercise in women late in gestation must be interpreted cautiously because the uterus may obstruct the vena cava in the supine position. Studies of exercising pregnant animals usually indicate a decreased uterine blood flow but an enhanced oxygen extraction; the lower blood flow may be limited to non-placental areas. The applicability of these results to humans is unknown.

Fetal heart rate has been reported to increase, decrease or remain unchanged during and after maternal exercise. Some of the discrepancies among studies may be because the measurement techniques do not account for artifact related to maternal movement. Fetal bradycardia is not uncommon following maximal maternal exertion.

The few training studies of pregnant women are limited in value by the inclusion of several exercise modes, inadequately defined intensity and duration of exercise, or omission of important cardiovascular variables. Nevertheless, these studies generally indicate increased performance or physiological fitness with training during pregnancy. The literature suggests normal or improved parturition and fetal outcome for women who exercise during pregnancy, although large well-designed prospective studies are lacking. Recommendations for exercising during pregnancy are provided.

Keywords

Cardiac Output Stroke Volume Aerobic Exercise Fetal Heart Rate Post Partum 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. American College of Obstetrics and Gynecology. Exercise during pregnancy and the postnatal period, American College of Obstetricians and Gynecologists, Washington, DC, 1985Google Scholar
  2. American College of Sports Medicine. Guidelines for exercise testing and prescription, 3rd ed., Lea & Febiger, Philadelphia, 1986Google Scholar
  3. Artal R, Gardin SK. Historical perspectives. In Artal R & Wiswell RA (Eds) Exercise in pregnancy, pp. 1–6, Williams & Wilkins, Baltimore, 1986Google Scholar
  4. Artal R, Romern Y, Paul RH, Wiswell R. Fetal bradycardia induced by maternal exercise. Lancet 2: 258–260, 1984PubMedCrossRefGoogle Scholar
  5. Artal R, Rutherford S, Romern Y, Kammula RK, Dorey FJ, et al. Fetal heart rate response to maternal exercise. American Journal of Obstetrics and Gynecology 155: 729–733, 1986aPubMedGoogle Scholar
  6. Artal R, Wiswell RA. Exercise prescription in pregnancy. In Artal R & Wiswell RA (Eds) Exercise in pregnancy, pp. 225–228, Williams & Wilkins, Baltimore, 1986Google Scholar
  7. Artal R, Wiswell RA, Greenspoon J, Romern Y. Pulmonary response to exercise in pregnancy. In Artal R & Wiswell RA (Eds) Exercise in pregnancy, pp. 147–154, Williams & Wilkins, Baltimore, 1986bGoogle Scholar
  8. Artal R, Wiswell RA, Romern Y, Dorey F. Pulmonary responses to exercise in pregnancy. American Journal of Obstetrics and Gynecology 154: 378–383, 1986cPubMedGoogle Scholar
  9. Åstrand PO, Rodahl K. Textbook of work physiology, 3rd ed., McGraw-Hill Book Company, New York, 1986Google Scholar
  10. Atkins AFJ, Watt JM, Milan P, Davies P, Crawford JS. A longitudinal study of cardiovascular dynamic changes throughout pregnancy. European Journal of Obstetrics and Gynecology 12: 215–224, 1981CrossRefGoogle Scholar
  11. Bader RA, Bader ME, Rose DJ. The oxygen cost of breathing in dyspneic subjects as studied in normal pregnant women. Clinical Science 18: 223–235, 1959PubMedGoogle Scholar
  12. Bader RA, Bader ME, Rose DJ, Braunwald E. Hemodynamics at rest and during exercise in normal pregnancy as studied by cardiac catheterization. Journal of Clinical Investigation 34: 1524–1536, 1955PubMedCrossRefGoogle Scholar
  13. Beller JM, Dolny DG. Effect of an aerobic endurance exercise program on maternal and fetal heart rate during the second and third trimester. Medicine and Science in Sports and Exercise 19 (Suppl.): S5, 1987CrossRefGoogle Scholar
  14. Berkowitz GS, Kelsey JL, Holford TR, Berkowitz RL. Physical activity and the risk of spontaneous preterm delivery. Journal of Reproductive Medicine 28: 581–599, 1983PubMedGoogle Scholar
  15. Boss S. A star runner sets fast pace in motherhood. New York Times, June 4, 1986Google Scholar
  16. Brownlee S. Moms in the fast lane. Sports Illustrated, May 30, 1988Google Scholar
  17. Bruser M. Sporting activities during pregnancy. Obstetrics and Gynecology 32: 721–725, 1968PubMedGoogle Scholar
  18. Caldwell F, Jopke T. Quéstions and answers: ACSM 1985. Physician and Sportsmedicine 13(8): 145–147, 1985Google Scholar
  19. Carpenter MW, Sady SP, Haydon B, Sady MA, Coustan DR. Maternal exercise duration and intensity affect fetal heart rate. Submitted for publication, 1989aGoogle Scholar
  20. Carpenter MW, Sady SP, Hoegsberg B, Sady MA, Haydon B, et al. Fetal heart rate response to maternal exertion. Journal of the American Medical Association 259(20): 3006–3009, 1988PubMedCrossRefGoogle Scholar
  21. Carpenter MW, Sady SP, Sady MA, Haydon B, Coustan DR, et al. Effect of weight gain during pregnancy on exercise performance. Submitted for publication, 1989bGoogle Scholar
  22. Chandler KD, Bell AW. Effects of maternal exercise on fetal and maternal respiration and nutrient metabolism in the pregnant ewe. Journal of Developmental Physiology 3: 161–176, 1981PubMedGoogle Scholar
  23. Clapp JF. Acute exercise stress in the pregnant ewe. American Journal of Obstetrics and Gynecology 136: 489–494, 1980PubMedGoogle Scholar
  24. Clapp JF, Dickstein S. Endurance exercise and pregnancy outcome. Medicine and Science in Sports and Exercise 16(6): 556–562, 1984PubMedCrossRefGoogle Scholar
  25. Clapp JF, Wesley M, Sleamaker RH. Thermoregulatory and metabolic responses to jogging prior to and during pregnancy. Medicine and Science in Sports and Exercise 19:124–130, 1987PubMedCrossRefGoogle Scholar
  26. Cohen GC, Prior JC, Vigna Y, Pride ṠM. Intense exercise during the first two trimesters of unapparent pregnancy. Physician and Sportsmedicine 17(1): 87–94, 1989Google Scholar
  27. Collings C, Curet LB. Fetal heart rate response to maternal exercise. American Journal of Obstetrics and Gynecology 151: 498–501, 1985PubMedGoogle Scholar
  28. Collings CA, Curet LB, Mullin JP. Maternal and fetal responses to a maternal aerobic exercise program. American Journal of Obstetrics and Gynecology 146: 702–707, 1983Google Scholar
  29. Curet LB, Orr JA, Rankin JHG, Ungerer T. Effect of exercise on cardiac output and distribution of uterine blood flow in pregnant ewes. Journal of Applied Physiology 40: 725–728, 1976PubMedGoogle Scholar
  30. Dale E, Mullinax KM, Bryan DH. Exercise during pregnancy: effects on the fetus. Canadian Journal of Applied Sport Sciences 7(2): 98–103, 1982Google Scholar
  31. Dressendorfer RH. Physical training during pregnancy and lactation. Physician and Sportsmedicine 6(2): 74–80, 1978Google Scholar
  32. Durnin JVGA, McKillop FM, Grant S, Fitzgerald G. Energy requirements of pregnancy in Scotland. Lancet 2: 897–900, 1987PubMedCrossRefGoogle Scholar
  33. Editorial. Maternal instincts. Runners World, February 19, 1988Google Scholar
  34. Edwards MJ, Metcalfe J, Dunham MJ, Paul MS. Accelerated respiratory response to moderate exercise in late pregnancy. Respiration Physiology 45: 229–241, 1981PubMedCrossRefGoogle Scholar
  35. Erdelyi GJ. Gynecological survey of female athletes. Journal of Sports Medicine and Physical Fitness 2: 174–179, 1962Google Scholar
  36. Erkkola R. The influence of physical training during pregnancy on physical work capacity and circulatory parameters. Scandinavian Journal of Clinical and Laboratory Investigation 36: 747–754, 1976aPubMedCrossRefGoogle Scholar
  37. Erkkola R. The physical work capacity of the expectant mother and its effect on pregnancy, labor and the newborn. International Journal of Gynaecology and Obstetrics 14:153–159,1976bPubMedGoogle Scholar
  38. Gee JBL, Packer BS, Millen JE, Robin ED. Pulmonary mechanics during pregnancy. Journal of Clinical Investigation 46: 945–952, 1967PubMedCrossRefGoogle Scholar
  39. Goodlin RC, Buckley KK. Maternal exercise. Clinics in Sports Medicine 3(4): 881–894, 1984Google Scholar
  40. Gorski J. Exercise during pregnancy: maternal and fetal responses: a brief review. Medicine and Science in Sports and Exercise 17(4): 407–416, 1985PubMedCrossRefGoogle Scholar
  41. Guyton AC. Textbook of medical physiology, WB Saunders, Philadelphia, 1986Google Scholar
  42. Guzman CA, Caplan R. Cardiorespiratory response to exercise during pregnancy. American Journal of Obstetrics and Gynecology 108(4): 600–605, 1970PubMedGoogle Scholar
  43. Hall DC, Kaufmann DA. Effects of aerobic and strength conditioning on pregnancy outcomes. American Journal of Obstetrics and Gynecology 157: 1199–1203, 1987PubMedGoogle Scholar
  44. Hart MV, Hosenpud JD, Hohimer AR, Morton MJ. Hemodynamics during pregnancy and sex steroid administration in guinea pigs. American Journal of Physiology 249 (Regulatory Integrative Comparative Physiology 18): R179–R185, 1985PubMedGoogle Scholar
  45. Hauth JC, Gilstrap LC, Widmer K. Fetal heart rate reactivity before and after maternal jogging during the third trimester. American Journal of Obstetrics and Gynecology 142: 545–547, 1982PubMedGoogle Scholar
  46. Hohimer AR, Bissonnette JM, Metcalfe J, McKean TA. Effect of exercise on uterine blood flow in the pregnant pygmy goat. American Journal of Physiology 246 (Heart Circulation Physiology 15): H207–H212, 1984PubMedGoogle Scholar
  47. Hutchinson PL, Cureton KJ, Sparling PB. Metabolic and circulatory responses to running during pregnancy. Physician and Sportsmedicine 9(8): 55–61, 1981Google Scholar
  48. Ihrman K. A clinical and physiological study of pregnancy in a material from Northern Sweden. VIII. The effect of physical training during pregnancy on the circulatory adjustment. Acta Sociologica Medica Upsala 65: 335–347, 1960Google Scholar
  49. Jarrett JC, Spellacy WN. Jogging during pregnancy: an improved outcome? Obstetrics and Gynecology 61(6): 705–709, 1983PubMedGoogle Scholar
  50. Jones RL, Botti JJ, Anderson WM, Bennett NL. Thermoregulation during aerobic exercise in pregnancy. Obstetrics and Gynecology 65: 340–345, 1985PubMedGoogle Scholar
  51. Jovanovic L, Kessler A, Peterson CM. Human maternal and fetal response to graded exercise. Journal of Applied Physiology 58: 1719–1722, 1985PubMedCrossRefGoogle Scholar
  52. Katz VL, McMurray R, Berry MJ, Cefalo RC. Fetal and uterine response to immersion and exercise. Obstetrics and Gynecology 72: 225–230, 1988PubMedGoogle Scholar
  53. Knuttgen HG, Emerson K. Physiological response to pregnancy at rest and during exercise. Journal of Applied Physiology 36(5): 549–553, 1974PubMedGoogle Scholar
  54. Korcok M. Pregnant jogger: what a record! Journal of the American Medical Association 246: 201, 1981PubMedCrossRefGoogle Scholar
  55. Kulpa PJ, White BM, Visscher R. Aerobic exercise in pregnancy. American Journal of Obstetrics and Gynecology 156: 1395–1403, 1987PubMedGoogle Scholar
  56. Longo LD. Maternal blood volume and cardiac output during pregnancy: a hypothesis of endocrinologic control. American Journal of Physioloigy 245 (Regulatory Integrative Comparative Physiology 14): R720–R729, 1983Google Scholar
  57. Lotgering FL, Gilbert RD, Longo LD. Exercise responses in pregnant sheep: oxygen consumption, uterine blood flow, and blood volume. Journal of Applied Physiology 55(3): 834–841, 1983PubMedGoogle Scholar
  58. Lotgering FL, Gilbert RD, Longo LD. The interactions of exercise and pregnancy: a review. American Journal of Obstetrics and Gynecology 149(5): 560–568, 1984PubMedGoogle Scholar
  59. Lotgering FL, Gilbert RD, Longo LD. Maternal and fetal responses to exercise during pregnancy. Physiological Reviews 65(1): 1–36, 1985PubMedGoogle Scholar
  60. Lyons HA, Antonio R. The sensitivity of the respiratory center in pregnancy and after administration of progesterone. Transactions of the Association of American Physicians LXXII: 173–180, 1959Google Scholar
  61. McArdle WD, Katch FI, Katch VL. Exercise physiology. In Energy, nutrition, and human performance, 2nd ed., Lea & Fe-biger, Philadelphia, 1986Google Scholar
  62. McMurray RG, Katz VL, Berry MJ, Cefalo RC. The effect of pregnancy on metabolic responses during rest, immersion, and aerobic exercise in the water. American Journal of Obstetrics and Gynecology 158: 481–486, 1988aPubMedGoogle Scholar
  63. McMurray RG, Katz VL, Berry MJ, Cefalo RC. Cardiovascular responses of pregnant women during aerobic exercise in water, a longitudinal study. International Journal of Sports Medicine 9: 443–447, 1988bPubMedCrossRefGoogle Scholar
  64. Metcalfe J, Stock MK, Barron DH. Maternal physiology during gestation. In Knobil E & Neill J (Eds) The physiology of reproduction, pp. 2145–2176, Raven Press, New York, 1988Google Scholar
  65. Morris N, Osborn SB, Wright HP, Hart A. Effective uterine blood flow during exercise in normal and pre-eclamptic pregnancies. Lancet 2: 481–484, 1956CrossRefGoogle Scholar
  66. Morton MJ, Metcalfe J. Changes in maternal hemodynamics during pregnancy. In Artal R & Wiswell RA (Eds) Exercise in pregnancy, pp. 113–126, Williams & Wilkins, Baltimore, 1986Google Scholar
  67. Morton MJ, Paul MS, Campos GR, Hart MV, Metcalfe J. Exercise dynamics in late gestation: effects of physical training. American Journal of Obstetrics and Gynecology 152(1): 91–97, 1985aPubMedGoogle Scholar
  68. Morton MJ, Paul MS, Metcalfe J. Exercise during pregnancy. Medical Clinics of North America 69(1): 97–108, 1985bPubMedGoogle Scholar
  69. Mullinax KM, Dale E. Some considerations of exercise during pregnancy. Clinics in Sports Medicine 5(3): 559–570, 1986PubMedGoogle Scholar
  70. Myhrman P, Granerus G, Karlsson K, Lundgren Y. Cardiac output in normal pregnancy measured by impedance cardiography. Scandinavian Journal of Clinical and Laboratory Investigation 42: 513–520, 1982PubMedCrossRefGoogle Scholar
  71. O’Neill ME, Cooper KA, Hunyor SN, Boyce ES. ‘Pseudo’ fetal bradycardia during maternal exercise. Journal of Applied Physiology 62: 849–850, 1987PubMedGoogle Scholar
  72. Orr J, Ungerer T, Will J, Wernicke K, Curet LB. Effect of exercise stress on carotid, uterine, and iliac blood flow in pregnant and nonpregnant ewes. American Journal of Obstetrics and Gynecology 114: 213–217, 1972PubMedGoogle Scholar
  73. Paolone AM, Shangold M. Artifact in the recording of fetal heart rates during maternal exercise. Journal of Applied Physiology 62: 848–849, 1987PubMedGoogle Scholar
  74. Paolone AM, Shangold M, Paul D, Minnitti J, Weiner S. Fetal heart rate measurement during maternal exercise — avoidance of artifact. Medicine and Science in Sports and Exercise 19(6):605–609, 1987PubMedCrossRefGoogle Scholar
  75. Pernoll ML, Metcalfe J, Kovach PA, Wachtel R, Dunham MJ. Ventilation during rest and exercise in pregnancy and postpartum. Respiration Physiology 25: 295–310, 1975aPubMedCrossRefGoogle Scholar
  76. Pernoll ML, Metcalfe J, Schlenker TL, Welch E, Matsumoto JA. Oxygen consumption at rest and during exercise in pregnancy. Respiration Physiology 25: 285–293, 1975bPubMedCrossRefGoogle Scholar
  77. Pleet H, Graham JM, Smith DW. Central nervous system and facial defects associated with maternal hyperthermia at four to 14 weeks gestation. Pediatrics 67(6): 785–789, 1981PubMedGoogle Scholar
  78. Pomerance JJ, Gluck L, Lynch VA. Physical fitness in pregnancy: its effect on pregnancy outcome. American Journal of Obstetrics and Gynecology 119(7): 867–876, 1974PubMedGoogle Scholar
  79. Rauramo I, Forss M. Effect of exercise on maternal hemodynamics and placental blood flow in healthy women. Acta Obstetrica et Gynecologica Scandinavica 67: 21–25, 1988CrossRefGoogle Scholar
  80. Rose DJ, Bader ME, Bader RA, Braunwald E. Catheterization studies of cardiac hemodynamics in normal pregnant women with reference to left ventricular work. American Journal of Obstetrics and Gynecology 72(2): 233–246, 1956PubMedGoogle Scholar
  81. Rowell LB. Human circulation. In Regulation during physical stress, Oxford University Press, New York, 1986Google Scholar
  82. Ruhling RO, Cameron J, Sibley L, Christensen CL, Bolen T. Maintaining aerobic fitness while jogging through pregnancy: a case study. Medicine and Science in Sports and Exercise 13(2):93, 1981CrossRefGoogle Scholar
  83. St John Repovich WE, Wiswell RA, Artal R. Sport activities and aerobic exercise during pregnancy. In Artal R & Wiswell RA (Eds) Exercise in pregnancy, pp. 205–214, Williams & Wilkins, Baltimore, 1986Google Scholar
  84. Sady SP, Carpenter MW, Sady MA, Haydon B, Hoegsberg B, et al. Prediction of V̇O 2 Max during cycle exercise in pregnant women. Journal of Applied Physiology 65(2): 657–661, 1988PubMedGoogle Scholar
  85. Sady SP, Carpenter MW, Thompson PD, Sady MA, Haydon B, et al. Cardiovascular response to cycle exercise during and after pregnancy. Journal of Applied Physiology 66(1): 336–341, 1989aPubMedCrossRefGoogle Scholar
  86. Sady MA, Haydon B, Sady SP, Carpenter MW, Coustan DR, Thompson PD. Cardiovascular response to exercise during pregnancy and at 2 and 6 months postpartum. Submitted for publication, 1989bGoogle Scholar
  87. Shangold M, Mirkin G. The complete sports medicine book for women, Simon & Schuster, New York, 1985Google Scholar
  88. Sibley L, Ruhling RO, Cameron-Foster J, Christensen C, Bolen T. Swimming and physical fitness during pregnancy. Journal of Nurse-Midwifery 26(6): 3–12, 1981PubMedCrossRefGoogle Scholar
  89. Slavin JL, Lutter JM, Cushman S, Lee V. Pregnancy and exercise. In Puhl et al. (Eds) Sport sciences perspectives for women, pp. 151–160, Human Kinetics Books, Champaign, IL, 1988Google Scholar
  90. South-Paul J, Rajagopal KR, Tenholder MF. The effect of participation in a regular exercise program upon aerobic capacity during pregnancy. Obstetrics and Gynecology 71(2): 175–179, 1988PubMedGoogle Scholar
  91. Teruoka G. Labour physiological studies on the pregnant woman. Arbeitsphysiologie 7: 259–279, 1933Google Scholar
  92. Ueland K, Novy MJ, Metcalfe J. Cardiorespiratory responses to pregnancy and exercise in normal women and patients with heart disease. American Journal of Obstetrics and Gynecology 115(1): 4–10, 1973PubMedGoogle Scholar
  93. Ueland K, Novy MJ, Peterson EN, Metcalfe J. Maternal cardiovascular dynamics. IV. The influence of gestational age on the maternal cardiovascular response to posture and exercise. American Journal of Obstetrics and Gynecology 104(6): 856–864, 1969PubMedGoogle Scholar
  94. Ueland K, Parer JT. Effects of estrogens on the cardiovascular system of the ewe. American Journal of Obstetrics and Gynecology 96: 400–406, 1966PubMedGoogle Scholar
  95. US Department of Health and Human Services. Health promotion and disease prevention United States, 1985. DHHS Publication No. 88–1591, National Center for Health Statistics, Hyattsville, MD, 1988Google Scholar
  96. Walters WAW. Cardiovascular function in pregnancy. In Shearman RP (Ed.) Human reproductive physiology, pp. 336–375, Blackwell Scientific, Oxford, 1979Google Scholar
  97. Walters WAW, Lim YL. Cardiovascular dynamics in women receiving oral contraceptive therapy. Lancet 2: 879–881, 1969PubMedCrossRefGoogle Scholar
  98. Wells CL. Exercise during pregnancy. Women, sport and performance, pp. 127–158, Human Kinetics Publishers, Champaign, IL, 1985Google Scholar
  99. Widlund G. The cardio-pulmonal function during pregnancy: a clinical-experimental study with particular respect to ventilation and oxygen consumption among normal cases in rest and after work tests. Acta Obstetricia et Gynecologica Scandinavica 25(Suppl. 1): 1–125, 1945Google Scholar
  100. Wirth V, Emmons P, Larson D. Part One. Running through pregnancy: not only is it safe, it may save your life. Runners World, November: 55–59, 1978Google Scholar
  101. Wirth V, Larson D. Part Two. Running after pregnancy: positive steps to getting back on your feet fast. Runners World, December: 45–47, 1978Google Scholar
  102. Wong SC, McKenzie DC. Cardiorespiratory fitness during pregnancy and its effect on outcome. International Journal of Sports Medicine 8(2): 79–83, 1987PubMedCrossRefGoogle Scholar
  103. Zaharieva E. Survey of sportswomen of the Tokyo Olympics. Journal of Sports Medicine and Physical Fitness 2: 174–179, 1965Google Scholar
  104. Zaharieva E. Olympic participation by women: effects on pregnancy and childbirth. Journal of the American Medical Association 221(9): 992–995, 1972PubMedCrossRefGoogle Scholar

Copyright information

© ADIS Press Limited 1989

Authors and Affiliations

  • Stanley P. Sady
    • 1
    • 2
  • Marshall W. Carpenter
    • 1
    • 2
  1. 1.Brown University Program in Medicine, Department of MedicineThe Miriam HospitalProvidenceUSA
  2. 2.Department of Obstetrics and GynecologyWomen and Infant’s HospitalProvidenceUSA

Personalised recommendations